Cardiovascular Risk in 

the Cambodian Community

Formative Research from 

Lowell, Massachusetts

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

National Heart, Lung, and Blood Institute 
A collaborative report from the National Heart, Lung, and Blood Institute, 

the Asian & Pacific Islander American Health Forum, 

and Lowell Community Health Center
i

Table of Contents 

Acknowledgments.......................................................................................................................... iii 

I. Foreword..............................................................................................................................v 

II. Executive Summary.............................................................................................................1

III. Introduction..........................................................................................................................2 

IV. Methodology........................................................................................................................3 

A. Community-Based Partner.............................................................................................3 

B. Data Collection ..............................................................................................................3 

C. Instruments.....................................................................................................................3 

D. Interviewer Training ......................................................................................................3 

E. Translation of Research Instruments .............................................................................4 

V. Demographics ......................................................................................................................4 

VI. Results..................................................................................................................................6 

A. What Does the Heart Symbolize?..................................................................................6 

B. Concept of Health ..........................................................................................................6 

C. Prevention and Causes of Poor Health or Illness...........................................................6 

D. Major Health Concerns..................................................................................................7 

E. Cambodian Lifestyle in the United States and in Cambodia .........................................7 

i. Nutrition.............................................................................................................7 

ii. Physical Activity................................................................................................8 

iii. Tobacco..............................................................................................................9 

iv. Alcohol.............................................................................................................11 

v. Stress................................................................................................................11 

vi. Mental Health...................................................................................................12 

F. Personal Health ............................................................................................................13 

i. Perceptions of Obesity .....................................................................................13 

ii. Factors Associated With Cardiovascular Disease............................................13 

iii. Perceptions of High Blood Pressure ................................................................13 

iv. Perceptions of High Blood Cholesterol ...........................................................14 

v. Perceptions of Heart Disease ...........................................................................14 

vi. Changes in Lifestyle Because of Heart Disease ..............................................14 

vii. Alternative Health Practices ............................................................................14 

G. Health Education and Promotion.................................................................................15 

i. Health Information Sources .............................................................................15 

ii. Engaging Community Residents in Heart Health............................................16 

iii. Barriers to Accessing Medical Help or Services .............................................16 

VII. Discussion..........................................................................................................................16 
ii

VIII. Limitations of the Study.....................................................................................................19

IX. Conclusion .........................................................................................................................19 

X. Appendices.........................................................................................................................20 

A. Appendix A: Informed Consent Forms.......................................................................21 

i. Focus Group.....................................................................................................22 

ii. Key Informant Interview..................................................................................23 

iii. Indepth Interview.............................................................................................24 

B. Appendix B: Training Materials .................................................................................25 

i. Key Informant Interview Training Protocol ....................................................26 

ii. Key Informant Interview Training Handout....................................................27 

iii. Indepth Interview Training Protocol................................................................30 

iv. Indepth Interview Training Handout ...............................................................31 

C. Appendix C: Interview Guides ....................................................................................36 

i. Focus Group Guide..........................................................................................37 

ii. Key Informant Interview Guide.......................................................................43 

iii. Indepth Interview Guide ..................................................................................49 
iii

Acknowledgments 

Advisory Committee 

Magelende McBride, Ph.D., M.S.N., R.N. 

Community Liaison 

Curtiss Takada Rooks, Ph.D. 

Consultant 

Asian & Pacific Islander American Health Forum staff 

Gretchenjan C. Lactao, B.A. 

Research Associate 

Susana M. Lowe, Ph.D. 

Principal Investigator 

Lowell Community Health Center staff 

Dorcas Grigg-Saito, M.S. 

Executive Director 

Karena Heang 

Community Health Educator, Cambodian Community Health 2010 Program 

Pahim Kay 

Community Health Advocate, Cambodian Community Health 2010 Program 

Sovann Kheam 

Community Health Educator, Cambodian Community Health 2010 Program 

Buntha Krouch 

Community Health Educator, Cambodian Community Health 2010 Program 

Sidney L. Liang, B.S. 

Program Director, Cambodian Community Health 2010 Program 

Niem Nay-Kret 

SABAI Program Coordinator, Cambodian Community Health 2010 Program 

Rithyvuth Sap 

Community Health Educator, Cambodian Community Health 2010 Program 
iv

Lowell Community Health Center staff (continued) 

Sivkheng Sar 

Community Health Advocate, Cambodian Community Health 2010 Program 

Chanda Soth 

Community Health Educator/Administrative Assistant, Cambodian Community Health 2010 

Program 

National Heart, Lung, and Blood Institute; Office of Prevention, Education, and Control 

staff 

Matilde Alvarado, M.S.N., R.N. 

Coordinator, Minority Health Education and Outreach Activities 

Robinson Fulwood, Ph.D., M.S.P.H. 

Senior Manager for Public Health Program Development 

Ellen Sommer, M.B.A. 

Public Health Advisor 

Juliana Tu, M.S., C.H.E.S. 

Community Health Specialist 

We would especially like to thank the members of the Cambodian community in Lowell, 

Massachusetts, who generously gave their time, effort, and invaluable insight for this report. 
v

I. Foreword

The Healthy People 2010 report outlines the current status of the Nation’s health and the health 

objectives to be reached by the end of the decade. The two main goals of Healthy People 2010

are to increase the quality and years of healthy life and to end disparities in the burden of disease. 

The National Heart, Lung, and Blood Institute (NHLBI) is committed to meeting the goals set 

forth in Healthy People 2010, including ending the burden of disease for all racial and ethnic 

groups. The Institute has developed education programs and initiatives to address high blood 

pressure, high blood cholesterol, early warning signs of heart attack, asthma, obesity, and sleep 

disorders. 

According to the 2000 Census, more than 1.8 million Southeast Asians are living in the United 

States, and more than 9 percent (171,937) of those are Cambodians. From 1975 to 2000, 

Cambodians, with Vietnamese and Laotians, made up the largest group of refugees to immigrate 

to the United States.1

 Beginning in the mid- to late-1970s, thousands of Cambodians fled 

Cambodia to escape the atrocities of the Khmer Rouge.2

 The largest numbers of Cambodians 

live in Long Beach, California, and in Lowell, Massachusetts. Sizable communities also exist in 

Pennsylvania and Washington State. 

We now have the opportunity to build partnerships within Cambodian communities and to focus 

local community action on creating heart disease prevention activities. Through the 

development and implementation of focused, culturally sensitive, and language-appropriate heart 

health strategies, we can help to prevent the development of heart disease risk factors in 

Cambodian communities and help to address the Healthy People 2010 goal of eliminating racial 

and ethnic disparities in heart disease risk. Together, we can make a difference! 

Claude Lenfant, M.D. 

Director 

National Heart, Lung, and Blood Institute 

National Institutes of Health 

 

1

 U.S. Department of Health and Human Services. Administration for Children and Families. Office of Refugee 

Resettelement Annual Report to Congress, 2000. 2

 Wetzel L, Huong J. EthnoMed: Cambodian Cultural Profile, 1995. 
1 

II. Executive Summary 

Asian Americans and Pacific Islanders (AAPIs) are the fastest growing racial/ethnic group in the 

United States. They have varying socioeconomic characteristics, levels of acculturation, 

immigration history, and health profiles. The AAPI population is extremely diverse; its 

members have ancestral ties to approximately 50 Asian and Pacific Islander nations. Heart 

disease is the leading cause of death among these groups, but its impact on each group varies. 

Although few studies exist on the cardiovascular health of Cambodians in the United States, 

several studies suggest that they are at high risk for cardiovascular disease (CVD) based on their 

lifestyle behaviors.3

 

3

 Ma GX, Tan Y, Feeley RM, et al. Perceived risks of certain types of cancer and heart disease among Asian 

American smokers and non-smokers. Journal of Community Health 2002; 27(4): 233 – 46. 

The National Heart, Lung, and Blood Institute (NHLBI) worked in partnership with the Asian & 

Pacific Islander American Health Forum (Health Forum) to conduct an assessment of the 

cardiovascular health status of AAPIs. The Cambodian community is the third of four AAPI 

populations studied. The other populations studied are Filipinos, Vietnamese, and Native 

Hawaiians. 

This report focuses on the Cambodian population. Three formative research methods were used 

to study the Cambodian communities: (1) focus groups with staff and volunteers from a local 

community service agency, (2) key informant interviews with community leaders, and (3) 

indepth interviews with community residents conducted by trained bilingual (English and 

Khmer) facilitators. This report provides insights into the Cambodian community, its 

perceptions and knowledge of heart disease, and motivations to making healthy lifestyle changes. 

Results from this study indicate that Cambodians in the United States are at high risk for 

developing CVD. Stress from acculturation and financial problems, as well as mental health 

problems are primary issues that plague this refugee population. Nevertheless, the need for 

healthy eating habits, regular checkups with a health care professional, physical activity, 

smoking cessation, and other heart healthy practices are important concerns identified by the 

community. Health education interventions for Cambodians should focus on primary prevention 

of heart disease risk factors and behavior modifications. 
2 

 III. Introduction 

Since 1972, the NHLBI has translated and disseminated information to the public to promote 

public health and prevent and control heart, lung, and blood diseases and sleep disorders. To 

date, the NHLBI has supported national cardiovascular health initiatives for the African 

American, American Indian/Native American, and Latino populations. This is its first national 

effort in support of a National Asian American and Pacific Islander (AAPI) Cardiovascular 

Initiative. NHLBI’s main objective is to collaborate with AAPI community-based organizers, 

key informants, and community members to conduct cardiovascular health needs assessments in 

specific ethnic communities. 

In August 2000, NHLBI funded the Asian & Pacific Islander Health Forum (Health Forum) to 

conceptualize and implement a formative research project to gain a greater understanding of the 

attitudes and knowledge of health practices related to CVD among selected AAPI communities. 

This report highlights the main findings from the Cambodian community. 

The 2000 Census reports that the second largest concentration of Cambodians (19,696) live in 

Massachusetts, and one-half of the Cambodian residents in Massachusetts live in the city of 

Lowell.4

 

4

 U.S. Census Bureau. The U.S. Census 2000. 

 It is believed that the true size of the Cambodian community may be much larger, because of 

underreporting in the immigrant and refugee population. 

The information collected under this project was approved as part of the Office of Management 

and Budget (OMB) blanket clearance project. Blanket clearance number 0937 was approved and 

administered by the National Institutes of Health (NIH) as a means to expedite the collection of 

consumer information to enhance program planning and development activities and to improve 

delivery to and utilization of health information by NIH customers. 
3 

IV. Methodology 

A. Community-Based Partner 

For the Cambodian needs assessment study, the Health Forum partnered with Lowell 

Community Health Center (LCHC). LCHC provides culturally appropriate health care services 

to immigrants, particularly Southeast Asians, in the city of Lowell. 

B. Data Collection 

The data were collected through three methods: 

1. Focus group 

Focus group participants included 1 LCHC staff member and 10 community residents. 

The focus group, facilitated by the primary investigator from the Health Forum, was 

conducted in English and Khmer; most participants spoke in Khmer. The focus group 

was tape recorded, transcribed, and translated. 

2. Key informant interviews 

Four key leaders from the Cambodian community were interviewed. Interviewees were 

required to have held a leadership position in the Cambodian community of Lowell, 

Massachusetts. 

3. Community indepth interviews 

Interviews were conducted with 26 Cambodian community residents. Interviewees, ages 

18–70, had low incomes and literacy levels; 10 interviewees were over age 50. Of the 26 

interviewees, 22 were conducted in Khmer; 4 were conducted in English. 

C. Instruments 

Three sets of questionnaires were developed: focus group questions, key leader questions, and 

community resident questions. Focus group and key leader questions were designed to capture 

information about individual experiences and observations on community health attitudes and 

behaviors. The indepth interview questions were designed to capture information about 

individual health practices. Unless otherwise specified, the quantitative data in this report are 

based on the findings from 26 community residents. 

D. Interviewer Training 

The training materials used to conduct focus groups in the Cambodian community were revised 

slightly by the Health Forum to make them culturally appropriate for this study. One interviewer 

at LCHC was trained to conduct the key informant interviews, and four other interviewers were 

trained to conduct the indepth interviews. 
4 

E. Translation of Research Instruments 

Step 1: The instruments used to conduct the Filipino and Vietnamese cardiovascular risk 

 assessments were reviewed to ensure cultural appropriateness for the Cambodian 

 cardiovascular risk assessment. 

Step 2: LCHC staff modified the instruments to make them culturally and linguistically 

 appropriate, reduce repetition, and increase clarity in the interview process. In addition, 

 some questions pertaining to the refugee experience were added. All changes were 

 approved by NHLBI. 

Step 3: Two independent translators provided a written translation of the revised documents. 

 LCHC staff approved the translations before adopting them for use. 

V. Demographics 

The participants in this study varied greatly by age, gender, occupation, and socioeconomic 

status. The following tables and figures provide a demographic description of the different target 

groups participating in the Cambodian project in Lowell. Of the 26 community residents 

interviewed, 14 were male, and 12 were female. The mean age was 48 years old (SD=13.51 

years). 

Table 1. Number of participants by needs assessment methodology, sex, and age 

Group Male Female Age range 

Focus group 7 4 24–70 years old 

Key leaders interview 2 2 38–45 years old 

Community residents interview 14 12 25–68 years old 

Total 23 18 24–70 years old 

Table 2. Number and percent of community resident participants by age and sex 

Age: Grouped by sample distribution Male Female Total (%) 

25–29 years old 2 1 3 (11.5%) 

30–45 years old 6 4 10 (38.5%) 

46–60 years old 2 4 6 (23.1%) 

61+ years old 4 3 7 (26.9%) 

Total 14 12 26 (100%) 

In general, the community residents sampled had low levels of educational attainment. Of the 

26 community residents, 23 percent had received 13 or more years of education, and 12 percent 

had received 9–12 years of education. (See figure 1.) Among all community resident 

participants, 65 percent had received less than 9 years of education. 
5 

Figure 1. Percent of community resident participants by educational attainment 

0 10 20 30 40 50 60 70 80 90 100

13+

9 through 12

<9

Years of education received 

Percent of community residents

Of the 26 community residents, 12 percent were employed in administrative support, service, 

industrial, or sales positions, and 4 percent were employed in professional/managerial or 

technical positions. (See figure 2.) Nearly half (48 percent) did not receive a steady income 

because they were either unemployed or homemakers. (See figure 2.) 

Not shown in the figure is household income and size. The range of annual household income 

was $40,001 to $60,000. The average household size was 4.7 people. Also not shown in the 

figure is the fact that the community residents worked an average of 35.1 hours/week 

(SD=16.11); nearly one-half worked more than 40 hours/week. 

Figure 2. Percent of community resident participants by occupational status 

n=26

12%

4%

16%

32%

36%

Administrative support,

service, industrial, sales

Professional/managerial,

technical

Homemaker

Unemployed

Other
6 

All community residents interviewed reported that they were born in Cambodia and that Khmer 

was their native language. Two were naturalized U.S. citizens. The residents’ length of stay in 

the United States ranged from 1–26 years. 

VI. Results 

A. What Does the Heart Symbolize? 

All the participants said that the heart symbolizes love, health, and caring for others. To the key 

leaders, the heart also symbolizes kindness and the willingness to help and share with others. To 

the community residents, the heart also symbolizes trust, a whole and fulfilling life, and 

sympathy. 

B. Concept of Health 

The focus group participants, key leaders, and community residents all said that good health 

meant not being sick and not having to see a doctor. Community residents said that people who 

are healthy live long and happy lives. Community residents defined healthy people as 

individuals who are physically, mentally, and spiritually balanced. 

Key leaders noted that in addition to being happy and having a good strong family, religion plays 

a significant role in Cambodian health. Because religion is so important to their lives, 

community residents say that temples are among the most popular places for community 

gatherings. Temple activities provide congregants with a sense of belonging and serve as a 

means for expressing and expanding the Cambodian culture. Cultural profiles describe most 

Cambodians as Buddhist, but a small number are Christian. 

C. Prevention and Causes of Poor Health or Illness 

Cambodians believe in preventing disease rather than treating it; therefore, focus group 

participants said medicinal herbs and teas are commonly used to protect one’s health. 

Community residents noted lifestyle behaviors as reasons for poor health, e.g. poor nutrition, 

lack of exercise, drinking alcohol, stress, fatigue, smoking, substance abuse, and lack of health 

education. However, none of the interviewees saw a link between lifestyle behaviors and 

personal risk for heart disease. 

Key leaders and focus group participants added that another cause of poor health could be 

spiritual. They believe that having bad karma or committing a sin will bring one illness. Often, 

community residents wear jewelry with images of Buddha or they hang cultural and/or religious 

placards on their doors to protect themselves from illness. 
7 

D. Major Health Concerns 

Table 3 lists the major health concerns according to the key leaders in the community (1 is 

ranked as the most common concern). 

Table 3. Major health concerns 

1 2 3 4 

 CVD (heart disease, 

high blood pressure, 

and high blood 

cholesterol) 

 Diabetes 

 Hepatitis 

 Alcohol-related 

problems 

 Liver cancer 

 Mental illness 

 Asthma 

 HIV/AIDS 

Key leaders felt that the health and wellness of the community are being threatened by high 

unemployment rates, low job security, poverty, lack of housing, lack of qualified bilingual and 

bicultural health care providers, and lack of Khmer language health education. 

E. Cambodian Lifestyle in the United States and Cambodia 

i. Nutrition 

Each community resident was asked about the type of food they had eaten 2 days before 

the interview. Generally, the community residents ate healthy food; more than 60 percent 

had consumed at least 3 or more servings of fruits and vegetables during those 2 days 

(figure 3). Nearly all the residents ate fresh fruits and vegetables as well as lean meats 

and lowfat dairy products (data not shown). Also, the residents mostly ate home-cooked 

meals, and 64 percent of them cooked traditional Cambodian dishes. They rarely ate at 

fast food restaurants—only when asked by their children. Although most community 

residents had healthy eating habits, 27 percent did not understand the role of nutrition in 

heart disease prevention and said that eating a lowfat diet is not important. 

Figure 3. Percent of community residents by type of food reported and number of 

servings over a 2-day period 

0 20 40 60 80 100

Vegetables

Fruits

Dairy

Eggs

Red meat

Chicken

Fish

Vegetable protein

Snacks

Food type

Percent of community residents

3+ servings

1 - 2 servings
8 

Key leaders stated that a typical Cambodian diet consists of rice, vegetables, fish, and 

soup. For special celebrations, rice, soup, and fried dishes are more common. 

Community residents said that traditional Cambodian dishes are typically flavored with 

fish sauce, monosodium glutamate (MSG), pepper, and lemon grass. Red meat, chicken, 

fish, and vegetables are usually prepared as part of the main entrees, while fruits are 

common snacks. The following tables list the types of common ingredients, vegetables, 

and fruits used in traditional Cambodian dishes. 

Table 4. Ingredients in traditional Cambodian dishes 

Curry paste Lemon grass Onion Sugar 

Fish sauce Lima beans Pepper Tamarind 

Galanga Mint Salt Vegetable oil 

Garlic MSG Soy sauce 

Table 5. Common vegetables 

Beets Carrots Green beans Potato 

Bitter melon Cauliflower Green peppers Tomato 

Broccoli Cucumber Lettuce Turnip 

Cabbage Eggplant Peas Water grass 

Table 6. Common fruits 

Apple Grapes Mango Plum 

Banana Jackfruit Nectarine Strawberries 

Durian Kiwi Orange Watermelon 

Grapefruit Lychees Pear 

The community residents believed that the diets of Cambodians change after migrating to 

the United States. Cambodians tend to eat more meat and less fish, fruits, and vegetables 

in the United States. Key leaders said that people living in Cambodian refugee camps 

were unable to make healthy food choices and were often given salty canned foods. 

Although focus group participants and community residents think that there are too many 

preservatives in food and genetically modified foods, they have more opportunities to 

choose healthy foods because of the variety and affordability of food in the United States. 

ii. Physical Activity 

In general, the community residents thought that physical activity was important. 

Seventy-seven percent of the residents were active at least once last month. More than 

one-half were regularly involved in formal or organized activities, but not necessarily at a 

rigorous level (figure 4). 
9 

Figure 4. Percent of community residents engaging in physical activity by attitudes 

and behavior 

0 10 20 30 40 50 60 70 80 90

Exercise is very important

Exercise is somewhat important

Active 1+ times last month

Participate in formal or organized activities

Attitudes and behavior

Percent of community residents

The community residents were asked about the physical activities in which they were 

most involved. Table 7 lists those activities. 

Table 7. Physical and recreational activities in which residents are most involved 

Dancing Running Walking 

Gardening Swimming Weight lifting 

Housework Volleyball 

Key leaders observed that stress, lack of time, lack of motivation, and lack of support 

were the top reasons people do not exercise. Because of these reasons, key leaders think 

that asking people to exercise at least 30 minutes a day several times a week would be too 

demanding. However, community residents said that people can become motivated if 

they understood the importance of physical activity in disease prevention and overall 

health. 

The community residents said temple-sponsored activities and exercise programs are two 

formal physical activities in which people are most involved. Picnics and sporting events 

at temples bring family and friends together. Events held at faith-based organizations are 

particularly important for older community residents, since the elderly are frequently 

inactive and prefer to spend time praying and socializing at temple rather than being 

physically active in their neighborhood. 

iii. Tobacco 

Among the 26 community residents, nearly 30 percent were smokers or had smoked in 

the past. Of the 6 smokers, 1 smoked 20 cigarettes a day, 3 smoked once a day, 1 

smoked once a week, and 1 smoked once a month. The residents who were exposed to 
10 

environmental tobacco smoke were exposed through family members (8 percent), friends 

(8 percent), and coworkers (15 percent). (See figure 5.) 

Figure 5. Percent of community residents exposed to environmental tobacco smoke 

by source of exposure 

0

5

10

15

20

25

Family Friends Coworkers

Sources of exposure

Percent of community residents

Some of the smokers tried to quit smoking, while others had no intention of quitting. The 

community residents correctly identified some of the ways smoking can harm the body 

(e.g., causes lung diseases, makes one weak, and can kill), but the key leaders explained 

that quitting the smoking habit is hard. They said that the addiction to tobacco is too 

great and existing tobacco cessation programs are difficult to follow or do not meet their 

needs. 

Focus group participants and key leaders agreed that smoking is a common practice in 

Cambodian culture. It is more socially acceptable for men than women to smoke. Focus 

group participants and community residents say that family, friends, and social norms 

(i.e., smokers live a “trendy” lifestyle) are the biggest influences leading people to smoke 

in the United States. Focus group participants believed that peer pressure and media 

campaigns encouraging smoking play a large role in influencing teens to start smoking. 

Table 8 lists the most common socialization factors the community residents named as 

influences leading Cambodians to smoke. 

Table 8. Factors that influence smoking 

Social Pressure Environment Individual Factors Media 

 Peer pressure 

 Family 

 Coworkers 

 Friends 

 Social 

gatherings 

 Smokers in the 

home 

 Cultural and 

social norm 

 Entertainment 

 Habit 

 Depression 

 Stress 

 Building selfconfidence 

 Books 

 Magazines 

 Television and 

radio 

 Free 

promotional 

items 
11 

iv. Alcohol 

Of the 26 community residents, 7 drink alcohol regularly. Figure 6 displays the 

frequency of community residents’ drinking: 12 percent reported drinking daily, 4 

percent drink weekly, 16 percent drink monthly, and 68 percent never drink (figure 6). 

Figure 6. Percent of community residents who drink alcohol by frequency of 

alcohol consumption 

n=26

12%

4%

16%

68%

Daily

Weekly

Monthly

Never

According to focus group participants, alcohol use is also a part of the Cambodian culture 

and is more common among youth. They explained that drinking is a leisure and social 

activity known to relieve stress, aid in sleep, and even boost energy, depending on the 

situation. 

v. Stress 

The focus group participants, key leaders, and community residents all said that stress 

significantly affects their health status. Table 9 lists the factors that increase stress 

according to all three categories of interviewees. 

Table 9. Common causes of stress 

Financial worries Relationships 

Adaptation and acculturation Health 

Generation gap within the family Communicating in English 

Work Caring for someone who is not well 

Housing Distance from the homeland 

School 

Although many causes of stress were named, three were most often named—financial 

worries, adaptation and acculturation, and generation gaps. These are discussed below. 
12 

Financial worries are a major source of stress for Cambodians. Focus group participants 

said that people often work several jobs to make enough money to support the family. 

They add that Cambodians typically have below-average incomes, thus decreasing their 

opportunities for higher education and higher paying jobs. 

Adaptation and acculturation also cause great stress for the Cambodian community. 

Immigrating to the United States often means separating family members from their 

social support networks. Without community support and extended family members 

nearby, immigrants have a more difficult time adjusting to their new environment. 

A generation gap between grandparents, parents, and children is another cause for stress. 

The focus group participants said that Cambodian youth who grow up in the United 

States live in a culture that their parents and grandparents do not fully understand. 

Parents feel isolated from their children, resulting in tension within the family. 

Table 10 lists the ways community residents relieve stress. 

Table 10. Common methods of stress relief 

Exercising (includes walking and group sports) Window shopping 

Talking with friends Having a picnic 

Driving around town Meditating 

Watching movies 

vi. Mental Health 

Focus group participants said that mental health plays an important role in the overall 

health of Cambodians. In fact, mental health problems are one of the most prevalent 

health problems among Cambodian immigrants. Several studies have shown that posttraumatic stress disorder, depression, and anxiety all appear in this population, sometimes 

crippling the victims.5

 

5,6 Palinkas LA, Pickwell SM. Acculturation as a risk factor for chronic disease among Cambodian refugees in the 

United States. Social Science and Medicine 1995; 40(12): 1643–53. 

Mental health disorders stemming from the refugee experience have resulted in 

Cambodians making the least progress in adjusting to life in the United States, compared 

to other Southeast Asians, further exacerbating stress levels.6

The focus group participants explained that when people in the community feel stressed, 

they turn to monks for spiritual healing. Cambodians prefer monks, because Cambodia 

has no mental health professionals (e.g., psychiatrists and psychologists). 
13 

F. Personal Health 

i. Perceptions of Obesity 

All the interviewees said that in the Cambodian culture being overweight or obese is a 

positive reflection of one’s health, wealth, and happiness. They added that many 

Cambodians find overweight and obese people attractive because it is a “rich disease,” 

i.e., people who have a lot of money can afford to buy and eat lots of food. The 

interviewees correctly identified a poor diet, overeating, and living a sedentary lifestyle 

as causes of overweight and obesity. However, targeted programs are needed to educate 

the community about the health consequences of overweight and obesity as well as how 

to maintain a healthy weight. 

ii. Factors Associated With Cardiovascular Disease 

When the community residents were surveyed, 8 percent had family members with heart 

disease. When asked about their own heart disease risk, 24 percent were on a special 

physician-ordered diet; 12 percent were diagnosed with diabetes; 8 percent were 

diagnosed with high blood cholesterol; 12 percent were diagnosed with high blood 

pressure; 4 percent had had a stroke; and 8 percent had had a heart attack. (See figure 7.) 

Figure 7. Percent of community residents with various CVD-related factors 

0 10 20 30 40 50

Have had a heart attack

Have had a stroke

Diagnosed with high blood pressure

Diagnosed with high blood cholesterol

Diagnosed with diabetes

Special diet

Family member with heart disease

Factors associated with CVD

Percent of community residents

iii. Perceptions of High Blood Pressure 

All the interviewees said the community lacks knowledge and understanding of high 

blood pressure. Although key leaders and community residents identified a high-sodium 

diet as one cause of high blood pressure, focus group participants said the community has 

misconceptions about what high blood pressure is and how to treat it. Early intervention 
14 

and education for the prevention of high blood pressure is important for this population, 

because high blood pressure has been documented in Cambodian school-aged children.7

 

7

 Munger RG, Gomez-Marin O, Prineas RJ, et al. Elevated blood pressure among Southeast Asian refugee children 

in Minnesota. American Journal of Epidemiology 1991; 133(12): 1257–65. 

 

iv. Perceptions of High Blood Cholesterol 

All the interviewees said that knowledge and understanding about high blood cholesterol 

is also lacking. The interviewees recognized the factors associated with increasing high 

blood cholesterol levels, such as eating foods high in fat and cholesterol and a lack of 

exercise. However, they believed those behaviors to be strongly linked to diabetes rather 

than heart disease. 

v. Perceptions of Heart Disease 

Although the interviewees correctly identified lack of physical activity, high blood 

cholesterol, poor diet, smoking, and alcohol abuse as risk factors for heart disease, more 

education about heart disease is needed. For instance, high blood pressure and 

overweight were not mentioned as other risk factors for heart disease. Community 

residents said that most Cambodians with heart disease do not know that they have it. 

Information about heart disease is shared from one person to another, usually family 

members or friends, by word of mouth and is based on personal experiences. The key 

leaders said that many people are afraid of sudden death from a heart attack or stroke. 

vi. Changes in Lifestyle Because of Heart Disease 

The key leaders stated that when people are diagnosed with heart disease, they are 

inclined to visit their physicians more regularly. Although people are advised by their 

physicians to eat a proper diet, get enough sleep, and be physically active every day, 

according to the key leaders, residents need skills and social support to comply with their 

physicians’ advice. Key leaders believe that people have a difficult time changing their 

health behaviors, even after being diagnosed with heart disease, because few skillbuilding programs and support groups exist to encourage healthy lifestyle changes. 

vii. Alternative Health Practices 

The interviewees said that people only seek medical care when they are sick. The focus 

group participants and key leaders said that traditional Eastern medicine is the first line of 

defense against disease. Community residents see Western medicine as more effective, 

but Eastern medicine is preferred because it is more accessible. Cambodians traditionally 

manage illness with self-care and self-medication. Traditional self-care includes home 

remedies, over-the-counter medication, herbal medicine, coining, cupping, prayers with 
15 

monks, and consultations with palm readers. Because Western medicine is costly, 

Cambodian immigrants generally consult Western physicians only when their own 

remedies do not work. 

Community residents who have health insurance (approximately 65 percent) prefer 

Western medicine and even feel more comfortable with a non-Cambodian health care 

provider. Focus group participants added that the younger generation of Cambodians has 

greater trust in Western medicine. These findings indicate that new immigrants are more 

likely to choose self-care and traditional medicine, whereas more acculturated 

Cambodians are more likely to choose Western medicine. 

G. Health Education and Promotion 

i. Health Information Sources 

Key leaders said that, although many people get health information through family and 

friends, media can play an important role in health education to reach a larger portion of 

the population at one time. Community outreach materials (e.g., flyers), radio, 

newspaper, and television are the media most utilized for distribution of information. 

Figure 8 shows the percentage of residents who seek health information, the sources, and 

the preferred language. Most residents prefer health information in Khmer rather than 

English. In fact, 96 percent of the residents felt that it was important to have public 

health education and prevention materials in their native language. 

Figure 8. Percentage of community residents who report sources of health 

information by information source and language 

0 20 40 60 80 100

Television

Radio

Newspaper or magazine

Public education materials

Flyers

Friends and family

Health care provider

Sources

Percent of community residents

Language

not specified

Khmer

English
16 

ii. Engaging Community Residents in Heart Health 

The key leaders and community residents said that community health centers, mutual 

assistance associations, and temples are the sites most frequently attended for health care 

services. 

iii. Barriers to Accessing Medical Help or Services 

All of the interviewees said the three biggest barriers to accessing medical help or 

services are: (1) cultural and linguistic barriers between patients and health care 

providers, (2) transportation issues, and (3) high cost of health care. These barriers are 

particularly troublesome for new immigrants. 

VII. Discussion 

Findings from this cardiovascular health needs assessment will aid the development of future 

heart health programs in the Cambodian community. This section discusses specific ideas for 

prevention and intervention programs recommended by focus group participants, key leaders, 

and community residents. 

 Provide programs that help build trust between patients and providers 

Gaining the trust of Cambodians is the first step to providing health care to this population. 

Disease prevention, from a Western viewpoint, is a new concept to many Cambodians. Results 

from a heart health education intervention pretest, conducted in Ohio, found that only 10.7 

percent of 224 Cambodian immigrants surveyed were aware of the ways to prevent heart 

disease.8 Moreover, Cambodians, particularly new immigrants, cannot communicate effectively 

in English. Community residents recommended that culturally competent and/or bilingual 

providers or health educators have increased personal contact with the community they serve 

through home visits. The residents believed that, in this intimate setting, providers and educators 

can effectively distribute health education materials and answer questions about the American 

health care system. Community residents also recommended open houses at local hospitals and 

clinics so that the public can become familiar with Western medical facilities and practices in a 

friendly manner. 

 Teach behavior change for the prevention of CVD 

The participants in this study understood that poor health is a result of poor health behaviors. 

They also understood that diseases should be prevented. However, their knowledge about 

prevention was limited to Eastern medicine, in which medicinal herbs and teas as well as 

religious placards are popular methods of prevention. Programs teaching behavior change for 

prevention are necessary to help reduce this population’s risk for CVD. While some participants 

 

8

 Chen, Jr. MS, Anderson J, Moeschberger M, et al. An evaluation of heart health education for Southeast Asians. 

American Journal of Preventive Medicine 1994; 10(4): 205–8. 
17 

practiced healthy behaviors and even knew about risk factors, they were unable to identify the 

causal relationship between their own health behaviors and the prevention of heart disease. This 

claim is supported by a study that showed that 94 percent of Southeast Asians in Ohio had no 

knowledge of CVD, and 85 percent had no knowledge of prevention.9

 Improve access to health information 

The interviewees stressed the need for improved access to health information. Key leaders 

believed that the most effective way to educate Cambodians about heart health is through free 

community workshops that are culturally appropriate and offer personal testimonies and handson activities. Community residents said that workshops could be enhanced with tips on stress 

management. They also said that health fairs are popular in the Cambodian community. 

 Improve the quality of health information 

Key leaders said that health messages that are essential address the causes, prevention, and 

treatment of high blood pressure, high blood cholesterol, obesity; tips on how to stop smoking 

and drinking too much alcohol are also needed. Key leaders said there are significant numbers 

of both elders and youth in the Cambodian community. Khmer is the main language used in the 

community, especially among the elderly; however, English is widely spoken among the younger 

generation. Therefore, health education information must be available in Khmer and English to 

reach a wider audience by using few words, simple vocabulary, and colorful illustrations. A 

recent mental health needs assessment of refugees by the Massachusetts Department of Mental 

Health found that literacy and English proficiency levels were low among Cambodians living in 

Massachusetts—only 5.3 percent of the people surveyed could communicate in English.10 

Key leaders said that health information in an audio and/or video format is preferred. Written 

materials about preventive health are often discarded, as individuals may not be able to read 

them or do not believe the information applies to them. Furthermore, Cambodians in the United 

States are predominantly illiterate or semiliterate in their own language—many came from rural 

areas where schools and education were inaccessible.11

 Conduct prevention and intervention programs at faith-based organizations 

The Cambodian culture and religion play a significant role in the way Cambodians live. 

Temples and other faith-based organizations help new immigrants, who are seeking support and 

guidance, to build relationships within their chosen community. Other residents go to temple to 

pray and meet friends. All Cambodians celebrate Cambodian holidays at temples, such as the 

Khmer New Year and the Water Festival. Because temples are common and comfortable 

gathering places for the community residents, they are suitable venues for heart health 

intervention programs. 

 

9

 Chen, Jr. MS, Kuun P, Guthrie R, et al. Promoting heart health for Southeast Asians: A database for planning 

interventions. Public Health Reports 1991; 106(3): 304–9. 10 Massachusetts Department of Public Health, Office of Refugee and Immigrant Health. Refugees and Immigrants 

in Massachusetts: An Overview of Selected Communities, 1999. 

11 Wetzel L, Huong J. EthnoMed: Cambodian Cultural Profile, 1995. 
18 

 Teach coping strategies 

Stress is a major issue for any refugee community. Aside from its impact on one’s mental 

health, stress may increase the presence of risk factors such as high blood pressure. Programs 

teaching individuals and families how to cope with financial burdens, language barriers, 

acculturation, and so forth, can give people greater ability to take care of themselves and their 

families. If more attention is needed, consistent followup and referrals should be made. Focus 

group participants recommended peer role models or mentoring programs for youth-related 

problems. 

 Offer nutrition and cooking classes 

Sodium-based sauces are staple ingredients of Cambodian diets, as in other Asian diets. 

Frequent consumption of high sodium foods increases one’s chances for high blood pressure and 

consequently developing heart disease. Therefore, key leaders recommended that classes should 

be offered to the public on proper nutrition, including cooking demonstrations of lowfat and lowsalt recipes. 

 Improve smoking cessation programs 

Key leaders said that smokers found quitting smoking very difficult because of a lack of 

culturally appropriate smoking cessation programs in Cambodian communities. Programs 

should be tailored to men, as more Cambodian men than women smoke, and should include 

strategies on how to overcome peer pressure, particularly for youth. 

Also, stressing the consequences of smoking may be an effective way to help this population quit 

smoking. A recent 5-year study, on the decisional balance for smoking cessation of Southeast 

Asian men in the United States, sampled 101 Cambodian men in Franklin County, Ohio.12 The 

study found that men who were exposed to more messages on the negative consequences of 

smoking were more successful in quitting smoking than those who heard positive messages 

about the health benefits of being a nonsmoker. 

 Provide community activities to promote physical activity

To encourage the community to become more physically active, focus group participants 

recommended increasing opportunities for group sports for various age groups. For example, 

soccer and volleyball appeal to youth, while gardening would appeal to the elderly. These 

programs can take place at the local gyms, parks, and community center. It is important to offer 

transportation options ranging from carpools to walking buddies. Key leaders believe that group 

activities will help community residents build support groups, self-esteem, and ultimately 

improve their physical fitness. 

 

12 Lafferty CK, Heaney CA, Chen MS. Assessing decisional balance for smoking cessation among Southeast Asian 

males in the United States. Health Education Research Theory and Practice 1999; 14(1): 139–46. 
19 

VIII. Limitations of the Study 

 More detailed information is needed on various aspects of the Cambodian diet. A list of 

traditional dishes, as well as descriptions of food preparations, can better assess the effects of 

diet and eating behaviors on the community’s risk for CVD. 

 Some survey questions were repetitive and require further modification. 

 This study was limited by a small geographic area and relatively small sample size. Results 

should not be generalized either to the larger Cambodian community in Massachusetts or to 

all Cambodians in the United States. Epidemiological studies and qualitative research to 

further assess CVD risk are warranted. Mixed-methods research, especially studies 

conducted in partnership with CBOs, would enhance the capacity to develop more informed 

and effective CVD prevention and intervention programs. 

IX. Conclusion 

The present assessment of this population shows high risk for heart disease in Cambodian 

communities. Individuals who were surveyed had limited knowledge of heart disease, were not 

regularly screened, ate increasingly high-fat and high-sodium foods, had low levels of physical 

activity, smoked, and lived stressful lifestyles. 

Further studies on Cambodian-specific heart disease risk are needed to support future community 

heart health programs. The Cambodian population continues to grow at a rapid rate in the 

United States, consequently increasing the burden of CVD in this country. Tailored 

interventions offered through community health clinics, mutual assistance associations, and 

faith-based organizations are ideal networks for reaching the Cambodian community with heart 

health messages. 

The plight of Cambodian refugees is fraught with acculturation, language barriers, and financial 

strains. Their struggles to establish a happy and peaceful life in the United States should inspire 

all minority health advocates to help build healthy hearts in all Cambodian communities. 
20 

X. Appendices
21 

Appendix A: Informed Consent Forms
22 

Focus Group 

Contact person(s): Name 

 Address 

 Phone number 

Thank you for your interest and willingness to help us. You are being asked to participate in a 

discussion group. We hope to learn more about better ways to reach people in the community. 

We want to do this by better understanding your health, your health attitudes and beliefs, and 

your local community health services. We do not expect these discussion questions or the 

interview to cause you any discomfort. 

If you decide to volunteer, you will be asked to participate in a discussion group that should 

require about 1–2 hours. 

Participant’s Initials: ____ 

You will receive $30 for your invaluable input and participation. Also, this community 

assessment may have implications for prevention of heart disease and development of 

interventions to improve the health of the community. 

You will not be asked to provide your name or any other identifying information on the 

questionnaires. 

If you feel uncomfortable at any time, you should feel free to leave the discussion or interview. 

Participant’s Initials: ____ 

Permission: Your signature, below, will indicate that you have decided to volunteer as a 

discussion/interview participant and that you have read and understood the information provided 

above. 

Signature of Participant_______________________ Date _________ 

Signature of Investigator______________________ Date _________ 
23 

Key Informant Interview 

Contact person(s): Name 

 Address 

 Phone number 

Thank you for your interest and willingness to help us. You are being asked to participate in a 

discussion group. We hope to learn more about better ways to reach people in the community. 

We want to do this by better understanding your health, your health attitudes and beliefs, and 

your local community health services. We do not expect these discussion questions or the 

interview to cause you any discomfort. 

If you decide to volunteer, you will be asked to participate in a discussion group that should 

require about 1–2 hours. 

Participant’s Initials: ____ 

You will receive $20 for your invaluable input and participation. Also, this community 

assessment may have implications for prevention of heart disease and development of 

interventions to improve the health of the community. 

You will not be asked to provide your name or any other identifying information on the 

questionnaires. 

If you feel uncomfortable at any time, you should feel free to leave the discussion or interview. 

Participant’s Initials: ____ 

Permission: Your signature, below, will indicate that you have decided to volunteer as a 

discussion/interview participant and that you have read and understood the information provided 

above. 

Signature of Participant_______________________ Date _______ 

Signature of Investigator______________________ Date _______ 
24 

Indepth Interview 

Contact person(s): Name 

 Address 

 Phone number 

 

Thank you for your interest and willingness to help us. You are being asked to participate in a 

discussion group. We hope to learn more about better ways to reach people in the community. 

We want to do this by better understanding your health, your health attitudes and beliefs, and 

your local community health services. We do not expect these discussion questions or the 

interview to cause you any discomfort. 

If you decide to volunteer, you will be asked to participate in a discussion group that should 

require about 1–2 hours. 

Participant’s Initials: ____ 

You will receive $15 for your invaluable input and participation. Also, this community 

assessment may have implications for prevention of heart disease and development of 

interventions to improve the health of the community. 

You will not be asked to provide your name or any other identifying information on the 

questionnaires. 

If you feel uncomfortable at any time, you should feel free to leave the discussion or interview. 

Participant’s Initials: ____ 

Permission: Your signature, below, will indicate that you have decided to volunteer as a 

discussion/interview participant and that you have read and understood the information provided 

above. 

Signature of Participant_______________________ Date _______ 

Signature of Investigator______________________ Date _______ 
25 

Appendix B: Training Materials 
26 

Key Informant Interview Training Protocol 

1. Go over the purpose of the program and the scope of the study. 

2. Discuss the target population. 

3. Talk about the questionnaire. 

4. Talk about using a conversational interview style. 

5. Talk about tape recording the interview. 

6. Stress the importance of neat handwritten notes. 

7. Talk about the cultural and linguistic appropriateness of the interview protocol. 

8. Take a break. 

9. Practice role-playing the interview, following my example. Go over the following steps. 

a. Making an appointment. 

b. Creating a timeline. 

c. Finding a location for the interview. 

d. Arranging travel. 

e. Confirming with the interviewee the day before. 

f. Signing the informed consent form. 

g. Conducting the interview. 

h. Looking at NHLBI materials. 

10. Find a partner with whom to practice. 

11. Discuss any further modifications or issues. 

12. Schedule a followup training if needed. 
27 

Key Informant Interview Training Handout 

Purpose 

To collect information about community health needs, knowledge, attitudes, behaviors, and 

cultural beliefs and practices about having a healthy heart and preventing heart disease from four 

Asian American and Pacific Islander groups. These ethnic groups include Filipino, Vietnamese, 

Cambodian, and Native Hawaiian. The information obtained through active community 

participation will be used to guide the development of culturally and linguistically appropriate 

resources to increase the community’s awareness of heart disease and encourage heart healthy 

behaviors. 

 Personal and demographic information 

 Health education 

 Community health services 

It is very important to write your notes neatly so that we can read them later. Please write your 

notes in English, or translate them afterwards into English. 

Who Should Be Invited to Participate in a Key Informant Interview? 

Some of you will be doing key informant interviews. Each CBO should interview two key 

informants. Key informants should be people who are seen as leaders in the Cambodian 

community. They may hold a position of leadership (e.g., a director of a program, political 

leader, active teacher) or they may be leaders through their efforts outside of a formal job (i.e., a 

person who is active in the community but isn’t necessarily paid to do their community work). 

Cultural and Language Appropriateness 

When we designed the interview protocol, we knew that each interviewer would have his or her 

own style and also his or her own suggestions about how useful the questions are and whether 

they are culturally appropriate. We will go over the questionnaire (in English and in the native 

language) section by section and discuss it. If we agree upon modifications, we can hand mark 

them on the forms. I will make multiple copies of ones with modifications. You will use these 

revised questionnaires when you do your interviews. 

Pre-Interview 

It is important to call the interviewees right away to schedule interviews. Tell them that they 

have been identified as leaders in the community, and that you would like to interview them to 

learn more about heart health and the Cambodian community. Inform them that the program is 

sponsored by the National Heart, Lung, and Blood Institute and is partnered with the Asian & 

Pacific Islander American Health Forum and your CBO. They will receive $20 as a token of 

appreciation for doing the interview. Let them know that the interview should last about 1 hour 

and 15 minutes. Tell them that their names will not be used, but the information they provide 

will help develop health promotion programs for Cambodians. Let them know that you would 
28 

like to tape record the interview to ensure that we capture everything they discuss in the 

interview. 

Tell them when you are available, and see if they can interview during one of those times. 

Please schedule for 11⁄2 hours of their time, and let them know where the interview will be (e.g., 

at your CBO or at their office, if you are willing to travel). Make sure you have some time 

before and after the scheduled interview time, in case the person comes late or if the interview 

runs long. 

Confirm appointments: Call them the day before or the day of the interview to confirm they can 

still do the interview. It really helps to do this, so that they know when they are coming. If there 

is a problem, you can reschedule. 

At the Interview 

Thank them for coming to the interview. Tell them you will be interviewing them about health 

issues, but first you would like them to look at the informed consent form and to sign it. Briefly 

describe the informed consent form. They can look at it as you talk. Give them time to read it 

themselves, and to ask you questions if they have any. If they agree, then they need to initial and 

sign the form, and you will also sign. You will keep one copy, and they will keep the other copy. 

Tape recording: The questions in this interview are designed to gather a lot of information from 

each person. We want to hear their opinions, their experiences, and their ideas for their 

community. Because of this, we would like to you to tape record the interview. You will need 

to ask consent from the person. If they say no, then we will rely solely on your notes. If they 

say yes, then you can have them initial the line on the form that gives their consent to tape 

record, and you can begin tape recording. 

Note taking: It is very important for you to take neat notes while you are interviewing the key 

informants. It is especially critical if they do not agree to be tape recorded. 

Advice about the Interview Process

Open-ended questions: Open-ended questions are questions that don’t have a yes/no or 

black/white/brown answer. An example of an open-ended question would be if I asked you, 

“What kind of fruits do you like?” The person can answer however they like, such as, “I like 

papaya, mango, and bananas.” They can also answer, “I don’t like fruit at all.” 

On the other hand, closed questions are useful when you are asking a lot of people the same 

questions. You want to give them choices, so that you can analyze what a large group of people 

said about something. For example, if I ask you, “Do you like apples or bananas better?” I have 

only given you two choices that are predetermined. You can say either apples or bananas. This 

is an example of a closed question. In the indepth interview questionnaire, there are many 

multiple-choice questions (questions that have a set number of answers are also closed questions) 

such as, “How stressful is your life?” Possible responses could be: (a) not stressful, (b) a little 

stressful, (c) somewhat stressful, and (d) very stressful. If I asked this question of a group of 

soldiers stationed in Virginia, where there is no current military conflict, I could add up their 

answers and have a pretty good sense of how stressful their lives were. Then I could ask a group 
29 

of soldiers stationed in the Middle East, where there is conflict, and I would be able to compare 

their answers with those of the soldiers in Virginia. We could guess that where there is military 

conflict, there might be more stress. Multiple-choice questions are helpful when asking general 

questions for larger groups of people. 

You can still make comparisons when you ask open-ended questions, but the type of information 

you gather with open-ended questions tells you more information about a certain subject. For 

example, I could ask the soldiers, “What causes you stress in your job?” Their answers would 

give me more depth (more information about one subject). But it would be harder to ask a group 

of 300 soldiers in each place to tell me what causes their stress, and then to put together all of 

their answers in a simple fashion. We would have to take into consideration complex answers 

like, “missing home because they just had their first child; a particular supervisor doesn’t like 

them; the food is bad; they have allergies to a certain plant in the region.” These kinds of 

answers are very rich in telling us about their experiences, but it would be hard to say that most 

soldiers are stressed because of one reason. 

In summary, open-ended questions and closed questions have different purposes. During the key 

informant interview, you will ask mostly open-ended questions, because we are interested in 

detailed information about certain subjects from a few people. During the indepth interview, we 

are looking for detailed information about some subjects, but also simple categories of 

information on other subjects for comparison with larger numbers of people. So, for the openended questions you will take notes, and for the closed questions you will circle a choice. 

Use examples: Sometimes it can be helpful to use examples. The problem with giving examples 

right away is that once people hear the examples you read, they tend to pick one of those choices. 

If you don’t give them those examples, they are likely to answer in their own way. For instance, 

if I ask you, “Whom do you generally go to when you feel sick? For example, the doctor or your 

mom.” The person may respond by saying the doctor when, in fact, they may actually tend to 

look up their illness in a book. But, because you gave them an example, they picked one of 

them. Psychologically, this is called “leading” (leading someone to a certain answer by 

persuasion). 

Examples are also helpful when the question is unclear to vague. For instance, I may ask, “What 

are some cultural practices to treat illness that you were raised with?” The person may wonder 

what you mean by cultural practices. You could clarify by saying, “For example, in the Chinese 

culture, some people see an herbalist. Are there things that people do in the Cambodian culture 

to treat illness that are different from the American culture?” By giving an example, I can show 

the person what type of question I am asking, because somehow the question wasn’t clear. 

Again, use examples with caution because they can psychologically lead people to pick the 

examples you gave. 

Completing the Interview 

After asking the key informant if they have anything else they would like to add (take notes if 

they do have things to add), thank the person for their help and for their time. Give them the $20 

dollar stipend. Remind them that if they have any questions, they can call the number on the 

informed consent form, and someone will try to answer their questions. 
30 

Indepth Interview Training Protocol 

1. Go over the purpose of the program and the scope of the study. 

2. Discuss the target population. 

3. Talk about the questionnaire. 

4. Talk about using a conversational interview style. 

5. Discuss reading most questions directly. Food questions accompany the calendar, which 

is filled in after the interview is over. 

6. Stress the importance of neat, handwritten notes. 

7. Talk about the cultural and linguistic appropriateness of the questionnaires. 

8. Take a break. 

9. Practice role-playing the interview, following my example. Go over the following steps. 

a. Make an appointment. 

b. Create a timeline. 

c. Find a location for the interview. 

d. Arrange for travel to the interview site. 

e. Confirm with the interviewee the day before the interview. 

f. Sign the informed consent form. 

g. Conduct the interview. 

h. Look at NHLBI materials. 

10. Give instructions on filling out the food questions. 

11. Find a partner with whom to practice. 

12. Discuss any further modifications or issues. 

13. Schedule a followup training if needed. 
31 

Indepth Interview Training Handout 

Purpose 

To collect information about community health needs, knowledge, attitudes, behaviors, cultural 

beliefs and practices about having a healthy heart and preventing heart disease from four AAPI 

groups. These ethnic groups include Filipino, Vietnamese, Cambodian, and Native Hawaiian. 

The information obtained through active community participation will be used to guide the 

development of culturally and linguistically appropriate resources to increase the community's 

awareness of heart disease and encourage heart healthy behaviors. 

Who Should Be Invited To Participate in the Indepth Interviews? 

 Twenty adults, 18–50 years old; 5 adults over 50 years old 

 Females and males (equal numbers) 

 Immigrant and second-generation Cambodian Americans (equal numbers) 

 Persons with high school education or less 

 Low-income individuals (divided equally between people with an annual household income 

of $5,000 to $15,000 and people with an annual household income of $15,001 to $35,000) 

Interview a total of 25 people who fit the above criteria. The reason we ask for equal numbers of 

men and women and equal numbers in the education and income areas is to get a variety of 

people and experiences. It may be difficult, however, to find participants who match all the 

criteria. 

The Indepth Interview 

During the indepth interview, you will be gathering detailed information about an individual’s 

life including: 

 Physical activity 

 Eating behaviors 

 Tobacco and alcohol use 

 Health history 

 Personal and demographic information 

 Health education 

 Community health services 

Please remember that you are having a real conversation with the person. Imagine you are really 

curious about a friend, and you decide to find out as much as possible from him or her. It will be 

more fun for both you and the person being interviewed if you talk about the issues with genuine 

interest. 

You can read most of the questions out loud and circle or write down their response. The one 

section that is different is the food section. 
32 

It is very important to write your notes neatly so that we can read them later. Please write your 

notes in English or translate them afterward into English. 

Cultural and Language Appropriateness 

When we designed the questionnaire, we knew that the interviewers would have their own styles 

and also their own suggestions about how useful the questions are and whether they are 

culturally appropriate. We will go over the questionnaire (in English and in the native language) 

section by section and discuss it. If we agree upon modifications, we can mark them by hand on 

the forms. I’ll make multiple copies of those that have modifications. You will use these revised 

questionnaires when you do your interviews. 

Pre-Interview 

It is important to call people right away to schedule interviews. You can tell them that you 

would like to interview them to learn more about Cambodian health and that they will receive 

$15 at the end of the interview. You can let them know that the interview should last about 1 

hour and 15 minutes. Tell them that their names will not be used, but the information they 

provide will help develop health promotion programs for Cambodians. 

Tell them when you are available, and see if they can interview during one of those times. 

Please schedule for 11⁄2 hours of their time, and let them know where the interview will be (e.g., 

at your CBO or at their house, if you are willing to travel). Make sure you have some time 

before and after the scheduled interview time, in case the person comes late or the interview runs 

long. 

Confirm appointments: Call them the day before or the day of the interview to confirm they can 

still do the interview. It really helps to do this, so that they know when they are coming. If there 

is a problem, you can reschedule. 

At the Interview 

Thank them for coming to the interview. Tell them you will be interviewing them about health 

issues, but first you would like them to look at the informed consent form and sign it. Briefly 

describe the informed consent form. They can look at it as you talk. Give them time to read it 

themselves, and to ask you questions if they have any. If they agree, then they need to initial and 

sign the form, and you will also sign. You will keep one copy, and they will keep the other copy. 

Conducting the Indepth Interview 

It will be helpful to sit with the interviewee at a table or desk. Sit facing the interviewee, but be 

flexible to move so that he or she can see the form. He or she may, at times, want to see the 

questions directly to jog his or her memory for answers. 

Section A—Physical Activity: These are simple questions. Be aware that many people are 

physically active, but they don’t think of it as physical activity because it’s not “exercise” or 

“sports.” For example, for many people, their paid work involves physical activity (e.g., 

custodians and janitors walk a lot; construction workers exert a lot of energy building; caretakers 
33 

of young children chase children all day; housekeepers pick up and do physical cleaning). 

Similarly, people can also be active for nonpaid work (e.g., taking care of one’s own small 

children; doing lots of laundry; gardening; cooking and cleaning). Please make sure you ask 

about these kinds of activities in addition to the activities many people think of, such as 

basketball, swimming, Tai Chi, etc. 

Section B—Eating Behaviors: Instructions for Section B are on the form. We will go through 

those together. Basically, you are given two calendar sheets. On the first one, you will fill out 

information about what the interviewee ate the day of the interview (today) and the last 2 days 

(yesterday and the day before). In your Section B instructions (page 94), you will see questions 

you can read aloud, and also a list of the types of foods to ask about. These are prompts, which 

are to help you and the person remember different categories of food as they tell you what they 

ate. 

We are very interested in the ethnic foods they eat, particularly from the Cambodian culture. We 

are also interested in who generally cooks the food they eat (e.g., do they eat out most of the 

time, does the mom in the household do most of the cooking, etc.). After you take note of the 

foods they ate over the last 2 days (2-day data), then you can use the second calendar sheet to 

discuss a typical week for them. We are interested in asking them about a typical week because 

what they ate in the last 2 days may be unusual for them (e.g., perhaps they have been sick, so 

they ate less than usual, or work has been busy so they have eaten a lot of fast food). Remember 

to use your prompts to cover “who cooks,” what types of ethnic foods, and categories of food 

such as fruits, fish, grains, etc. After you finish discussing a typical week (“typical week data”), 

return to page 95 and resume asking questions B1 to B3. 

At the end of the whole interview, you will go to page 107, and fill out the answers to the food 

questions based on the “2-day data.” Please note we are not asking about alcoholic beverages on 

these charts. That is the next section. 

Section C—Tobacco and Alcohol Use: This section includes detailed questions about the 

person’s current behaviors and past history of using tobacco and drinking alcohol. Sometimes 

people are sensitive about talking about these areas. Try to reassure the interviewee that there 

are no right or wrong answers, and you are not judging them. Sometimes their pattern of using 

tobacco or drinking may not fit the categories we put on the form. If it does not, please write 

notes about quantity (how much) and also type of product (e.g., whiskey, beer, red wine, white 

wine). This information is useful because different drinks have different levels of alcohol. 

Several questions ask about how the Cambodian culture views tobacco and also about what tends 

to influence people to smoke. Please try to engage the interviewee in talking about his or her 

own views as well as whether those views come from their cultural heritage. Have ideas about 

tobacco changed in Cambodia since they came to the United States? Here is an opportunity to 

find out more about cultural norms (how certain cultures tend to do things). 

Section D—Health History: In this section, you will ask the interviewee about his or her 

personal and family history of heart problems. You will see many questions that are meant to 

find out how he or she views different health issues, like “what makes people sick?” and “how 

people can prevent or avoid getting sick?” You will ask about cultural perspectives on these 

topics. Similarly, it is important to find out what kind of health and medical services they use. 
34 

As you know, people have many ways of treating illness besides going to a Western doctor or 

hospital. You will help us find out what those ways are, so we can better understand how people 

think about and treat their health. In this interview, we really want to find out how important 

people’s traditions and cultural practices can be in making decisions about their health. 

 

Section E—Personal Information: These questions are very straightforward. If none of the 

categories fit their answer, then just write down their answer on the form beside the categories. 

Section F—Health Education: Because this program is being sponsored by the NHLBI, we 

would like you to ask questions about what kind of health education information they receive, 

and where and how often they get it. Their answers will help the NHLBI figure out where they 

should give out health education materials and whether there should be translations into different 

languages. 

Section G—Community Health Services: Here we are interested in the person’s opinion and 

ideas about useful health information programs. The NHLBI would like to get ideas from 

community members about types of programs that people would like to see and where they 

would like to see them. Treat the person like an expert on what he or she would like to see 

happen, and how health professionals can effectively reach people in the community. 

The last questions involve showing the person some sample pamphlets that NHLBI has 

published. Ask them if they would like pamphlets like these to be developed for Cambodians 

and what suggestions they would have for making useful education materials (e.g., translated 

into Khmer, types of pictures, cookbooks vs. factual information about heart health, etc.). 

Advice About the Interview Process 

Open-ended questions: Open-ended questions are questions that don’t have a yes/no answer. 

An example of an open-ended question would be if I asked you, “What kind of fruits do you 

like?” The person can answer however they like, such as, “I like papaya, mango, and bananas.” 

They can also answer, “I don’t like fruit at all.” 

On the other hand, closed questions are useful when you are asking a lot of people the same 

questions. You want to give them choices, so that you can analyze what a large group of people 

said about something. For example, if I ask you, “Do you like apples or bananas better?” I have 

only given you two choices that are predetermined. You can say either apples or bananas. This 

is an example of a closed question. In the indepth interview questionnaire, there are many 

multiple-choice questions (questions that have a set number of answers are also closed questions) 

such as, “How stressful is your life?” Possible responses could be: (a) not stressful, (b) a little 

stressful, (c) somewhat stressful, and (d) very stressful. If I asked this question of a group of 

soldiers stationed in Virginia, where there is no current military conflict, I could add up their 

answers and have a pretty good sense of how stressful their lives were. Then I could ask a group 

of soldiers stationed in the Middle East, where there is conflict, and I would be able to compare 

their answers with those of the soldiers in Virginia. We could guess that where there is military 

conflict, there might be more stress. Multiple-choice questions are helpful when asking general 

questions for larger groups of people. 
35 

You can still make comparisons when you ask open-ended questions, but the type of information 

you gather with open-ended questions tells you more information about a certain subject. For 

example, I could ask the soldiers, “What causes you stress in your job?” Their answers would 

give me more depth (more information about one subject). But, it would be harder to ask a 

group of 300 soldiers in each place to tell me what causes their stress and then put together all of 

their answers in a simple fashion. We would have to take into consideration complex answers 

like, “missing home because they just had their first child; a particular supervisor doesn’t like 

them; the food is bad; they have allergies to a certain plant in the region.” These kinds of 

answers are very rich in telling us about their experiences, but it would be hard to say that most 

soldiers are stressed because of one reason. 

In summary, open-ended questions and closed questions have different purposes. During the key 

informant interview, you will ask mostly open-ended questions, because we are interested in 

detailed information about certain subjects from a few people. During the indepth interview, we 

are looking for detailed information about some subjects, but also simple categories of 

information on other subjects, for comparison with larger numbers of people. Therefore, for the 

open-ended questions you will take notes and for the closed questions you will circle a choice. 

Use examples: Sometimes it can be helpful to use examples. The problem with giving examples 

right away is that once people hear the examples you read, they tend to pick one of those choices. 

If you don’t give them those examples, they are likely to answer their own way. For instance, if 

I ask you, “Whom do you generally go to when you feel sick? For example, the doctor or your 

mom.” The person may respond by saying the doctor when, in fact, they may actually tend to 

look up their illness in a book. But, because you gave them an example, they picked one of 

them. Psychologically, this is called “leading” (leading someone to a certain answer by 

persuasion). 

Examples are also helpful when the question is unclear or vague. For instance, I may ask, “What 

are some cultural practices to treat illness that you were raised with?” The person may wonder 

what you mean by cultural practices. You could clarify by saying, “For example, in the Chinese 

culture, some people see an herbalist. Are there things that people do in the Cambodian culture 

that people do to treat illness that are different from the American culture?” By giving an 

example, I can show the person what type of question I am asking, because somehow the 

question was not clear. Again, use examples with caution because they can psychologically lead 

people to pick the examples you gave. 

Completing the Interview 

After asking the interviewees if they have anything else they would like to add (take notes if they 

do have things to add), thank them for their help and for their time. Give them the $15 dollar 

stipend. Remind them that if they have any questions, they can call the number on the informed 

consent form, and someone will try to answer their questions. 
36 

Appendix C: Interview Guides 
37 

Focus Group Guide 

Today’s Date: 

Time: 

Focus Group Location: 

Address: 

Community Organization Sponsor(s): 

Focus Group Facilitator: 

Focus Group Recorder: 

Sign In Sheet 

Name Age Sex Ethnicity ZIP code Organization 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 
38 

I. Introduction 

 Greetings and thank you for coming. This focus group is to assist us in understanding our 

community’s ideas, attitudes, and practices about heart health, general wellness, and 

preventive health. This includes the various health and community resources available to 

you and other community residents. 

 This community assessment is being conducted in conjunction with the [insert name of local 

organizations] and the Asian & Pacific Islander American Health Forum. This project is 

funded by the National Heart, Lung, and Blood Institute in an effort to develop effective 

messages and programs to promote heart health in the Cambodian community. Your 

participation is very important because you know your own community best. There are no 

right or wrong answers to any of the questions. Feel free to express your ideas, opinions, or 

experiences. 

 As you may have noticed, there is a tape recorder in the middle of the table. We hope that 

having a tape recorder will not make you feel uncomfortable. We want to make sure we 

capture all your ideas and that we do not miss any of the valuable information the group may 

offer. The tape recorder ensures this. There will also be a recorder who will be writing your 

response on the flip chart to make sure that we capture what you are saying correctly. 

 Please be assured that your individual comments here today are confidential in the sense that 

we will not identify, by name, anyone’s statements. We would like you to sign an informed 

consent form to ensure your confidentiality and to affirm your voluntary participation in this 

discussion. 

 Let’s go through the informed consent form. [Pass out informed consent form to participants 

and go over entire form.]

 Before we begin, does anyone have any questions or comments? 

II. Attitudes About Heart Disease 

Let’s start our discussion 

A. Cultural Meaning of Prevention 

1. What does good health mean to you? Are there any folktales, sayings, or symbols 

about health in general in your culture? 

2. What does the word “prevention” mean in your culture? 

3. What does being ill or sick mean to you? Are there any folktales, sayings, or symbols 

about illness or disease in general in your culture? 
39 

B. Community Health Concerns 

1. What do you feel are the top health problems (or diseases/sicknesses) in the [insert 

name] community (e.g., diabetes, cancer, etc.)? [Use flip chart to list responses. Then 

ask the group to rank the top five health concerns they have identified.]

C. Heart Disease 

Now let’s talk more about heart disease (e.g., heart attack, high blood pressure, stroke, 

or stress) and factors that increase a person’s chances of getting heart disease. 

1. If heart disease was mentioned and ranked, ask: Why did you rank heart disease 

where you did? How concerned are people in the Cambodian community about heart 

disease compared to what you’ve just listed? [If heart disease was not ranked, then 

ask, How about heart disease? Compared to the problems you mentioned and rank, 

how important is heart disease in your community?]

2. How do people in the community think they develop heart disease? [Probe: What are 

the causes of heart disease?]

3. Do you know someone who has heart disease? 

4. What are some of the things people can do to prevent heart disease? 

5. In the Cambodian culture, how do people take care of the heart? What does the heart 

symbolize in the Cambodian culture? Are there any folktales or sayings about the 

heart health in your culture? 

I’m going to ask you some questions about three different topics: high blood pressure, 

cholesterol, and obesity. There will be the same questions for each topic. Please don’t 

feel like you have to be an expert on these things—I’m asking just to get a sense of what 

you think. 

D. High Blood Pressure, Cholesterol, and Weight 

1. What do people think high blood pressure is? [Probe for words used to describe or 

refer to high blood pressure, such as stress.] 

2. How about high cholesterol? 

3. How do people view obesity or being overweight in the Cambodian culture? [Probe 

for gender issues.]

4. How do these issues of high blood pressure, cholesterol, or obesity affect the 

community’s health? 

5. What do you think people should do if they are diagnosed with high blood pressure, 

cholesterol, or obesity? 

6. How realistic is it for people to control or manage these health problems? 

E. Smoking 

1. How does the Cambodian community view tobacco smoking? How does tobacco 

 smoking affect your health? In what way? 

2. How realistic is it for people in the community to quit smoking? 
40 

F. Nutrition 

1. What kinds of food do you like to eat? What kinds of food do you like to prepare for 

you and your family at home? 

2. Do you cook anything different for special celebrations? 

3. How often do you eat out? What types of food do you eat when you eat out? 

4. Do you think that the kinds of food you eat can affect your heart? How? 

5. What makes it hard for people to eat foods low in salt? 

6. What would help people to eat food low in salt? 

7. How realistic is it for people in the community to eat foods low in salt? 

8. What was your typical diet like in Cambodia? 

9. How did the immigration or refugee processes affect your diet? Have you lived in 

other countries besides Cambodia and the United States? What did you eat in those 

places? 

G. Stress 

1. Could you talk about the tensions people experience at work, in their family, etc.? 

2. How do these tensions affect your health?

H. Physical Activity and Exercise Patterns 

1. When you look around the Cambodian community here in [insert name of city or 

town], how physically active are the people in the community? 

2. What types of physical activities or exercise do people do for fun (e.g., at play, sports 

 leagues, etc.)? What types of physical activities or exercise do people do on their own 

 (e.g., morning walks or running)? What types of physical activities or exercise do 

 people do as a group (e.g., sports leagues, exercise classes, community garden, or 

 morning walks with friends)? 

3. What types of physical activities or exercise do people do at home (e.g., gardening, 

lawn mowing, house cleaning)? What types of physical activities or exercise do 

people do at work (e.g., walking clubs)? 

4. What types of physical activities or exercise do people in your community tend to 

 prefer? 

5. Why do you think people are not active? 

6. What would help people become more active? [Use a flip chart to list the reasons that 

make it difficult for people to be physically active and ways to solve or overcome 

those difficulties.]

7. How realistic is it for people in the community to exercise 30 minutes on most days 

of the week? 

8. Are there any differences in how active people are or what kinds of activities they do 

here in the United States vs. in Cambodia? 
41 

III. Health Care Options, Access, and Services 

1. When people in the community get sick, what do people tend to do? 

2. Whom do they go to see first? [Probe for use of self-treatment, such as taking herbs, overthe-counter medicine.]

3. What do people expect from the person they first go see? 

4. Do people in the community go for regular health checkups? If so, where do people in the 

community go for regular health checkups? [Probe: What other things people do regularly 

or routinely to maintain their health and well-being ,e.g., visit clergy, have acupuncture, 

etc.?]

5. What health care services are available in the community or neighborhoods? [Probe: Are 

there other health care services people use in the community? Probe for use of non-Western 

health care services, e.g., traditional healers, herbalists, etc.] 

6. What are some of the reasons that make it difficult for people in the community to receive 

health care services? [Use flip chart to record responses. Probe for language, 

transportation, race/culture, insurance, trust, etc.]

7. Could you talk about any language barriers that affect people receiving health care? 

8. Using the flip chart as reference, ask: What would encourage people to use existing health 

care services in the community? 

9. What kinds of heart health education programs and activities do you think could be 

developed in the community that would reduce the risk for heart disease? What should these 

programs include? [Probe: What kinds of activities or programs would encourage people to 

do things that would lower their blood pressure? What kinds of activities of program would 

encourage people to exercise more? To eat food with less fat? To eat food with less salt? 

To maintain a healthy weight?]

IV. Sources of Health Information and Languages

1. Where do people in your community get information about health? [Use the flip chart to 

make a list of sources of health information. If not mentioned, ask: Do you use the Internet 

to find information about health?] 

2. How useful or effective are these materials in educating the Cambodian community about 

heart health issues? 

3. Would people receive the information on issues not related to health from the same sources 

(e.g., community issues such as census participation, immigration, community events)? 

Now, we would like to ask you about any information you receive on heart health or prevention 

of heart disease—such as brochures, TV ads, radio ads, etc. 

4. What information format is most appealing to the Cambodian community (e.g., brochures, 

television ads, radio ads, videotapes, audiotapes, interviews, etc.)? 

5. What languages or dialects do most people in the Cambodian community [insert name of city 

or town] speak? Which ones do you think are the best languages or dialects for getting 

information to community residents? 
42 

6. Who should deliver health messages to the community? [Probe for credible spokespersons in 

the community.] 

7. What activities do people in your community participate in local ethnic group organizations? 

What about churches? What about ethnic celebrations or events? 

Followup: Which organizations? Which churches? Which ethnic celebrations or 

events? 

Followup: Why do you think people like to participate that organization? Why do you 

think people like to participate in that church (or those churches)? Why do you think 

people like to participate in that celebration/event?

8. Are there any additional ways in which [insert name of your CBO] outreaches to the 

community? 

V. Reactions to Selected Health Education Materials 

Now we would like to get your reactions to a few health education materials. Your input will 

help us develop Cambodian-specific materials. We want your impressions of these materials. 

We are not asking you to read the material at this time. 

[Show materials and ask the group and give them a few seconds to look at it.] 

Ask the group: What do you like the best and why? What do you like the least and why? 

VI. Closing 

 We are now finished with the discussion. Before we leave, does anyone have other 

responses or comments about the information discussed today? 

 Once again, I want to reassure you that everything you said here is today is strictly confidential 

and anonymous. Your names will not be connected to the information given today. 

 Thank you for coming. The information that you have provided is very important. You have 

been very helpful to us. 
43 

Key Informant Interview Guide 

Today’s Date: 

Time: 

Interview Location: 

Address: 

Community Organization Sponsor(s): 

Interviewer: 
44 

I. Introduction 

 Thank you for coming. Because you have been identified as a leader in the Cambodian 

community, we hope you will assist us in understanding your community’s ideas, attitudes, 

and practices about heart health, wellness, and health promotion and disease prevention. 

This includes the various health and community resources available to you and other 

community residents. 

 This community assessment is being conducted in conjunction with the Cambodian 

community organization and the Asian & Pacific Islander American Health Forum. This 

project is funded by the National Heart, Lung, and Blood Institute in an effort to develop 

effective messages and programs to promote wellness and heart health in the Cambodian 

community. Your participation is very important because you have an indepth knowledge 

and insight into your community. 

 Please be assured that your individual comments here today are confidential in the sense that 

we will not identify by name your statements. We would like you to sign an informed 

consent form to insure your confidentiality and to affirm your voluntary participation in this 

discussion. 

 Let’s go through the informed consent form. [Give copy of informed consent form and go 

through entire form.] 

 Before beginning, do you have any questions or comments? 

II. Respondent Demographic Information

Age: 

Sex: 

Ethnicity: 

Birth country: 

Native language: 

Citizenship, which country? 

Years in the United States? 

What is your role in the community (both formal and informal)? 

With what organizations or institutions are you affiliated? 

III. Community Context and Sources of Information 

1. To begin, can you describe the Cambodian community in [insert name of city or town]? 

[Probe: Are most of the Cambodian people in this community long-term residents? Would 

you consider it a youthful or an elderly community?] 
45 

2. What languages or dialects do most people in the community speak, and which ones do you 

think are the most effective for getting information to community residents? 

3. How active are most people in the community in local ethnic group organizations, churches, 

and ethnic celebrations or events? 

Followup: Which organizations, churches and ethnic celebrations or events do 

people like to go to? 

Followup: Why do you think people like to go to those organizations, churches, or ethnic 

celebrations or events? 

4. How do people in your community get information about health? [Check the sources that 

participants identify.] 

 Family, especially those family members in the health care professions 

 Friends, especially those friends in the health care professions 

 Cambodian radio 

 Local English radio 

 Cambodian newspaper 

 Local English newspaper 

 Cambodian television 

 Local English television 

 Community organization newsletter 

 Flyers—community outreach materials 

 Brochures and educational materials in (Western) doctor’s offices, health 

maintenance organization (HMO), or other health service provider 

 Information from “cultural or traditional” healer (e.g., acupuncturist) 

5. What information format is most appealing to the Cambodian community (e.g., brochures, 

television ads, radio ads, videotapes, or audiotapes, etc.)? 

6. What can you tell us about the network of ethnic community organizations and services in 

[insert name of city or town]? Are they well integrated? Are there overlaps in services or 

efforts by the community organizations? 

7. What do you see as the greatest assets of [insert name of city or town]? What do you see as 

some of the important needs? 

A. Cultural Meaning of Prevention 

1. What does good health mean in the Cambodian culture? Are there any folktales, 

sayings, or symbols about health in general in your culture? 

2. What does the word “prevention” mean in your culture? 

3. What does being ill or sick mean in the Cambodian culture? Are there any folktales, 

sayings, or symbols about illness or disease in general in your culture? 

B. Community Health Concerns 

1. What do you feel are the greatest threats to health and wellness in your community? 

2. What do you feel are the top five health problems (or diseases/sicknesses) in the 

community (e.g., diabetes, cancer, etc.)? For whom? 
46 

C. Heart Disease 

Now let’s talk about heart disease (e.g., heart attack, high blood pressure, stroke, or 

stress) and the factors that increase a person’s chances of getting heart disease. 

1. If mentioned and ranked ask: Why did you rank heart disease where you did? If not, 

then ask: How about heart disease? Compared with the problems you mentioned and 

ranked, how important is heart disease in your community? 

2. What is the top concern related to cardiovascular health and heart disease? 

3. What do people think are the major causes of heart disease? 

4. Do you know someone who has heart disease? 

5. What are some of the things people can do to prevent heart disease? 

6. In the Cambodian culture, what do people do to take care of their heart? What does 

the heart symbolize in the Cambodian culture? Are there any folktales or sayings 

about the heart health in your culture? 

I am going to ask you some questions about three different topics: high blood pressure, 

cholesterol, and obesity. There will be the same questions for each topic. Please don’t 

feel like you have to be an expert on these things—I am asking just to get a sense of what 

you think with regard to the community. 

D. High Blood Pressure, Cholesterol, and Obesity 

1. What do you think high blood pressure is? 

2. How about high cholesterol? 

3. How do people view obesity or being overweight in the Cambodian culture? [Probe 

for gender issues.] 

4. How do these issues of high blood pressure, cholesterol, and obesity affect the 

community’s health? 

5. What do you think people should do if they are diagnosed with high blood pressure, 

cholesterol, or obesity? 

6. What stops people from controlling their problems with these health issues? 

7. How would people control these problems with high blood pressure, cholesterol, or 

obesity? 

8. How realistic is it for people to control or manage these health problems? 

E. Smoking 

1. How does the Cambodian community view tobacco smoking? How does tobacco 

smoking affect your health? In what way? 

2. How realistic is it for people in the community to quit smoking? 

F. Nutrition 

1. What kinds of food do Cambodian people most often eat for special holidays, family 

gatherings, or celebrations? 
47 

2. Do people in the Cambodian community tend to eat differently or similarly to the way 

they ate in Cambodia? Please explain. Are the styles of eating in the United States 

more or less healthy than the old ways? In what way? 

3. What was your typical diet like in Cambodia? 

4. How did the immigration or refugee processes affect your diet? Have you lived in 

other countries besides Cambodia and the United States? What did you eat in those 

places? 

G. Physical Activity and Exercise Patterns 

1. When you look around the Cambodian community here in [insert name of city or 

town], how physically active are the people in the community? 

2. What types of physical activities or exercise do people do for fun (e.g., at play, sports 

leagues, etc.)? What types of physical activities or exercise do people do on their 

own (e.g., morning walks or running)? What types of physical activities or exercise 

do people do as a group (e.g., sports leagues, exercise classes, community gardening, 

or morning walks with friends)? 

3. What types of physical activities or exercise do people do at home (e.g., gardening, 

lawn mowing, and house cleaning)? What types of physical activities or exercise do 

people do at work (e.g., walking clubs)? 

a) Why do you think some people are not active? 

b) What would help people become more active? 

4. How realistic is it for people in the community to exercise 30 minutes on most days 

of the week? 

V. Health Care Options, Access, and Services 

1. When people in the community get sick, what do people tend to do? 

2. Whom do they go to see first? [Probe for use of self-treatment, such as taking herbs, overthe-counter medicine, taking medicine from the Cambodian culture.] 

3. Do people in the community go for regular health checkups? If so, where do people in the 

community go for regular health checkups? 

4. What other things people do regularly or routinely to maintain their health and well-being 

(e.g., visit clergy, have acupuncture, etc.)? 

5. What health care services are available in your community or neighborhood? 

6. Are there other health care services people use in the community? [Probe for use of nonWestern health care services, e.g., traditional healers, herbalists, etc.] 

7. What proportion of the community uses Western medicine and health care services? What 

are the alternative health care services you see people use? 

8. Who or what types of organizations are seen as having credibility in providing health care 

education and/or services? 

9. What are some of the factors that make it difficult for folks in the Cambodian community to 

receive health care services (e.g., language, transportation, race/culture, insurance, trust)? 

10. What would encourage people to use existing health care services in the community? 

11. If not addressed ask: Do most folks in your community have health insurance? If not, ask: 

Why do you think that is (e.g., cost, not important, not available)? 
48 

12. For heart disease in particular, what kinds of activities do you think could be developed in 

the community that would reduce the risk for heart disease? What are the elements it should 

have? [Probe: What kinds of activities or programs would encourage people to do things 

that would lower their blood pressure? What kinds of activities of program would encourage 

people to exercise more? To eat food with less fat? To eat food with less salt? To maintain 

a healthy weight?] 

VI. Reactions to Selected Health Education Materials 

Now we would like to get your reactions to a few health education materials. Your input will 

help us develop specific materials for your community. We want your impressions of these 

materials. We are not asking you to read the materials at this time. 

What do you like the best and why? What do you like the least and why? 

VII. Closing 

 We are now finished with the discussion. Before we leave, do you have other responses or 

comments about the information discussed today? 

 Once again, I want to reassure you that everything you said here today is strictly confidential 

and anonymous. Your name will not be connected to the information given today. 

 Thank you for coming. The information that you have provided is very important. You have 

been very helpful to us. 

 
49 

Indepth Interview Guide 

Seven areas are explored: 

Section A: Physical Activity 

Section B: Eating Behaviors 

Section C: Tobacco and Alcohol Use 

Section D: Health History 

Section E: Personal and Demographic Information 

Section F: Health Education 

Section G: Community Health Services 

Note: This will be administered by a trained interviewer in an interactive 

discussion. Each CBO will identify and interview 10 participants. 

Date: 

Time: 

Location: 

Interviewer: 

Respondent Demographic Information 

Age: 

Sex: 

Ethnicity: 

Birth country: 

Native language: 

Nationality: 

Years in the United States: 

Number of adults in your household (including self): 

Number of children in your household: 
50 

Section A: Physical Activity 

A1. How important is getting daily physical activity for you? 

1. Not important 

2. Somewhat important 

3. Very important 

9. N/A 

A2. During the last month, did you participate in any physical activities, such as walking, 

hiking, basketball, volleyball, swimming, gardening, etc.? 

0. No 

1. Yes (If yes, answer the next five questions) 

A2a. Please tell me the type(s) of physical activities that you did. 

A2b. Of these physical activities you just told me about, which is the one you do the most? 

A2c. Which is/are your favorite activities? 

A2d. Are any of your activities in leagues, classes (recreation or school), or some other formal 

 clubs? 

A2e. Which of these activities are with friends, relatives, etc.? 

A2f. Are you physically active at home or at work (e.g., carrying laundry, walking up stairs, 

 physical labor for work like walking, lifting, and building)? 

A3. What motivates you or would motivate you to be physically active? 

A4. What makes it hard for you to be physically active? 

A5. How are physical or recreational activities viewed within the Cambodian culture? Are 

 these activities different or similar in Cambodia and here in the United States? 

Section B: Eating Behaviors 

Interviewer Instructions: 

Please pull out calendar sheets (will be supplied). Explain that you will be going over the 

calendar with them to ask them some questions about diet and other behaviors. 

You may wish to state: “Now I’m going to ask you some questions about the foods you eat. I 

find it’s easiest to talk about it if we look at a calendar together, and just talk about the typical 

foods you generally have. Is that okay? Thanks. First I’m going to ask you what you ate the 

last few days, including today. It may seem a little strange, but it will give us a clear 

understanding of your diet for a few days. Please tell me how typical the last 2 days were in 

terms of your regular eating habits.” 

Interviewer will ask what they ate today, yesterday (morning, mid-day, evening, night), and for 

the last 2 days, including today. As the interviewer writes down the foods on the calendar, they 

check with the participant as to the accuracy of the information. Note that the interviewer will 

fill in the answers to food questions at end of the interview (page 56) with or without the 

participant, depending on the time. This information is based on the 2-day data. 

After filling in the information from above onto the 2-day calendar, ask the following questions: 
51 

B1. How important is it to have a lowfat diet? 

1. Not important 

2. Somewhat important 

3. Very important 

9. N/A 

B2. Can you name some of the traditional ingredients you put in your food? Name them in your 

 native language. If you could not buy these traditional ingredients, what types of 

 “American” ingredients would you use as a substitute? 

B3. How has living in the United States affected how you eat? Is it more or less healthy? 

 Please be specific. 

Section C: Tobacco and Alcohol Use 

C1. Do you smoke cigarettes, cigars, and pipes or chew tobacco? Please specify. 

0. No 

1. Yes (If yes, answer the next 4 questions) 

9. N/A 

C2. If you smoke, how long have you been smoking? 

C3. If you smoke, how often do you smoke? 

 0. Rarely, on special social occasions (How many cigarettes/cigars at an event?) 

 1. Occasionally, about once a month (How many cigarettes/cigars on each occasion?) 

 2. Regularly, several times a week 

 3. Daily 

 9. N/A 

C4. On average, about how many cigarettes do you smoke each day? 

 1. 1–4 cigarettes 

 2. 5–8 cigarettes 

 3. 9–12 cigarettes (about half a pack) 

 4. 12–16 cigarettes 

 5. 17–20 cigarettes (about a pack) 

 6. 20–40 cigarettes 

 7. 40+ cigarettes (2 packs) 

 9. N/A 

C5. When you are at home, where do you primarily smoke? 

1. Inside the house 

2. Outside the house 

3. Other 

9. N/A 

C6. Did you ever smoke? 

0. No 

1. Yes 

9. N/A 

C7. If yes, how long ago did you stop smoking? What method(s) did you use to quit smoking? 

 (If they have smoked off and on: Please describe pattern of quitting and starting again.) 

C8. How long did you smoke? How much did you smoke daily, when you used to smoke? 
52 

C9. Who exposes you to tobacco smoke? (Check all that apply.) 

 Family 

 Friends 

 Coworkers or students 

 Clients or customers 

 Strangers 

 Others (specify) 

C10. How do you think tobacco affects your health? 

C11. How do you feel tobacco smoking is viewed in the Cambodian community here in [insert 

 name of city or town]? 

C12. How is using tobacco viewed in Cambodia? Do those attitudes affect how you or others in 

 the Cambodian community think about tobacco or smoking? 

C13. What do you think influences Cambodian men, women, and kids to use tobacco (e.g., 

 social gatherings, magazine ads, movies, cultural norms, etc.)?

C14. Do you drink alcohol? 

0. No (If no, then skip to section D) 

1. Yes 

9. N/A 

C15. How often do you drink alcohol? 

0. Never 

1. Rarely, on special social occasions. What kind of occasions? 

2. Occasionally, about once a month 

3. Once per week 

4. Regularly, several times a week 

5. Daily 

9. N/A 

C16. When you drink alcohol, what do you tend to drink? How much? 

C17. What motivates you to drink? 

C18. What would motivate you to stop or reduce drinking? 

C19. What makes it difficult to stop or reduce drinking? 

D1. How tall are you? 

D2. How much do you weigh? 

Section D: Health History 

D3. Do any of your family members have heart disease? 

0. No 

1. Yes 

9. N/A 

D4. Has a doctor ever told you that you have or have had any of the following? (Check all that 

apply.) 

 Diabetes 

 Hypertension (high blood pressure) 

 High cholesterol (How many times?) 

 Heart attack 

 Stroke 
53 

IF YES TO D3 OR D4, THEN ANSWER THE NEXT FOUR QUESTIONS: 

D5. Do you or a family member have heart disease? How did you or your family member find 

 out about having heart disease? 

D6. How do you think you/your family member developed or got heart disease? 

D7. What do you do to on a daily basis to take care of your heart? Has this resulted in any 

 changes in your family? [Probe for cultural methods of taking care of the heart.] 

D8. Can you tell me what it is like to live with heart problems? [Probe: experiences of living 

with heart disease.]

D9. What does the heart symbolize in your culture? 

D10. Are you on a special diet (lowfat or low salt) ordered by a doctor? Do you follow it? 

 Why or why not? 

0. No 

1. Yes 

9. N/A 

D11. Can you share some cultural perspectives on some of these topics? Any differences for 

 men or women? 

 What causes illness or bad health? 

 How do you prevent illness? 

 What is the meaning of health? 

 What do people think about heart disease? 

 What do people think about obesity? 

 What do people think causes high blood pressure? 

 What do people think causes high blood cholesterol? 

D12. How do you view Western medicine? [Probe for cultural attitudes regarding use of 

 Western medicine.] 

D13. Whom do you generally go to if you get sick? Probe for the following:

 Self-treatment of family, friends, etc. 

 Traditional healers (be specific) 

 Western doctor (where do they access this—community, clinic, hospital, etc.?) 

D14. Whom do you prefer to see when you are sick? [Probe for what they think about Western 

 versus Eastern medicine. Also ask WHEN community members go to see a doctor, if they 

 did not mention it previously.] 

D15. Do you perceive your life as stressful? [Probe by asking about the person’s life in various 

 contexts.] 

 1. Not stressful 

 2. Somewhat stressful 

 3. Very stressful 

 9. N/A 

 Are there any tensions in life with children or family now? 

 How about with school or work or finances? 

 Are there any difficulties with language and communication here in the United 

States? 

 What kinds of tensions arise in families as a result of trying to balance integration 

into society and preservation of the Cambodian culture? 

 Are there tensions between young and old, newly arrived immigrants and older 

immigrant communities? 
54 

 Are you currently taking care of someone who is not well or because of familial 

obligation or responsibility (e.g., a sick mother or a grandchild)? 

D16. What causes you stress now? 

D17. What are of some of things you do to relieve stress? 

D18. How important is it for you to do stress-relieving activities? 

1. Not important 

2. Somewhat important 

3. Very important 

9. N/A 

Section E: Personal and Demographic Information

E1. How long have you lived in your current community (number of years)? 

E2. How many years of education do you and your spouse or partner have? 

 Self Spouse 

0. None  

1. 1–8 years  

2. 9–12 years  

3. Technical/professional  

4. Community college  

5. College (4 years)  

6. Postgraduate  

9. N/A  

E3. What kind of work do you do? 

1. Professional/managerial 

2. Technical 

3. Sales 

4. Administrative support (e.g., clerical, secretarial) 

5. Service 

6. Industrial 

7. Homemaker 

8. Unemployed 

9. Own a business 

10. Other (specify) 

E3a. How many hours per week do you spend working for pay? 

E3b. How many jobs do you have for pay? 

E4. What was your annual household income last year (all wage earners in the household)? 

1. < $5,000 

2. < $10,000 

3. < $20,000 

4. < $40,000 

5. < $60,000 

6. < $80,000 

7. < $100,000 

8. < $120,000 

9. > $120,000+ 

99. N/A 
55 

E5. What language do you use to communicate in your family? 

E6. Are there any problems with language and communication between the generations? How 

 is culture transmitted between the different generations? 

E7. Are you or anyone in your household involved in or is a member of an ethnic organization 

 or association? 

0. No 

1. Yes 

9. N/A 

E8. Do you have health insurance? If yes, with whom? [Probe for the quality and 

 comprehensiveness of health insurance coverage.]

0. No 

1. Yes 

9. N/A 

Section F: Health Education

F1. How important is it to have regular community health fairs in your neighborhood? 

1. Not important 

2. Somewhat important 

3. Very important 

9. N/A 

F2. Have you ever attended a community health fair? [Probe for how much people in the 

 community attend such fairs.]

 0. No 

1. Yes 

9. N/A 

F3. How important is it to have brochures, pamphlets, videos, and audiotapes in your native 

 language? 

 1. Not important 

2. Somewhat important 

3. Very important 

9. N/A 

F4. How important is it to have health education programs in your native language? 

 1. Not important 

2. Somewhat important 

3. Very important 

9. N/A 

F5. How often do you read or learn about health education information? 

 1. Rarely 

2. When something is wrong with a friend or relative 

3. When something is wrong with me 

4. For general knowledge and awareness 

9. N/A 
56 

F6. Do you receive health information from the following? 

 Most often Sometimes Rarely Never 

1 Friends or family 

2 Health care providers 

3 English radio 

4 Cambodian radio 

5 English television 

6 Cambodian television 

7 Local English newspaper 

8 Cambodian newspaper or 

magazines 

 

9 Flyers, community outreach 

materials 

10 Brochures or educational 

materials in doctor’s office etc. 

Section G: Community Health Services 

G1. What has your doctor or medical plan recommended that you have? (Check all that apply.) 

 Cholesterol check 

 Blood pressure check 

 Blood sugar test 

 Electrocardiogram, etc. 

 Other 

G2. What are some of the problems you have in getting medical help or health services? 

G3. What kinds of services are available in the community to help people lead healthier lives? 

Do you use these services? 

G4. What services would you like to see in the community to help people be healthy? 

G5. What is the best way to tell people in your community about services that help them be 

 healthy? 

G6. We’re almost through with the interview. Is there anything else you would like to add? 

G7. We’d like to ask you to look at these pamphlets and tell us if you think it would be useful to 

 have something like it in your native language. [Show pamphlets, and write comments in 

 the space below.] 

Interviewer: Please do not forget to fill in the food questions at the end of the interview. They 

are found on the following pages. After the interview is completed, you will circle the answer 

on the codes below. 

B4. About how many times was Cambodian food a large part of any of the meals you ate in the 

past 2 days? 

0. None 

1. 1–2 meals 

2. 3–4 meals 

3. 5–6 meals 

4. 7+ 

9. N/A 
57 

B5. About how many times was red meat a large part of any of the meals you ate in the past 2 

days? 

0. None 

1. 1–2 meals 

2. 3–4 meals 

3. 5–6 meals 

4. 7+ meals 

9. N/A 

B6. Generally speaking, was the red meat... 

1. Extra lean 

2. Lean 

3. “Regular” 

9. N/A 

B7. About how many times was chicken large part of any of the meals you ate in the past 2 

days? 

 0. None 

1. 1–2 meals 

2. 3–4 meals 

3. 5–6 meals 

4. 7+ meals 

9. N/A 

B8. Generally speaking, was the chicken... 

1. Skinless 

2. With skin 

9. N/A 

B9. About how many times was fish a large part of any of the meals you ate in the past 2 days? 

0. None 

1. 1–2 meals 

2. 3–4 meals 

3. 5–6 meals 

4. 7+ meals 

9. N/A 

B10. About how many times was a vegetable protein (tofu, beans, soy product) a large part of 

any of the meals you ate in the past 2 days? 

0. None 

1. 1–2 meals 

2. 3–4 meals 

3. 5–6 meals 

4. 7+ meals 

9. N/A 

B11. About how many times were dairy products a large part of any of the meals you ate in the 

past 2 days? 

0. None 

1. 1–2 meals 

2. 3–4 meals 

3. 5–6 meals 

4. 7+ meals 

9. N/A 
58 

B12. Generally speaking, are the dairy products you use... 

1. Fat free (i.e., skim milk) 

2. Lowfat (i.e., 2% fat milk) 

3. Full fat (i.e., whole milk) 

9. N/A 

B13. About how many times were eggs a large part of any of the meals you ate in the past 2 

days? 

0. None 

1. 1–2 meals 

2. 3–4 meals 

3. 5–6 meals 

 4. 7+ meals 

9. N/A 

B14. About how many servings of vegetables did you eat as a part of your meals in the past 2 

days? 

0. None 

1. 1–2 servings 

2. 3–4 servings 

3. 5–6 servings 

4. 7+ servings 

9. N/A 

B15. Generally speaking, were the vegetables... 

1. Dried 

2. Canned/jar 

3. Fresh 

4. N/A 

B16. What types of vegetables do you eat (e.g., green beans, carrots, beets, etc.)? 

B17. About how many servings of fruit did you eat in the past 2 days? 

1. 1–2 servings 

2. 3–4 servings 

3. 5–6 servings 

4. 7+ servings 

9. N/A 

B18. Generally speaking, was the fruit... 

1. Dried 

2. Canned/jar 

3. Fresh 

9. N/A 

B19. What type of fruits do you eat (e.g., bananas, apples, etc.)? 

B20. Generally speaking, who prepares the foods you eat? 

1. Self 

2. Other, same household 

3. Other, not restaurant 

4. A restaurant 

9. N/A 
59 

B21. Generally speaking, when you eat red meat, chicken, fish, and vegetables, were they 

prepared as part of the Cambodian meal? 

0. No 

1. Yes 

9. N/A 

B22. What are your favorite snack foods (e.g., candy, chips, cookies, cake, fruit)? 

B23. About how many snacks do you eat each day? 

0. None 

1. 1–2 snacks 

2. 3–4 snacks 

3. 5+ snacks 

 9. N/A 
The NHLBI Health Information Center is a service of the National Heart, Lung, and Blood 

Institute (NHLBI) of the National Institutes of Health. The NHLBI Health Information Center 

provides information to health professionals, patients, and the public about the treatment, 

diagnosis, and prevention of heart, lung, and blood diseases. For more information, contact: 

NHLBI Health Information Center 

P.O. Box 30105 

Bethesda, MD 20824-0105 

Phone: 301-592-8573 

TTY: 240-629-3255 

Fax: 301-592-8563 

Web: http://www.nhlbi.nih.gov 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

National Heart, Lung, and Blood Institute 

August 2003