here - Vietnamese Community of Orange County, Inc.

Transcription

Harmony in
Health Care:
A Resource Guide for
Culturally Appropriate Care
of Vietnamese Americans
Dear Healthcare Professionals,
Vietnamese Americans are a growing and dynamic part of the cultural fabric of this
country. Between 1975 and 1995, hundreds of thousands of refugees left Vietnam to
build their new life in the United States. The Vietnamese, along with the Cambodians
and Laotians, make up the largest group of refugees ever to immigrate to this country.
There are nearly 2 million Vietnamese Americans in the United States, making it the
fastest growing Asian Pacific Islander subgroup. It has been projected that by the
year 2030 the Vietnamese will be the largest API population in the United States.
The Vietnamese Community of Orange County, Inc. is proud to have the privilege
of meeting the healthcare and social service needs of the community for more than
30 years. The VNCOC, Inc. has been a powerful voice guided by a mission to enable
Vietnamese Americans to become active participating citizens in the mainstream
society through empowerment and capacity building. Through its programs that
cover the span of the human life cycle, the VNCOC, Inc. has positively impacted
the Vietnamese American community.
The creation of this Resource Guide is an important part of our outreach effort
to assist all healthcare providers in providing high quality care to Vietnamese
Americans. By working together we can enhance our efforts to meet Healthy
People 2010 goals in our community in a culturally appropriate manner. Cancer,
heart disease, diabetes, and mental health impact the Vietnamese American
and larger Asian Pacific Islander community disparately because of cultural
and sociodemographic factors. We encourage you to use the Resource Guide
to build strong patient – provider care relationships for harmony in health.
On behalf of the Board of Directors of the Vietnamese Community of
Orange County, Inc. I would like to give special thanks to the California
Endowment for a generous grant which made this Resource Guide possible.
Sincerely,
Vy Trac Do, Ph.D.
Chairman
VNCOC, Inc. Board of Directors
Table of Contents 1I
II
Acknowledgements
The Vietnamese Community of Orange County, Inc. wishes to acknowledge
the following valuable contributors to the Harmony in Healthcare:
A Resource Guide for Culturally Appropriate Care of Vietnamese Americans.
Advisory Committee
Alexander Tuan Dinh Pham, DDS
President
Asian American Dental Center
Helen F. McClure, M.A.
Professor/Counselor
Coastline College
Angie T. Hoang
Treasurer
Vietnamese Community of
Orange County, Inc. (VNCOC)
Michelle Mai Nguyen, R.Ph., Esq.
Anh H. Dao, M.D.
Associate Professor, Emeritus
Vanderbilt University Medical Center
Ann Tran
UCI School of Medicine
Quang Xuan Nguyen, M.D.
Rebecca Morgan, Psy.D.
Tanya Vu
Physician Liaison
Orange Coast Memorial
Medical Center
Chung The Bui, M.D.
Tao Tat Le, M.D.
Regional Medical Director
Health Net of California
Clayton Chau, M.D., Ph.D.
Program Medical Consultant
Associate Medical Director
Orange County Health Care Agency
Behavioral Health
Thunga Le
Vietnamese Community Relations Coordinator
Orange Coast Memorial Medical Center
Craig G. Myers
CEO
Coastal Community Hospital
Dennis Berg, Ph.D.
Program Evaluator
Emeritus Professor of Sociology
California State University, Fullerton
Duc Tien Nguyen, M.S./M.H.A., Ph.D.
Northwestern Polytechnic University
To Quang Pham, M.D.
Tuan Anh Phan, M.D.
Tuyet Thi Nguyen, Teacher
Secretary
Vy Trac Do, Ph.D.
Chairman
Elizabeth Tu Boi Vu Pham
Registered Pharmacist
VNCOC, Inc. Board Member
III
Acknowledgements (continued)
Funding
The creation of this Resource Guide is made possible by a grant from the California Endowment.
Program Staff
Terri Vise, MHA, FACMPE
Resource Guide Coordinator/Writer
Tricia T. Nguyen, MPH
Health Educator/Public Health
CEO, VNCOC, Inc.
Vietnamese Community of Orange County, Inc.
Board of Directors
Vy Trac Do, Ph.D., Chairman
Hung Phu Nguyen, Vice Chairman
Angie Thao Hoang, Treasurer
Tuyet Thi Nguyen, Secretary
Tu Boi Vu, R.Ph.
Duc Le
Diem Tuyet Pham
Thanh Cong Truong
Chau Doan Vo
Xuan Minh Pham
Hoang Thanh Pham
4 Introduction
IV
Table of Contents
Culture........................................... 1-18
Cardiovascular Risk and Exercise.............37
History of Immigration................................... 3
Cardiovascular Disease: Cholesterol
and Blood Cholesterol Testing................38
Vietnamese American Demographics........... 4
Types of Barriers to Healthcare..................5-6
Patients’ Cultural Perspectives..................7-8
Barriers to Cardiovascular Disease
Diagnosis and Care.................................38
Using an Interpreter.................................9-10
Diabetes Incidence / Prevalence...............39
Importance of Respect and Caring............. 11
Cultural Beliefs About Causes
of Diabetes..............................................39
Healing Practices........................................ 12
Other Traditional Healing Practices............. 13
Acculturation............................................... 14
Framing Questions for the Practitioner...15-16
Health Belief Model..................................... 17
Attitudes About Treatment of Diabetes.....40
Western Medicine vs. Eastern
Herbal Remedies.....................................41
Herbal Remedies and Insulin....................41
Sources of Information on Health............... 18
Framing Educational Information..............42
Cancer......................................... 19-32
Mental Health............................................44
Cancer Incidence and Mortality in Women... 21
Mental Health and Stigma.........................44
Cervical Cancer Screening.......................... 22
Barriers to Cervical Cancer Screening........ 23
Key Cultural Factors that Influence
Mental Health.................................... 45-46
Promoting Cervical Cancer Screening........ 23
Depression in Asian American Children....47
Breast Cancer............................................. 24
Depression in Asian American Adults.......48
Encouraging Mammograms........................ 24
Cancer Incidence and Mortality in Men...... 25
Prescribing Medications for
Mental Health..........................................49
Barriers to Colorectal Cancer Screening.... 26
Dementia in Older Asian Americans..........50
Colorectal Cancer Screening...................... 27
Hepatitis B – Transmission & Knowledge...... 28
Alcohol and Substance Abuse –
Barriers to Care.......................................51
Liver Cancer Incidence and Mortality......... 29
Gambling – Barriers to Care......................52
Impact of Hepatitis B.................................. 30
Reasons for Higher Risk in APIs...............52
Barriers to Testing....................................... 30
HIV / AIDS.................................................53
How Vietnamese Americans Relate
with Health Care Providers....................... 31
Tropical and Parasitic Diseases................54
Tobacco Use and Cancer............................ 32
References.................................. 55-68
Health.......................................... 33-54
Cardiovascular Health in
Vietnamese Patients................................35
Knowledge of Symptoms and
Risk Factors............................................35
Hypertension and Cardiovascular
Disease....................................................36
Dietary Habits and Portion Control...........43
References.......................................... 57-60
Bibliography........................................ 61-68
Patient Materials...................... 69-170
Patient Education Materials.............. 71-169
Additional Vietnamese Language
Patient Education Materials..................170
Table of Contents V
History of Immigration........................................................... 3
Vietnamese American Demographics................................... 4
Types of Barriers to Healthcare..........................................5-6
Patients’ Cultural Perspectives..........................................7-8
Using an Interpreter..........................................................9-10
Importance of Respect and Caring..................................... 11
Healing Practices................................................................ 12
Other Traditional Healing Practices..................................... 13
Acculturation....................................................................... 14
Framing Questions for the Practitioner..........................15-16
Health Belief Model............................................................. 17
Sources of Information on Health....................................... 18
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Culture
Culture
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 imminent 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.
Culture 3
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.
4 Culture
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 monochronic 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)
Culture 5
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
of 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.
6 Culture
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 be 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
the opposite side or shoulder, too. Likewise, the feet are the lowliest parts of the body and
should be kept on the floor.
(continued)
Culture 7
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
8 Culture
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. Impress 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)
Culture 9
•
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.
10 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
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
Culture 11
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
12 Culture
Other Traditional Healing Practices
Xong—a substance like Vicks® VapoRub is stirred into scalding water and the person may just
inhale the vapors or may be treated under a blanket to create a steam tent.
Smelling aromatic oils or ointments like menthol, eucalyptus or mint can be used for motion
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 herbal or Oriental Medicine 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.
Herbal teas, soups and condiments play a large role in traditional healing beliefs for a wide
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
Culture 13
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
14 Culture
Framing Questions 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)
Culture 15
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 your 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
16 Culture
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
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.
Culture 17
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 practices.
The Vietnamese American population is the most linguistically isolated and tend to prefer
seeing doctors who share their cultural background.”15
18 Culture
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Cancer
Cancer Incidence and Mortality in Women......................... 21
Cervical Cancer Screening.................................................. 22
Barriers to Cervical Cancer Screening................................ 23
Promoting Cervical Cancer Screening................................ 23
Breast Cancer...................................................................... 24
Encouraging Mammograms................................................ 24
Cancer Incidence and Mortality in Men.............................. 25
Barriers to Colorectal Cancer Screening............................. 26
Colorectal Cancer Screening.............................................. 27
Hepatitis B – Transmission & Knowledge............................ 28
Liver Cancer Incidence and Mortality.................................. 29
Impact of Hepatitis B........................................................... 30
Barriers to Testing............................................................... 30
How Vietnamese Americans Relate
with Health Care Providers................................................ 31
Tobacco Use and Cancer.................................................... 32
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
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
Cancer 21
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
22 Cancer
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
Cancer 23
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 U.S. 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. T
he wife usually lets the husband make all
decisions for her, including medical decisions. Therefore, it is important that the husband
understands the importance of a mammogram so he will support her need to obtain one.”23
24 Cancer
Cancer Incidence and Mortality in Men
Cancer Incidence per 100,000 – Men – 2000 - 2002
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
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
Cancer 25
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
26 Cancer
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
Cancer 27
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 U.S. for children less than 18 years of age.9
28 Cancer
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
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
Cancer 29
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 U.S. 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
30 Cancer
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.
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.”
Cancer 31
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
32 Cancer
Health
Cardiovascular Health in Vietnamese Patients.................... 35
Knowledge of Symptoms and Risk Factors........................ 35
Hypertension and Cardiovascular Disease......................... 36
Cardiovascular Risk and Exercise....................................... 37
Cardiovascular Disease:
Cholesterol and Blood Cholesterol Testing....................... 38
Barriers to Cardiovascular Disease Diagnosis and Care..... 38
Diabetes Incidence / Prevalence......................................... 39
Cultural Beliefs About Causes of Diabetes......................... 39
Attitudes About Treatment of Diabetes............................... 40
Western Medicine vs. Eastern Herbal Remedies................ 41
Framing Educational Information........................................ 42
Dietary Habits and Portion Control..................................... 43
Mental Health...................................................................... 44
Mental Health and Stigma................................................... 44
Key Cultural Factors that Influence Mental Health.........45-46
Depression in Asian American Children.............................. 47
Depression in Asian American Adults................................. 48
Prescribing Medications for Mental Health......................... 49
Dementia in Older Asian Americans.................................... 50
Alcohol and Substance Abuse – Barriers to Care............... 51
Gambling – Barriers to Care................................................ 52
Reasons for Higher Risk in APIs......................................... 52
HIV / AIDS........................................................................... 53
Tropical and Parasitic Diseases........................................... 54
mese American
na
t
ie
V
he
t
in
f
ie
A strong bel
good
ving a good soul,
ha
t
ha
t
is
y
it
un
comm
s a person to be
le
b
a
en
ls
a
or
m
values and good
ically strong.
mentally and phys
Health
Herbal Remedies and Insulin.............................................. 41
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
Health 35
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 in
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
36 Health
AAPI Women
All Women
AAPI Men
All Men
8.4
11.0
9.7
10.3
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:
•
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
Health 37
Cardiovascular Disease: Cholesterol
and Blood Cholesterol Testing
Many Vietnamese American patients are unaware of what causes an increase
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
Barriers 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
38 Health
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
non-Hispanic 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 API 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
•
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 U.S., 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
Health 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 medicine 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
40 Health
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.
Health 41
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
42 Health
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
Health 43
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.
44 Health
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 are immigrants themselves and/or operate near the ethnic
communities.”15 There are approximately only 70 API mental health providers available for every
100,000 APIs in the United States, as compared to 173 per 100,000 whites. Moreover, among
those API 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:
•
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
Health 45
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
46 Health
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-inflicted behaviors, or exhibit
other warning signs of depression should
be asked specifically about suicidal ideation
and intent.45
Health 47
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, United States, 2008,
A
young Asian Americans have one of the highest suicide rates of all racial and ethnic groups
in the country. Of reported data, Asian American women 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
48 Health
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
Health 49
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 networks.”51
50 Health
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
Health 51
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.”54
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 API population:
52 Health
•
Language and cultural barriers do not prevent participation in gambling activities.
•
Financial difficulties among API 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 API 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
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
Health 53
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. T
he infestation rate is different among the Asian subgroups with Hmong
being the highest at 76%, Cambodians second at 75% and V
ietnamese 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
54 Health
References
References.....................................................................57-60
Bibliography...................................................................61-68
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Patient Materials
Patient Education Materials.........................................71-169
Additional Vietnamese Language Patient
Education Materials......................................................... 170
Patient Materials
Additional Vietnamese Language Patient
Education Materials are Available at:
Vietnamese Health Information Translations from healthinfotranslations.org
http://www.healthinfotranslations.com/vietnamese.php
American Cancer Society – Asian and Pacific Islander Language Materials
http://www.cancer.org/docroot/home/index.asp?level=0
Spiral – Selected Patient Information Resources in Asian Languages
http://spiral.tufts.edu/
EthnoMed Patient Education Materials
http://ethnomed.org/patient_ed/viet/index.html
“In the strive to achieve cultural competency, this resource guide provides health care
organization clinicians a comprehensive knowledge base in working with Vietnamese and
Vietnamese-Americans. This handbook allows the clinicians to access practical information
quickly and easily in every day clinic practice.”
– CLAYTON CHAU, M.D., PH.D., ASSISTANT CLINICAL PROFESSOR OF PSYCHIATRY,
UNIVERSITY OF CALIFORNIA IRVINE SCHOOL OF MEDICINE
“This is a wonderfully informative guide to a variety of services, which it would take weeks for an
individual to locate on his or her own. Congratulations to the Vietnamese Community of Orange
County for putting this Resource Guide together.”
– CASEY DORMAN, PH.D., PSYCHOLOGIST AND AUTHOR
“As the County Health Officer, I applaud VNCOC for creating such a useful resource. I encourage
all health care workers to take the time to become familiar with the tool kit and learn more about
the resources provided. Thank you for putting together valuable information for both health care
workers and the community members they serve. You have assisted all of us in serving the
needs of the community and in helping to improve health in Orange County.”
– DR. ERIC HANDLER, HEALTH OFFICER ORANGE COUNTY HEALTH CARE AGENCY
170
VNCOC – Main
1618 W. First Street
Santa Ana, California 92703
Phone: 714-558-6009
Fax: 714-558-6120
Email: [email protected]
www.thevncoc.org
Asian Health Center
5015 W. Edinger Avenue # J-M
Santa Ana, California 92704-1968
Phone: 714-418-2040
Fax: 714-418-2045
Little Saigon Economic,
Social and Cultural Services Center
14541 Brookhurst Street, C9
Westminster, California 92683
Phone: 714-839-4441
Fax: 714-839-6668
Phu Dong Early Childhood
Development Center
12421 Magnolia Street
Garden Grove, California 92841
Phone: 714-534-9060
Fax: 714-534-9049

here - Vietnamese Community of Orange County, Inc.

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