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Harmony in Health Care: A Resource Guide for Culturally Appropriate Care of Vietnamese Americans


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Table of Contents 5

Culture

23

Cancer

37

Health

4 Table of Contents

History of Immigration............................................................................................6 Vietnamese American Demographics....................................................................7 Types of Barriers to Healthcare.......................................................................... 8-9 Patients’ Cultural Perspectives...................................................................... 10-11 Using an Interpreter........................................................................................ 12-13 Importance of Respect and Caring......................................................................14 Healing Practices..................................................................................................15 Other Healing Practices........................................................................................16 Acculturation........................................................................................................17 Reference Frame for the Practitioner............................................................. 18-19 Health Belief Model..............................................................................................20 Sources of Information on Health.........................................................................21 Cancer Incidence and Mortality in Women...........................................................24 Cervical Cancer Screening...................................................................................25 Barriers to Cervical Cancer Screening.................................................................26 Promoting Cervical Cancer Screening.................................................................26 Breast Cancer.......................................................................................................27 Encouraging Mammograms.................................................................................27 Cancer Incidence and Mortality in Men................................................................28 Barriers to Colorectal Cancer Screening..............................................................29 Colorectal Cancer Screening................................................................................30 Hepatitis B – Transmission & Knowledge.............................................................31 Liver Cancer Incidence and Mortality...................................................................32 Impact of Hepatitis B............................................................................................33 How Vietnamese Americans Relate with Health Care Providers..........................34 Tobacco Use and Cancer.....................................................................................35 Cardiovascular Health in Vietnamese Patients.....................................................38 Knowledge of Symptoms and Risk Factors.........................................................38 Hypertension And Cardiovascular Disease..........................................................39 Cardiovascular Risk and Exercise........................................................................40 Cardiovascular Disease: Cholesterol and Blood Cholesterol Testing..................41 Western Medical Care as a Barrier to Cardiovascular Disease Diagnosis and Care......................................................41 Diabetes Incidence / Prevalence..........................................................................42 Cultural Beliefs About Causes of Diabetes..........................................................42 Attitudes About Treatment of Diabetes................................................................43 Western Medicine vs. Eastern Herbal Remedies.................................................44 Herbal Remedies and Insulin................................................................................44 Framing Educational Information.........................................................................45 Dietary Habits and Portion Control.......................................................................46


Table of Contents Mental Health.......................................................................................................47 Mental Health and Stigma....................................................................................47 Key Cultural Factors that Influence Mental Health......................................... 48-49 Depression in Asian American Children...............................................................50 Depression in Asian American Adults...................................................................51 Prescribing Medications for Mental Health..........................................................52 Dementia in Older Asian Americans.....................................................................53 Alcohol and Substance Abuse – Barriers to Care................................................54 Gambling – Barriers to Care.................................................................................55 Reasons for Higher Risk in APIs...........................................................................55 HIV / AIDS.............................................................................................................56 Tropical and Parasitic Diseases............................................................................57 Dietary Habits and Portion Control.......................................................................46 Mental Health.......................................................................................................47 Mental Health and Stigma....................................................................................47 Key Cultural Factors that Influence Mental Health......................................... 48-49 Depression in Asian American Children...............................................................50 Depression in Asian American Adults...................................................................51 Prescribing Medications for Mental Health..........................................................52 Dementia in Older Asian Americans.....................................................................53 Alcohol and Substance Abuse – Barriers to Care................................................54 Gambling – Barriers to Care.................................................................................55 Reasons for Higher Risk in APIs...........................................................................55 HIV / AIDS.............................................................................................................56 Tropical and Parasitic Diseases............................................................................57

59-63 References

Table of Contents 5


6


Culture History of Immigration........................................................... 6 Vietnamese American Demographics................................... 7 Types of Barriers to Healthcare..........................................8-9 Patients’ Cultural Perspectives......................................10-11 Using an Interpreter........................................................12-13 Importance of Respect and Caring..................................... 14 Healing Practices................................................................ 15 Other Healing Practices...................................................... 16 Acculturation....................................................................... 17 Reference Frame for the Practitioner.............................18-19 Health Belief Model............................................................. 20 Sources of Information on Health....................................... 21

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History of Immigration Since the end of the Vietnam War in 1975, Vietnamese refugees have arrived in the United States in four waves. The first group consisted of professionals and people with ties to the U.S. who faced eminent Communist persecution. Between 1978 and 1984, less affluent Vietnamese fled religious and political persecution on small boats, creating the second wave of immigration. The “boat people” survived economic and political struggles at home, then days at sea followed by months or years in refugee camps. The third wave of immigration was from 1985 to 1990 and was made up of Amerasian children of U.S. servicemen and Vietnamese mothers. “The fourth phase of immigration began in 1990, when the U.S. government humanitarian operation allowed political prisoners recently released from Communist labor camps to immigrate to the United States, and continues to the present time.”1 This phase also included many elderly Vietnamese and others in poor health.

8 Culture


Vietnamese American Demographics “Vietnamese Americans are one of the fastest growing minority groups in the United States. It is projected that by 2030 there will be 3.9 million Vietnamese Americans living in the U.S. and that they will form the largest Asian-American subgroup in California.”2 “Vietnamese Americans have an average family income that is half that of other Asian Americans, with 30% living below the poverty level. Among Asian American subgroups, Vietnamese, Korean, and Chinese Americans are more likely to be uninsured than white Americans.” Knowledge of English is one of the most important factors influencing access to health care. According to the President’s Advisory Commission on Asian Americans and Pacific Islanders, 42% of Vietnamese American, 41% of Korean American, and 40% of Chinese American households are linguistically isolated. To be linguistically isolated means that no one in the household age 14 years or older speaks English “very well.”3 The majority of Asian Americans communicate in a language other than English at home with Vietnamese-Americans being the highest at 93%.4 Cultural barriers to healthcare include a clash between Western and Eastern medical practices, different time orientations between the cultures and a desire that the family will be involved in the patient’s health care.

Culture 9


Types of Barriers to Healthcare The three types of barriers include: 1) Medical practice barriers, 2) Socio-cultural barriers, and 3) Demographic barriers. Medical practice barriers Vietnamese Americans believe that Western medicine is too harsh on the body, or too “hot” and contributes to an imbalance in “hot/cold” or “yin/yang” forces. Vietnamese may feel like they need to hide their use of traditional health practices so that they do not lose respect or face to an American doctor’s unsupportive attitude.5 Preventative health care for Vietnamese Americans often involves diet and herbal remedies rather than screenings and tests. Screening tests may result in bad news that many Vietnamese Americans think they would be better off not knowing. Prevention instead focuses on a good diet, good spiritual balance, and herbal remedies.

Socio-cultural barriers Time orientation Vietnamese traditionally follow “P” or polychronic time, that emphasizes cycles, events and occurrences rather than monochromic or “M” time which is the highly structured time of western cultures. Misunderstandings about time frames and references between health care providers and Vietnamese American patients may cause missed or skipped appointments or untimely interventions.5 Importance of family “Vietnamese tend to be “high context” and identify more comfortably as group members rather than as separate individuals. This creates an expectation in patients that family members will provide emotional support, monitor their treatment and provide special resources such as ethnic food and/or medicine.”5

(continued) 10 Culture


Filial piety is the highest cultural value and commands children to obey and honor their parents. To be accused of neglecting parents or not fulfilling the obligation of filial piety is the most serious insult to a Vietnamese American. Health care providers should try to avoid making family members feel guilty about any aspect of a patient’s care. Fatalism An increased awareness of diseases might also act as a deterrent to seeking preventive care and screening tests. Not knowing is perceived as a protection from possible harm.�5

Demographic barriers Older Vietnamese Americans are least likely to have had health screenings or have the intention on obtaining important health screenings. Unmarried Vietnamese American men and women were also unlikely to have screening tests, particularly for sexually transmitted diseases (STDs), due to the cultural taboo of premarital sex and discussing these issues. Higher levels of education and acculturation increase the likelihood of understanding of the importance of disease screenings and obtaining screening tests.

Culture 11


Patients’ Cultural Perspectives Because of the amount of respect that Vietnamese patients accord people with high levels of education, patients may approach the physician-patient encounter feeling inferior. The desire to please and to not appear uncooperative is important and impacts communication. Patients will tend to not openly disagree or ask questions that may be viewed as confrontational. When spoken to, the Vietnamese patient’s first response may be to smile and say “yes”. This however, may not be a direct answer to a question, but instead an acknowledgement of the speaker. After this acknowledgement, the patient will then proceed to answer the question. When a Vietnamese patient appears to agree to a course of treatment, this does not guarantee compliance for a number of reasons including costs, side-effects, and lack of real understanding or forgetting. Issues with noncompliance in treatment can frequently be traced to health care providers believing that there was agreement on the course of treatment because of the patient’s “Ya, ya, Thua ba, ya, ya” response. The Vietnamese patient means “ya” as “yes, I hear you and I respect what you’re saying” (even if the request may not within the realm of possibility).6 The high cultural value of self control also extends to language in being cautious and thoughtful before speaking. There is a concern that saying the wrong thing would bring about discord and would interrupt the harmony and respect.

English-speaking patients use “yes” to indicate agreement with what the provider says, but not to show respect or disrespect. Vietnamesespeaking patients, however, use “ya” to indicate respect but not necessarily agreement.

The restraint in verbal communication also extends to non-verbal communication and touching another person during conversation is very limited. Some Vietnamese people consider the head as the “seat” and touching it, even in the process of physical examinations or giving care, may cause some important life force to escape. If the head must be touched, it is important to touch (continued) 12 Culture


the opposite side or shoulder, too. Likewise, the feet are the lowliest parts of the body and should be kept on the floor. Other non-verbal communication practices that show respect include: 1) avoiding direct eye contact when talking with someone who does not have equal standing in education, social status, age or gender; 2) showing respect by bowing the head slightly when entering the presence of an elderly person; 3) using both hands to give something to an adult, especially an elder; 4) motioning for someone to come by turning the palm downward and waving the fingers, rather than using an upturned palm, which is an insult. Respect and harmony are important values in all relationships and so there is a strong desire to not disappoint, embarrass, upset, or cause another person to lose face. Health providers should recognize that the negative response from a patient to a direct difficult or delicate question may be silence or a reluctant smile. Vietnamese Americans may use a smile to communicate many other states besides joy, such as an apology, stoicism in the face of difficulty, a response to a scolding, or a way to respond when it is improper to say “Thank you” or “I’m sorry” because of age or status. This means that health care providers need to be aware that even if a patient disagrees, feels neglected, in need, or angry, these emotions will not be expressed but will be conveyed with a quiet tone of voice and a smile.6

Culture 13


Using an Interpreter “Find a good bilingual person in the Vietnamese community who lives near enough to be called upon to help, either in person or on the phone, when needed. •

Get to know the interpreter beforehand and practice saying the Vietnamese name correctly. Usually a title should be used.

Be sure the interpreter understands the idea of confidentiality. I mpress on the interpreter that you consider him or her to be a bridge between the two groups of people involved, the family and the health team, and in a special way, an important member of both teams.

If the terminology for the anticipated causes, symptoms, suspected diagnosis, and other matters is not routine or familiar, review it briefly w ith the interpreter so these can be looked up or clarified before the interview.

The interpreter’s seat should be about half way between the provider and the patient. This helps the feeling that the interpreter is a bridge, not a member of only the health team or only the family.

Greet the family and then introduce the interpreter by name to the patient. If the patient is elderly, show respect by introducing to the patient, but then also include the accompanying family, who will likely be doing much of the communicating.

Always look and talk directly to the patient or family group, not at or to the interpreter.

To improve communication: 1) use short, direct sentences, 2) plan questions carefully to avoid double negatives and focus on one issue for yes and no answers, 3) avoid technical jargon, idioms and metaphors, 4) humor or jokes are often difficult to translate, 5) be aware that questions related to the reproductive system or sexual behavior are sensitive areas.

Be prepared to hear new names for familiar symptoms without showing surprise or scorn.

At the end of the interview, thank the family and specifically thank the interpreter.

(continued) 14 Culture


The Vietnamese interpreter is not only bilingual but also bicultural, so by working together, the health care professional can come to depend on the interpreter to not only translate the conversation, but also the culture.

If culture is being violated in some way, a good interpreter can raise the awareness of the provider immediately and come up with a solution to the situation.

After the interview, document the interpreter’s name in the medical record. Also, you can discuss with the interpreter any parts of the interview where there were problems and try to learn the cause and options for solutions in the future.

Validate any information or important decisions the professional understood has been made, including the plan of action.

Thank the interpreter and make sure that the arrangements for reimbursement, if any, are clear.”6

Culture 15


Importance of Respect and Caring Respect and caring are two of the most important qualities for Vietnamese Americans to perceive in encounters with health care providers. Clarify the role of family in making health decisions with the patients and invite the patient to include family members. “Asian Americans were more likely to feel that the doctor at the last visit did not spend as much time with them as they would like and did not treat them with a great deal of respect.

Try to take time at the beginning of the visit to encourage the patient to ask questions, and express a concern that they understand what they are being told.

Another study found Asian Americans valued physicians spending sufficient time and showing appropriate courtesy and respect significantly more than white patients valued these two aspects of care. Patients preferred doctors who did not behave in a rushed or hurried manner. Patients perceived those doctors who “take their time” to be more thorough and complete in their evaluations and diagnoses than other doctors. “Taking time” was also seen as a sign of respect for the patient, allowing them to have enough time to ask questions.”2

16 Culture


Healing Practices Healing Practice of Coining (cao gio) Coining is a procedure based on hot/cold physiology by the vigorous rubbing of a coin (sometimes heated with oil) on the skin so as to create red welts on the affected area. A layer of balm or ointment is spread on the skin usually on the chest, upper back or shoulders. A nickel or quarter is pressed on the skin and pulled in one direction a short distance without breaking the skin. If after repeating this several times, dark blood appears under the skin, then the treatment is working. This is thought to draw the sickness to the surface so that it may leave the body and the symptoms will be relieved. Coining is used for the relief of diseases caused by the wind entering the body, nausea, dizziness, headache and cold. It can be easily mistaken for child abuse, or serve as a distraction from the real problem.7

Skin Pinching (Bat gio) Skin pinching is most commonly used for a headache and is where the fingers and thumbs are pressed on both temples in an attempt to move the blood across the forehead to a spot in between the eyes. After this has been repeated several times, the area on the forehead between the eyes is pinched and twisted slightly. Skin pinching can also be used on the neck for a sore throat.7

Healing Practices of Cupping (Giac hoi) In cupping, small glasses are heated and then placed on the skin, creating a vacuum underneath the cup as it cools and raising the skin, leaving a small welt. This practice is done to relieve muscle aches, and is believed to chase pain caused by evil spirits out of the body, as well as alleviate pain caused by cold air. The suction is used to remove unwanted wind or other elements from the body.7

Culture 17


Other Traditional Healing Practices Xong—a substance like Vicks VapoRub is stirred into scalding water and t he person may just inhale the vapors or may be treated under a blanket to create a steam tent. melling aromatic oils or ointments like menthol, eucalyptus or mint can be used for motion S sickness, indigestion, or other illnesses caused by a cold wind. The oils can be rubbed on the temple, under the nose or on the abdomen or even taken internally in small amounts. alm and medicated plasters can be applied directly to the skin for bone and muscle problems B or other illnesses. Most of the balms are available in Oriental shops like Red Tiger Balm, Cu-La-Mac-Su, or Nhi Thien Duong. The ointments have a similar action of deep heat as the sports creams used by many Americans. erbal teas, soups and condiments play a large role in traditional healing beliefs for a wide H variety of symptoms and general health. The more complex herbal treatments are prepared by a pharmacist, but simpler ones are prepared at home and the recipe may have been in the family for generations and have a secret or mystical quality about them. Vietnamese Americans from the mountain region of Vietnam may use string tying to control spirits. The string may become dirty from being worn for a long period of time, but is harmless and is a source of security.6

18 Culture


Acculturation The pattern of immigration since 1975 has created a unique situation in the Vietnamese American community, which has many low income immigrants but also an educated and acculturated pool of professionals. The diversity of backgrounds along with a strong ethnic identity leads to health disparities but also, the capability to address the issues.8 “Typically, it takes three generations for immigrants to fully adopt the lifestyle of the dominant culture. This interval is about the amount of time that it takes to accept Western medical care more readily than traditional care. In general, the younger people are when they migrate, the more readily they adapt to living in a country in the West. Historically, men have acculturated more rapidly than women. This standard may be changing as more women enter the workforce.�3

Culture 19


Reference Frame for the Practitioner Consider a patient’s problem lists as representing potential difficulties encountered with a) loss, or potential threat of loss; b) life stage transitions; c) culturally patterned belief systems that potentially conflict with western medical practice. 1. “What do you call your problem? 2. What do you think caused your problem? 3. Why do you think it started when it did? 4. What do you think your sickness does to you? 5. How severe is your sickness? Do you think it will last a long time, or will it be better soon in your opinion? (continued)

20 Culture


6. What are the chief problems your sickness has caused for you? 7. What do you fear most about your sickness? 8. What kind of treatment would you like to have? 9. What are the most important results you hope to get from treatment?”9

More Framing Questions 10. “Should we expect complications? 11. What has been your extended family’s experience with illness?”10 12. “Has anyone in you family faced an illness similar to the one you have now? If so, what was its course? 13. What is your and your family’s past history of recuperation? 14. What might make healing now a struggle for you? 15. Do you see yourself as having much to live for?11

Questions for Patient’s Family Members 1. “What changes in family responsibilities do you think will be needed because of the patient’s sickness? 2. If the patient needs care or special help, what family members are going to be responsible for providing it? 3. If the illness is already chronic or appears likely to become chronic, what are the patient’s and family member’s plans for taking care of the problem over the long term?”12

Culture 21


Health Belief Model “The Health Belief model was the first to state that a patient’s belief in his or her personal susceptibility to, and the severity of a health condition, are important variables influencing the decision to take action to prevent health problems.”13 “This model has been used extensively across diverse ethnic and racial groups. It is a theoretical basis for determining perceived susceptibility and severity, barriers and benefits, and cues to action as they relate to testing such as Pap tests and HBV screening and vaccination.”14

22 Culture

Concept

Application

Perceived Susceptibility

Define population at risk, risk levels; personalize risk based on a person’s features or behavior, heighten perceived susceptibility if too low.

Perceived Severity

Specify consequences of the risk and condition.

Perceived Benefits

Define the action to take; how, where, when; clarify the positive effects to be expected.

Perceived Barriers

Identify and reduce barriers through reassurance, incentives and assistance.

Cues to Action

Provide how-to information, promote awareness, reminders.

Self-Efficacy

Provide training, guidance in performing action.


Sources of Information on Health “Asian Americans turn to ethnic media for health related information including references for a medical doctor fluent in their native language. This is more apparent in the Vietnamese American community where there is a wide variety of infomercials involving medical doctors, alternative practitioners and medical group practice. The Vietnamese American population is the most linguistically isolated and tend to prefer seeing doctors who share their cultural background.�15

Culture 23


24 Culture


Cancer Cancer Incidence and Mortality in Women......................... 24 Cervical Cancer Screening.................................................. 25 Barriers to Cervical Cancer Screening................................ 26 Promoting Cervical Cancer Screening................................ 26 Breast Cancer...................................................................... 27 Encouraging Mammograms................................................ 27 Cancer Incidence and Mortality in Men.............................. 28 Barriers to Colorectal Cancer Screening............................. 29 Colorectal Cancer Screening.............................................. 30 Hepatitis B – Transmission & Knowledge............................ 31 Liver Cancer Incidence and Mortality.................................. 32 Impact of Hepatitis B........................................................... 33 How Vietnamese Americans Relate with Health Care Providers................................................ 34 Tobacco Use and Cancer.................................................... 35

k lower ris t a e r a ns America n ia s A rectum, d n a n lo o Although c the lung, f o s r e c e higher v a h y for can e h ,t s prostate d n a t s infectiou o t brea d e t ela e ancers r c f o s e ors of th m rat u t ly r ula x.� s, partic n io it sopharyn d a n n o c d n a er mach, liv o t s , ix v cer

Culture 25


Cancer Incidence and Mortality in Women “Although Asian Americans are at lower risk for cancers of the lung, colon and rectum, breast and prostate, they have higher rates of cancers related to infectious conditions, particularly tumors of the cervix, stomach, liver and nasopharynx.”16 Cancer Incidence per 100,000 – Women – 2000 - 2002 California Cancer Registry (16) Cancer Site

Vietnamese

Chinese

Korean

Japanese

Non-Hispanic White

All Sites

274.8

265.8

251.2

295.5

446.1

Breast

55.5

75.1

50.7

102.8

152.9

Lung

37.8

29.8

26.1

22.8

57.6

Colorectal

33.0

41.5

33.1

50.2

42.8

Cervix

14.0

5.4

11.4

5.6

7.3

Cancer Mortality per 100,000 – Women – 2000 - 2002 California Cancer Registry (16)

26 Cancer

Cancer Site

Vietnamese

Chinese

Korean

Japanese

Non-Hispanic White

All Sites

105.1

109.0

105.6

122.0

167.7

Breast

9.0

13.2

7.7

17.1

27.4

Lung

23.3

23.9

22.7

19.5

44.9

Colorectal

7.1

13.8

12.8

15.1

15.7

Cervix

4.8

1.5

3.0

2.0


Cervical Cancer Screening Studies have revealed that a high number of Vietnamese American women have heard of cervical cancer (90%), but approximately one-fourth have never heard of the Pap test.8 Healthy People 2010 objectives specify that 97% of women aged 18 and older should have received at least one Pap test. According to the Northern California Cancer Center, from 1990 to 2002, only 50% of Vietnamese American women reported ever having had a pap smear, compared with 94.7% for women in the general US population. In California, cervical cancer is detected later in Vietnamese American women than in the general population.17 Vietnamese American women have the highest rates of cervical cancer of any racial or ethnic group in the United States (43 cases / 100,000 vs. 8.7 cases / 100,000 among white women); and, Vietnamese American women ages 55 to 65 have a rate 10 times higher than white women of the same ages. (181.6 cases / 100,000 vs. 17.8 cases / 100,000)18

Cancer 27


Barriers to Cervical Cancer Screening “Women with a female physician were more likely to have received a Pap test than women with a male physician and married women were more likely to have had a cervical cancer screening test in the last two years. The stigma associated with extra-marital sexual activity in the Vietnamese culture may also deter unmarried women from getting Pap smears.”17 The following factors were identified by Vietnamese American women as increasing the risk of cervical cancer: • • • •

women’s poor hygiene habits, abnormal or irregular menstrual periods, having the uterus surgically scraped (e.g., during an induced abortion or following a spontaneous abortion), and not observing the “sitting month” properly following child birth (the sitting month includes multiple traditional postpartum practices such as the avoidance of wind, sexual activity, and certain foods).19

Compared with U.S.-born API women, foreign born API women were significantly less likely to be screened for cervical cancer. However, rates of mammography screening between U.S.-born and foreign born API women were comparable.20

Promoting Cervical Cancer Screening Encouraging a relationship with a primary care provider and teaching the benefits of annual well visits are several factors that may increase screening rates. Women who perceived that they were treated respectfully were more likely to receive Pap tests. This is particularly important since the Vietnamese culture emphasizes “face” or respect for one’s position and dignity.”21 Vietnamese women who have a male physician are more likely to obtain a pap test if a female standby is available. The traditional values of modesty, respect for authority, and the desire to avoid conflict, create a situation where a female patient may want the test, but are hesitant to ask for a female standby to avoid appearing confrontational.21 28 Cancer


Breast Cancer Whereas the receipt of Pap tests in Vietnamese American women is low, the receipt of breast examinations is high and is comparable to other populations. Vietnamese American women report a high rate of breast self-examination, probably because it is self-administered.5 “ In general, Asian women with breast carcinoma are also more likely to receive a diagnosis at a later stage and have larger tumors at diagnosis than US non-Hispanic white women. Data from the California Cancer Registry has shown that more Vietnamese women (31%) with breast carcinoma received a diagnosis with regional spread compared with women in the general California population (27.4%). In addition 5.6% of Vietnamese women received a diagnosis with distant metastasis compared with 4.3% of women in the California general population.”21 he high percentage of Vietnamese American women who work in nail salons creates several T health issues. The workers constantly handle cosmetic products that contain carcinogens and endocrine disruptors that may increase a woman’s risk of breast cancer. An estimated 59—80% of California nail salons are run by Vietnamese American women who face socio-cultural barriers that may decrease their workplace safety and health care access.22

Encouraging Mammograms Although Asian American women report high levels of breast self-exams, as a group they underutilize mammography procedures. Low income and less acculturated Vietnamese women are associated with reduced frequency of mammograms or with never having a mammogram. “One of the main barriers for low income Vietnamese women to receive any type of preventative care, including mammograms, is transportation and lack of access to health care. It is important to involve the husband in the education process. The wife usually lets the husband make all decisions for her, even medical decisions for herself. Therefore, it is important that the husband understands the importance of a mammogram so he will support her need to obtain one.”23

Cancer 29


Cancer Incidence and Mortality in Men Cancer Incidence per 100,000 – Men – 2000 - 2002 California Cancer Registry (16) Cancer Site

Vietnamese

Chinese

Korean

Japanese

Non-Hispanic White

All Sites

376.1

334.4

359.2

364.3

560.8

Prostate

65.4

80.4

51.0

103.7

159.9

Colorectal

39.1

52.2

57.8

64.4

59.1

Lung

72.8

52.3

56.3

41.1

77.9

Liver

54.3

23.3

33.7

9.3

6.8

Cancer Mortality per 100,000 – Men – 2000 - 2002 California Cancer Registry (16)

30 Cancer

Cancer Site

Vietnamese

Chinese

Korean

Japanese

Non-Hispanic White

All Sites

174.4

159.8

204.1

165.1

225.4

Prostate

9.1

8.9

7.1

15.1

27.0

Colorectal

11.1

18.2

19.1

27.1

21.3

Lung

47.2

46.6

52.3

36.0

64.0

Liver

35.5

19.9

26.6

8.3

6.0


Barriers to Colorectal Cancer Screening A study by Walsh, et.al. found that Vietnamese Americans were less likely than whites to have had a sigmoidoscopy in the past 5 years, but were more likely than whites to plan to have the test in the next 5 years. It was also found that only 22% of Vietnamese Americans thought that endoscopic tests such as sigmoidoscopy and colonoscopy would be uncomfortable compared with 79% of whites.24 The importance of patient education cannot be underestimated since the same study found that 90% of whites had heard of colorectal polyp, but only 50% of Latinos and 29% of Vietnamese had heard of one. The majority of whites (84%) had heard of colonoscopy, whereas only 57% of Latinos and 70% of Vietnamese reported that they had heard of colonoscopy. However, recognition of FOBT (fecal occult blood test) was more common in the Vietnamese 79% than in whites 73% or Latinos 58%.24 Vietnamese and Latinos were less knowledgeable about colorectal cancer and colorectal cancer screening tests than were whites, although Vietnamese knew more about FOBT than members of other groups.24

Cancer 31


Colorectal Cancer Screening Physician recommendation is by far the most important factor influencing previous colorectal cancer screening and intention to be screened. Other important predictors of being up to date with screening include increasing age, having insurance, going to the d octor more frequently, family recommending it, and thinking that testing was necessary even if the patient felt healthy. Also Vietnamese Americans who knew someone with colorectal cancer or who worried about developing colorectal cancer were more likely to be screened. The primary reason for avoiding colorectal cancer screening is similar to other health screening tests, in that Vietnamese were more concerned that a screening test would find cancer, and that it is better to not know.24

32 Cancer


Hepatitis B – Transmission & Knowledge Over the years, it was believed that most Hepatitis B transmissions in the API population were from mother to newborn or “vertical” transmission. More recent cross-sectional seroprevalence study data from Southeast Asian refugees in the U.S. have shown that a more important factor in the spread of HBV infection is actually “horizontal” transmission, or transmission from other chronically infected members in the household or social networks.25 “One study of U.S. born Southeast Asian children showed that 60% of the children with chronic HBV infection were born to HbsAg-negative mothers, indicating a higher rate of horizontal than vertical transmission.”25 Awareness of Hepatitis B is greater among some recent Vietnamese immigrants that were exposed to Hepatitis B educational programs in Vietnam prior to immigration. Also, changes in immigration law after 1996 require proof of Hepatitis B vaccination as a condition of entry into the US for children less than 18 years of age.9

Cancer 33


Liver Cancer Incidence and Mortality(26) Liver Cancer Incidence per 100,000 – 2001 - 2005 – California Liver Cancer

All Groups

Vietnamese

Chinese

Korean

Japanese

Male

10.63

53.5

23.6

30.4

7.6

Female

3.66

15.6

6.1

12.7

7.0

Liver Cancer Mortality per 100,000 – 2001 - 2005 – California

34 Cancer

Liver Cancer

All Groups

Vietnamese

Chinese

Korean

Japanese

Male

7.39

32.2

20.7

22.1

6.4

Female

2.84

11.4

5.6

10.9

6.5


Impact of Hepatitis B The prevalence of hepatitis B surface antigen (HBsAg) positivity among Vietnamese refugees who arrived in the U.S. between 1984 and mid-1987 was 14.4% which is 47 to 140 times the rate in the general US population (0.1% to 0.3%). This translates to approximately one in seven Vietnamese Americans is a chronic carrier of HBV and can transmit the virus to others. The CDC estimates that 15 to 25% of those chronically infected with HBV die prematurely from hepatitis B-related liver disease, including cirrhosis and liver cancer. These statistics mean that it can be expected that from 2 to 4 of every 100 Vietnamese Americans will die from hepatitis B-related liver disease.25 “Hepatitis B virus (HBV) may be the primary factor in development of hepatocellular carcinoma (liver cancer) in as many as 80% of affected patients.”25 Vietnamese American males experience liver cancer rates that are more than 11 times the rate for white males. “In some Vietnamese populations, 83% have had acute or chronic manifestation of HBV compared to 3.8% of the general population.”27 Chronic hepatitis B viral infection rates for Vietnamese Americans are nearly 15% compared to less than 1% for the general United States population.28

Barriers to Testing The barriers to Hepatitis B testing for Vietnamese Americans are similar to the barriers for other screening tests and include: 1) feeling healthy, 2) not knowing where to go to be tested, 3) language problems, and 4) fear of a positive result.27 Language problems can be magnified when Vietnamese patients confuse Hepatitis B testing with serologic testing for other reasons particularly since testing explanations may be difficult to understand.28

Cancer 35


How Vietnamese Americans Relate with Health Care Providers Three themes related to how Vietnamese Americans relate with health care providers in cancer communication29 1) Attitudes about addressing screening with providers

• There is nothing wrong, so why bother

• Go to a fortune-teller and the ghosts will come out, sweep the floor and you will get dirt

2) Issues/problems communicating with physician about cancer

• I don’t know what he did

• I have to rely on the doctor to guide me

• He has no time

• He doesn’t say much

• I didn’t believe him

Attitudes about discussing screening with providers

3) Language/ Translation difficulties

• I have no one to translate for me

• I found a Vietnamese doctor

• When I go into the hospital, they speak and I don’t really understand

An Important Message to Communicate to Vietnamese American Patients about Cancer Screening

“Cancer screening is valuable, because it finds cancer before it is advanced enough to cause symptoms”

36 Cancer


Tobacco Use and Cancer Southeast Asian males have smoking rates of 39-41%. Only about 50% of patients, however, said that a physician had ever advised them to quit smoking and dentists had even lower rates of recommending that patients quit. While only a small fraction of API women smoke cigarettes (3%), nearly half (47%) live with a cigarette smoker. In a 2003 study, Ma and Fleisher found that overall knowledge among APIs about the risks of smoking in bladder, pancreatic, cervical and kidney cancers was very low. Their results suggest that the message that smoking increases the risk of these cancers has not reached or been accepted by a large proportion of the population.30 A 2005 study by Tang, et.al. found that Asian males with a high level of English proficiency had significantly lower smoking prevalence. However, the pattern was completely opposite for Asian women. Asian women with high English proficiency were more likely to smoke than Asian women with lower English proficiency.31 “2001 California Health Interview Survey (CHIS) data indicated that Korean and Vietnamese had overall higher smoking prevalence rates compared with the overall Asian-American rate and Californian rate. Chinese and South Asians in general had smoking prevalence rates lower than the overall Asian American rate and the overall Californian rate. Both cultural influences and socioeconomic status may contribute to the differences.�31

Cancer 37


38 Cancer


Health Title

Cardiovascular Health in Vietnamese Patients.................... 38 Knowledge of Symptoms and Risk Factors........................ 38 Hypertension And Cardiovascular Disease......................... 39 Cardiovascular Risk and Exercise....................................... 40 Cardiovascular Disease: Cholesterol and Blood Cholesterol Testing....................... 41 Western Medical Care as a Barrier to Cardiovascular Disease Diagnosis and Care.................... 41 Diabetes Incidence / Prevalence......................................... 42 Cultural Beliefs About Causes of Diabetes......................... 42 Attitudes About Treatment of Diabetes............................... 43 Western Medicine vs. Eastern Herbal Remedies................ 44 Herbal Remedies and Insulin.............................................. 44 Framing Educational Information........................................ 45 Dietary Habits and Portion Control..................................... 46 Mental Health...................................................................... 47 Mental Health and Stigma................................................... 47 Key Cultural Factors that Influence Mental Health.........48-49 Depression in Asian American Children.............................. 50 Depression in Asian American Adults................................. 51 Prescribing Medications for Mental Health......................... 52 Dementia in Older Asian Americans.................................... 53 Alcohol and Substance Abuse – Barriers to Care............... 54 Gambling – Barriers to Care................................................ 55 Reasons for Higher Risk in APIs......................................... 55 HIV / AIDS........................................................................... 56 Tropical and Parasitic Diseases........................................... 57

se American e m a n t ie V e h f in t A strong belie ood soul, good g a g in v a h t tha community is person to be a s le b a n e ls d mora values and goo g. hysically stron p d n a lly a t n me

Culture 39


Cardiovascular Health in Vietnamese Patients A strong belief in the Vietnamese American community is that having a good soul, good values and good morals enables a person to be mentally and physically strong. The heart is viewed as not just a pump but embodies the two concepts of Tam(soul) and Tim(heart). Tam represents how the mind functions in interpersonal communication and relationships and Tim pumps the blood, provides nutrition and oxygen, and supports the body. It is important to find balance in one’s life and make connections between Tam and Tim because they function together. The heart symbolizes love, respect, dedication to the family, soul, inner calm, and happiness.3

Knowledge of Symptoms and Risk Factors Because of lack of understanding about the risk factors associated with heart disease, many Vietnamese believe that death from heart disease is caused by a “bad wind,” a supernatural entity that brings people bad fortune.32 Studies have shown relatively low prevalence of hypertension and cardiovascular diseases in Vietnamese people, however, these diseases may be rising with increasing acculturation. Targeted health education programs and health provider education to individual patients represents a great opportunity to improve overall understanding and prevention.33 A 2008 study by Nguyen et.al. found that approximately 85% of Vietnamese Americans sampled knew that they should call “911” if they had a heart attack or stroke. However, only 59% knew that chest pain was a symptom of a heart attack and only 67% knew that sudden numbness or weakness of the face, arms or legs was a symptom of stroke.34

40 Health


Hypertension and Cardiovascular Disease There is a cultural belief in two opposite, but complementary, types of medicine, with modern medicine being “stronger, faster, and curative” and folk medicine being “weaker, slower, and preventative”. The drugs used on modern medicine are also considered too “hot” compared to folk or herbal medicines. Many Vietnamese Americans seek therapies from both types of medicine, However, no specific folk treatments are identified for hypertension or cardiovascular disease.33 Compared to most Americans, APIs are less likely to be aware of hypertension or to be undergoing treatment. In a study of Cambodian, Laotian and Vietnamese immigrants, 94 percent had no knowledge of what blood pressure is and 85 percent did not know how to prevent heart disease.35 Most Vietnamese patients correctly identify the relationship between obesity and hypertension, but do not know that having high blood pressure can lead to stroke, heart attack, and kidney and/or eye problems. It is important to educate Vietnamese American patients of the link between high blood pressure and heart disease since more sodium-based sauces are used in their food, exercise is not an important activity and some may drink in excess.32

Age-Adjusted Prevalence of Hypertension per 100,000(36)

Hypertension

AAPI Women

All Women

AAPI Men

All Men

8.4

11.0

9.7

10.3

Health 41


Cardiovascular Risk and Exercise A study of the Vietnamese community in Houston, Texas found that Vietnamese Americans who spoke Vietnamese were more likely than those who spoke English to eat less fruits and vegetables, to not exercise, and, among men, be current smokers. Among Vietnamese Americans, exercise is considered an image-related issue and not a health issue, so people do not exercise when they are healthy because there are no apparent problems. Exercise is viewed as a way to restore good health, rather than to prevent disease. When someone is diagnosed with heart disease, Vietnamese Americans embrace a number of ways to manage the problem:

42 Health

Exercise

Eat well

Eat regularly

Stay happy

Manage stress

Tai Chi

Boxing

Stay away from worries and stress

Live one day at a time

Stay calm

Manage anger32


Cardiovascular Disease – Cholesterol and Blood Cholesterol Testing Many Vietnamese American patients are unaware what causes an increases in a person’s chances of developing high blood cholesterol and think that a high-fat diet is a major cause. Vietnamese men are less likely to have their cholesterol checked and are not told or do not know their cholesterol levels, compared with Vietnamese women.32 44% of APIs had their blood cholesterol level checked within the past 2 years, compared to 54% of the total population. Studies show that there is no significant difference between the cholesterol levels of U.S. born Asians and foreign-born Asians. Lack of insurance, time constraints because of job or family, transportation issues, language barriers, too much paperwork and too many lab tests are all cited as barriers to getting screening tests and follow-up services for cardiovascular disease.36

Western Medical Care as a Barrier to Cardiovascular Disease Diagnosis and Care Although Western medicine has been consistently gaining the trust of more Vietnamese Americans, a majority of the population is still unaware of the need for regular checkups, and screening tests in particular. Part of the reason is because there is a lingering skepticism about the numerous tests conducted in Western medicine and the perception that people who get regular checkups have many problems and so it is not necessary to visit the doctor until a person is ill.32

Health 43


Diabetes Incidence / Prevalence Studies show that Asian Americans and Pacific Islanders (APIs) are affected by diabetes and its debilitating long-term complications at higher rates than nonHispanic whites. Approximately 10% of APIs are diagnosed with diabetes, about 1.7 times higher than the general U.S. population (5.9%). Rates of diabetes are significantly higher in API immigrant populations in the U.S. compared with rates in their native countries. In some AAPI sub-groups the prevalence of Type 2 diabetes is two to three times higher than for non-Hispanic whites.37

Cultural Beliefs about Causes of Diabetes

44 Health

When less acculturated Vietnamese Americans are asked what caused their diabetes, many patients mentioned worry and “sadness” brought on by stress. Patients are aware that diabetes is more common in the U.S. than in Vietnam and think this is because people are more worried and/or perspiring less in the United States. Perspiration was seen as positive because it removed body toxins that could damage important organs.36

“When my family had to leave Vietnam in a boat in 1978 and we all suffered so much, that’s when I got diabetes”

“I think I got diabetes because I was so weak after I spent all those years in a labor camp in North Vietnam, and also I was so sad about my brother dying in the war.”

“I’ve noticed that a lot of Vietnamese people get diabetes in the US, but almost no one got it in Vietnam. It could be because people are so worried all the time – about their children not listening to them, about money. Also, people sweat less here, and the heat can’t get out of their bodies, and that can bring on diabetes, too”36

Another barrier to diabetes self management can include a fatalistic attitude that is characterized by “diabetes cannot be cured” or “I am going to die anyhow.39


Attitudes About Treatment of Diabetes In traditional Chinese medicine, diabetes is thought to come from excess heat in the body. The medications of Western medicine are considered “hot” and full of undesirable chemicals. Eastern herbal is thought to be much safer than a doctor’s medicine because it cools the body and brings it back into balance. Prescription medicine has a lot of strong “hot” chemicals which create bad side effects if it is perceived that the dose is too high.38 A study done at the Nhan Hoa clinic in 2001 by Mull, et.al. found that some Vietnamese American patients had used eastern medicines for diabetes for as long as 6 months. During that time they had stopped their western doctor’s medicines for fear of undesirable “conflicts” or side effects. All of the patients abandoned eastern medicine after their serum glucose levels soared. They said that they had tried it because it had lacked the harmful side effects of western medicine, such as liver and kidney damage.38

Health 45


Western Medicine vs. Eastern Herbal Remedies Vietnamese American patients may lower their maintenance dose of oral medication whenever they feel out of balance. For example, patients may take half of their dose without telling their physician because of the side effect of feeling dizzy. Although providers may speak Vietnamese, the perception is that they won’t understand or don’t want to know, so the patient does not say anything. Although Eastern medicine is available in a capsule form, it is traditionally sold as a mixture of dried herbs wrapped in red or pink paper for good luck. The herbalist does not need to be available, an assistant can package the herbs. Herbal medications bought this way are expensive, a week’s supply can cost $35 - $70. To prepare the herbs, patients boil the herbs in several cups water until it is evaporated down to one cup, then strain out the leaves and drink the tea.38

Herbal Remedies and Insulin The same study of patients in Orange County, found that patients had used plant remedies, but only 2 had stopped their diabetes medications while using the remedies. Many had used bitter gourd which resembles a knobby cucumber and is used in both fresh and dried form. Five had made tea from guava leaves and 3 had drunk sap, imported from Vietnam, from the trunk of the seeded banana tree. All of these remedies were thought to lower serum glucose levels.38 There was a strong resistance to insulin injections. The reasons for disliking insulin included: 1) taking insulin indicated that a person was seriously and chronically ill, 2) the needle was painful, 3) as a very “hot” substance, insulin causes imbalance in the body and creates severe consequences such as blindness, and 4) a person might become dependent and require more and more insulin.38 Providers may inadvertently feed into patients’ negative attitudes about prescription medication by using insulin as a threat – warning people that if they do not take oral medications as prescribed, they will have to start taking insulin.

46 Health


Framing Educational Information A good approach for education of Vietnamese American patients is to seek compliance since the social implications of poor diabetes control carries more weight than personal empowerment. For example, the choice of checking feet daily versus having an amputation makes an impact on avoiding negative societal viewpoints. Discussing what the Vietnamese community would think of someone with a foot amputation and how preventive care of feet checks avoids the negative viewpoint can encourage patients.38

Health 47


Dietary Habits and Portion Control Food choices of Asian Americans and Pacific Islanders have changed due to their immigration to the United States and modern times. Instead of their traditional plant– and fish-based diets, many are choosing foods with more animal protein, animal fats and processed carbohydrates.39 Rice is the most commonly eaten starch in the Vietnamese diet and rather than discourage rice consumption, focus on portion control. To effectively illustrate a portion of rice, use a cupped hand rather than a fist. Since small amounts of meats or proteins is consumed in the Vietnamese diet and very little oil is used, compared to Chinese cooking, encourage a larger meat serving to balance rice consumption. With increasing acculturation, there is less emphasis on vegetables but dietary education is a good way to emphasize the importance of maintaining their culture. Emphasizing dairy foods for “strong bones� includes culturally appropriate foods such as tofu, soy milk, dried fish, bok choy and broccoli to ensure adequate calcium intake.40

48 Health


Mental Health “When a troubled Vietnamese American person and his or her family are not able to resolve the problem they often turn to resources available in the community such as elders, spiritual healers, ministers, monks, herbalists or fortune tellers.”15 “ Families tend to discourage the use of mental health facilities among family members until the disturbed members become unmanageable. Because the family represents the center of Asian social institutions, the burden of the stigma rests with the family rather than an individual.15 any come to mental health professionals as the last resort, while others are forced to receive M counseling by the courts, hospitals, schools and other social service agencies.15

Mental Health and Stigma “Asian Americans attach stigma to mental illness. They commonly seek alternative explanations for their symptoms rather than accept psychiatric diagnoses and treatment, because having a psychiatric disorder may involve feelings of shame or inadequacy. Patients and their families may resist discussing emotional issues because they fear “airing their dirty laundry in public or opening up to strangers. Asian patients often present with somatic symptoms and have often undergone multiple medical evaluations before a psychiatric or behavioral diagnosis is considered. Many Asian patients have non-classic presentations of common psychiatric syndromes. Asian patients with depression may not report a depressed mood or feeling sad, which are cardinal symptoms of depression. Unless the physician asks about the other cardinal symptom – lack of pleasure in usual activities (anhedonia) – the diagnosis may be missed.”41 Similarly, Asian patients with panic or anxiety disorder may not present with classic symptoms of palpitations or other cardiovascular symptoms. Instead, they report hot and cold intolerance or excessive emotionality, as well as such problems as dyspepsia or diarrhea.

Health 49


Key Cultural Factors that Influence Mental Health Occupational Issues “Language is one of the greatest barriers that Asians face when trying to access the system. There are, on a per-capita basis, profoundly less mental health professionals who care for these communities than found among the general population. It is also uncertain the number of Asian American health care providers who immigrants themselves and/or operate near the ethnic communities.”15 There are approximately only 70 AAPI mental health providers available for every 100,000 APIs in the United States, as compared to 173 per 100,000 whites. Moreover, among those AAPI mental health providers a fair number are not fluent in their native language in order to provide in-depth psychotherapy.42 “Among immigrants, many experience underemployment or unemployment. “Downward mobility” leads to low self-esteem, insecurity, and role reversal in the families.43 For acculturated and professional Asian Americans, a glass ceiling (a term that refers to a barrier to promotions and success because of one’s ethnicity and or gender and subtle discrimination often leads to frustration and dissatisfaction.15 “According to the Asian Women’s Health Organization, a leading front-line advocacy group, many Asian immigrants fall into a high risk category for mental illness. The risk indicators include:

50 Health

Severe trauma history due to war and political violence;

Racism

Cross-cultural adoption

Domestic violence

High level of cultural and linguistic isolation

Low socioeconomic status

Disintegration of the traditional family structure

Generational and cultural gap between parents and children.”44


Lack of Access to Care “Many studies have repeatedly demonstrated that Asian Americans who use mental health services are more severely ill than white Americans who use the same services. Nearly 1 out of 2 Asian Americans will have difficulty accessing mental health treatment because they do not speak English or cannot find services that meet their language needs.”15

Somatization “Somatization is the primary means of experiencing and expressing emotion for Asian American patients. The Diagnostic and Statistical Manual of Mental Disorders, DSM IV-TR illustrates an outline for cultural formulation and glossary of cultural-bound syndromes which denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular diagnostic category.”15

Health 51


Depression in Asian American Children Primary care providers may be the only opportunity to have debilitating depressive symptoms diagnosed when Asian American parents bring their children for routine or school-related checkups. Health care providers play a critical role in helping family members find culturally acceptable ways of discussing uncomfortable thoughts and feelings.45 Direct but careful inquiry is especially important for Asian immigrant children who may be the only English-speaking member of the family. The role of children and adolescents as “cultural brokers� for immigrant or less acculturated families is a major factor leading to psychological stress. Assessment of depression, anxiety disorders and other emotional and behavioral problems should include inquiries about the family’s previous efforts to manage these problems in the child or adolescent, including possible use of herbal remedies or other nonprescription medications. Children and adolescents who are reported to have made suicidal statements, have engaged in potentially self-injurious behaviors, or exhibit other warning signs of depression should be asked specifically about suicidal ideation and intent.45

52 Health


Depression in Asian American Adults Health care providers can communicate to their patients that having depression is a medical illness and is not a sign of weakness. It may be helpful to explain depression as a medical illness with signs and symptoms caused by a neurochemical imbalance in the brain. Since Asian patients tend to present with somatic complaints, symptoms that remain unresolved can be red flags for further probing. A provider can ask “For the past two weeks, have you been feeling sad or lack of interest or pleasure in usual activities?”46 Committing suicide in Asian cultures is considered an immoral and disrespectful act to one’s parents and ancestors. Many depressed Vietnamese American patients will express passive suicidal thoughts when questioned in a sensitive manner.46 ccording to the CDC, National Center for Health Statistics, Health, US 2001, Young Asian A Americans have the highest suicide rate out of all racial and ethnic groups in the country. Of reported data, Asian American women between the ages of 15—24 and over the age of 65 have the highest female suicide mortality rate among women across all racial and ethnic groups.47

Framing Question for Depression in Adults “Other patients with these symptoms sometimes lose hope, do you have thoughts of giving up?”

This question avoids confrontational statements and the shame that patients feel about having suicidal thoughts.48

Health 53


Prescribing Medications for Mental Health Health care providers can increase patient compliance by explaining that the patient’s symptoms indicate an imbalance in brain chemicals that regulate mood, energy, emotion, and bodily sensations and that the medications restore the balance but they need time to work because the symptoms have been present for some time and stress has lowered the supply of necessary chemicals. Providers should stress the importance of taking medications daily and that they will work with the patient, starting at a low dose and evaluating how it is working before increasing the dose. Explaining to the Vietnamese American patient that some side effects are expected but only for a limited time if the proper dose is used, is also important to increasing compliance. Providers can explain side effects by saying that they are early signs that the medicine is trying to restore balance.46 Advising patients to avoid using any herbal medications during the course of medication can be done by acknowledging their views and then stating that herbal medications can be discussed when an optimal dose of the medicine has been achieved.46 The main concerns about the use of herbal medicine are adulteration of herbs with pharmaceuticals, adverse effects of the herbs themselves, and possible herb-drug interactions.49

54 Health


Dementia in Older Asian Americans The Asian American elderly population is projected to increase by more than 300% between 2000 and 2050, and so the prevalence of dementing illness among Asian Americans is also projected to increase. A cross-ethnic study of knowledge of Alzheimer’s disease found that significantly more Asian Americans (53%) than Anglos (16%) agreed with the statement that “Alzheimer’s is a form of insanity.50 Family members blame the illness on psychosocial stressors and personal characteristics of the care receiver. “Thinking too much” is perceived as a cause and is a kind of thinking that involves excessive brooding and rumination, anxiety and emotional uneasiness. The cultural meaning of the explanation can be found in traditional East Asian medicine and Confucianism, traditions that are important among both Chinese and Vietnamese people.50 The view of older persons as confused or childish may also cause social distancing based on the belief that the person with dementia is incompetent in all areas of life. There may be decreased attempts to communicate with the older patient because the “person doesn’t understand anyway”. Sometimes the older person may be discouraged from talking in the presence of people from outside the family and the older person may not be included in social activities.50 The changes in social relations and the negative view of aging may become internalized, and lead older people to view themselves as being of less value. Suicide rates among older Asian American women in the U.S. shows in 1995, there were 8.6 suicides per 100,000 people among API women over age 65, compared with 5.8 suicides for age-matched white women and 2.1 suicides for aged matched African-American women.50 “In Kleinman’s terms what is at stake in the experience of dementia is the moral status of the family. Confucian ideas of the body and illness, for example, may lead to a view of illness as a sign of the moral status of the afflicted person because he or she has failed to exert appropriate discipline or respect. A loss in moral status manifests both as the intangible feeling of loss of face within the eyes of the community and the tangible fading of social network.51

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Alcohol and Substance Abuse – Barriers to Care Respect and harmony are such strong cultural forces that the fear of “losing face” in the community may cause family members to hide a patient’s alcohol or drug use by working harder to replace lost income and by blaming job stress or health problems for the patient’s substance abuse.52 Substance abuse becomes a family secret that is not discussed. Family members may even help make it easier for a patient to access alcohol or drugs to avoid a confrontation. Family members turn to each other for support, leaving the substance abuser feeling alienated. If family members eventually abandon the patient, they may themselves develop depression by feeling guilty and sad about their inability to help the family member. If patients stop their substance abuse, many Asian families consider the patient “cured” and do not see a need for continued help and counseling.52

56 Health


Gambling – Barriers to Care “The psychosocial dynamics of Vietnamese American families should encourage health care providers to explore pathological gambling; families that have been exposed to trauma have a higher rate of gambling. A community survey conducted in 2002 among Southeast Asian refugees reported that 59 percent of Laotians, Cambodians, and Vietnamese met the criteria for pathological gambling, approximately 30 times higher than the national average.53 In 2006, the UCLA Gambling Studies Program conducted a random survey at a Los Angeles casino and found that approximately 30 percent of the casino patrons surveyed identified themselves as Asian American or Pacific Islander, which is a much higher rate than the general population rate of 12 percent of APIs in California.54

Reasons for Higher Risk in APIs “There are several possible reasons for the increased risk of gambling problems in the AAPI population: •

Language and cultural barriers do not prevent participation in gambling activities.

Financial difficulties among AAPI communities may increase the perceived value of gambling as a way to get rich, particularly among immigrant APIs who may have fewer resources compared to long-established US residents.

Gambling is also culturally accepted and approved within many API cultures, with less stringent religious prohibitions against gambling.

Gambling in many AAPI cultures is an accepted form of entertainment, a rite of passage, and in general an activity that is promoted rather than restricted. Cultural values of luck, superstition, testing one’s fate with the ancestors, and numerology may reinforce gambling behaviors and involvement.”55

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HIV / AIDS “In 2005, about 1% of Asians and Pacific Islanders in the United States had HIV or AIDS, a lower proportion than among any other U.S. racial group. However, in 2001, HIV/AIDS was the seventh-leading cause of death among Asians and Pacific Islanders aged 15—19 and 25—34. API men have a much higher diagnosis rate of HIV/AIDS compared to women.”56 APIs are more likely to be at an advanced stage of AIDS and have opportunistic infections at the time of diagnosis. Compared with persons who have been tested for HIV, untested HIV-infected APIs may be more likely to have high risk behaviors and unknowingly infect other persons and may have a higher viral load (because they are not in medical treatment) that makes them more infectious. This is a major concern as many foreign-born APIs travel back and forth between the US and their home countries, where HIV is often more widespread.57

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Tropical and Parasitic Diseases “Parasitic infestations are common among Asians and Pacific Islanders with as many as 80% of refugees entering the United States having at least one type of disease. The infestation rate is different among the Asian subgroups with Hmong being the highest at 76%, Cambodians second at 75% and V ietnamese at 47%. “Parasitic infestations are common among Asians and Pacific Islanders with as many as 80% of refugees entering the United States having at least one type of disease. The infestation rate is different among the Asian subgroups with Hmong being the highest at 76%, Cambodians second at 75% and Vietnamese at 47%. The type of parasite also varies by Asian subgroups with Ascaris (roundworm) and Trichuris (whipworm) being more common in recent Vietnamese immigrants. Although malaria is not a significant problem in the United States, it may occur in refugees or travelers from areas where it is present. It is estimated that 99% of the cases are imported into the United States, and that 55% of the cases occur in Southeast Asian refugees and more often in men than in women. The 10—29 age group experiences the highest incidence and usually of the form of Vivax malaria (82%)”58

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60 Health


References

Culture Health 61


References (1)

Sorkin D., Tan A., Hays R., Mangione, C., Ngo-Metzger, Q. 2008. Self-Reported Health Status of Vietnamese and non-Hispanic White Older Adults in California. J Am Geriatr Soc.1 – 6.

(2)

Ngo-Metzger Q., Legedza A., Phillips R. 2004. Asian American’s Reports of Their Health Care Experiences: Results of a National Survey. J Gen Intern Med 19:111 – 119.

(3)

Kramer E., Kwong K., Lee E., Chung H. 2002. Cultural Factors Influencing the Mental Health of Asian Americans. West J Med 176: 227-231.

(4)

U.S. Census Bureau. “We the People: Asians in the United States – Census 2000” Special reports, December 2004. pg. 11.

(5)

Rangavajhula R., Hofvendahl-Clark K. 2004. Vietnamese American Women and Cervical Cancer Screening: A Missed Opportunity? California Journal of Health Promotion 2(1) 120 – 126.

(6)

Giger, J., Davidhizar, R. Transcultural Nursing: Assessment and Intervention. Mosby, St. Louis, MO. 2004.

(7) (8)

Nguyen T., McPhee S., Bui-Tong N., et.al. 2006. Community-based Participatory Research Increases Cervical Cancer Screening among Vietnamese Americans. Journal of Health Care for the Poor and Underserved. 17: 31 – 54.

(9)

Kleinman A., Eisenberg L., Good B. 2006 (reprinted from 1978). Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research. FOCUS 4(1):140 – 149.

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