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Increasing the cultural competence of health care providers serving Minnesota's diverse populations
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Common health equity issues for Vietnamese populations
Cultural competence is the ability to recognize and understand the role culture plays in health care and to adapt care strategies to meet patient needs.
Get to know patients on an individual level. Each person’s preferences, practices, and health outcomes are shaped by many factors. Generalizations in this material may not apply to your patients.
Generational conflict occurs in some Vietnamese American families as young people conform to individual rather than traditional collective behaviors.
Vietnamese in Minnesota
Minnesota was home to 23,000 foreign-born Vietnamese in 2013, who largely arrived in the 1980s. In 2013, more Vietnamese Americans were foreign-born (64%) than born in the U.S. (36%). According to the 2010 U.S. Census, Minnesota cities were not among the top 10 U.S. metropolitan areas with Vietnamese populations.
Mass immigration to the U.S. began in 1975 with the fall of Saigon at the end of the Vietnam War (often referred to as the American War by Vietnamese). More than 125,000 Vietnamese who had ties with the government or with Americans escaped from invading communists. In 1977, a second wave of refugees began fleeing Vietnam as a result of new communist re-education policies, torture, and forced relocation. In the early 1980s, more than two million Vietnamese people fled in small, overcrowded boats to other Southeast Asian countries for asylum. Many then made their way to the U.S.
According to Pew Research Center analysis in 2015, 34 percent of foreign-born and 88 percent of U.S. born Vietnamese indicated that they speak English proficiently.
In general, the Vietnamese population in the United States is susceptible to the same chronic illnesses as the overall population, such as cancer, heart disease, stroke, hypertension, and diabetes. Some health issues could be biologically tied to race; many are tied to social inequities, including poverty. When included in the data for Asian-Americans, the true picture of Vietnamese-American health may be missed.
Social determinant disparities
Social determinants of health are economic and social conditions that influence the health of people and communities.
The Vietnamese community in Minnesota is diverse. Many aspects of Vietnamese-Minnesotan culture reflect the culture of the general U.S. population and generational differences impact social practices. A traditional Vietnamese family is patriarchal, with two to four generations and extended family often living in the same home. Data from the 2015 American Community Survey indicated that 32 percent of Vietnamese Americans lived in multigenerational households.
Family members are expected to work and behave for the good of the group. Younger generations are conforming to American individualistic models and not upholding the traditional collectivistic model, which causes generational conflict. Traditionally, the father has ultimate responsibility and is the head of the household, although due to Western influence gender roles now vary greatly. In the U.S., arranged marriages are declining. Parents today take more of an advisory role in the choice of a child’s mate. Divorce is uncommon and is considered shameful, especially for women. Vietnamese people use the family name first, then the middle name, with the first name last. Most names have a specific meaning and can be used for either gender.
Prior to the Vietnam War, Buddhism was practiced by 90 percent of the population in Vietnam. Today, the Vietnamese practice a variety of religions. Many are Roman Catholics, a result of Vietnam’s occupation by the French, Portuguese, and Spanish. They also may worship spirits and natural forces, or practice ancestor worship or astrology. Confucianism and Taoism have strongly influenced Vietnamese cultural traditions. Many customs are rooted in both the Confucian respect for education, family, and elders, and the Taoist desire to avoid conflict. Stoicism is a highly respected trait.
As immigrants acculturate, they replace traditional meals with fast food, contributing to an increase in obesity, diabetes, and hypertension. A typical Vietnamese diet is generally healthy, with rice or noodles, fresh vegetables, and fish or meat. However, the diet also can be high in sodium from fish sauce and MSG, and low in fiber from lack of whole grains. Dairy and soy products are not part of a typical Vietnamese diet, although most children drink milk. Many adults are lactose intolerant and lack calcium.
Rice and traditional desserts high in sugar and saturated fats from coconut milk and oil can cause weight gain and high blood sugar. In Vietnamese culture, chubby children are considered healthy and a sign of prosperity. Vietnamese people may be susceptible to weight gain, high cholesterol, and diabetes.
Some Vietnamese families may prefer that the diagnosis of a serious or terminal illness not be disclosed directly to an older family member to prevent additional stress for the older adult, making informed consent and decisions regarding code status awkward. Older Vietnamese Americans are less likely to seek medical attention and treatment, than later generations, unless extreme circumstances arise.
Many Vietnamese had severe health problems on arrival in the U.S. from poor living conditions, starvation, and abuse during the Vietnam War and in refugee camps. Medical problems included tuberculosis, hepatitis B, malaria, malnutrition, trichinosis, anemia, leprosy, and intestinal parasites. Because of exposure to Agent Orange, older immigrants are at risk for cancers, immune deficiency, endocrine disruption, and neurological damage. The most common cancers seen are prostate, breast, lung, and colorectal cancer. Rates of smoking among men are very high with smoking-related cancer endemic in this population.
In Minnesota, Vietnamese who consume large quantities of fish taken from lakes and rivers are at risk of exposure to mercury and PCBs. The Minnesota Department of Health advises clinicians to encourage their patients to replace some fish in their diet with alternative protein sources.
Many Vietnamese believe that Asian people are different physiologically from white people. Western medicines are thought of as “hot” and too potent for their physiology. They may not take medicines as prescribed. Symptoms are often attributed to a physical weakness; for example, a weak heart is expressed by panic, palpitations, and dizziness; a weak kidney is expressed by impotence; a weak stomach or liver is expressed by indigestion; and a weak nervous system is expressed by headache or lack of concentration.
Often, elders do not trust Western medicine and use it only as a last resort. They may resist immunizations and invasive procedures, and view a clinician who does not intrude on the body as the best healer. Some believe a physician should be able to diagnose a problem by looking at them and feeling their pulse. Vietnamese people also believe in the medicinal properties of foods such as mung beans, green beans, and bitter melon, which is believed to help control blood pressure. Acupuncture is used widely for arthritis pain, stroke, visual problems, and other symptoms.
Clinicians should be aware of dermabrasive procedures used by Vietnamese patients that leave marks on the skin—and not misinterpret the marks as signs of physical abuse. These procedures based on the Chinese philosophy of hot/cold physiology are often used to treat headache, cough, nausea, and other maladies. Cutaneous hematomas are made on the face and trunk by pinching and pulling the skin to release excessive air, by rubbing skin with a coin or spoon, or by cupping—heating air in a cup with a flame, then placing the cup on the skin. As the air cools, it contracts and pulls on the skin, leaving a purple mark. Moxibustion, often combined with acupuncture, is the process of making superficial circular burns on the skin with ignited incense or other material placed directly on the skin.
Vietnamese patients may smile easily and often, regardless of underlying emotions. Because they value politeness and respect for authority, patients may not voice concerns or ask providers questions. If they disagree or do not understand, they may simply listen and answer “yes,” then not comply with recommendations or return for further care. Vietnamese patients may not take appointment times literally, arriving late so as not to appear overly enthusiastic.
Approximately one in five of all adults in the U.S. experiences mental illness in a given year. In Vietnam, elders had authority and were respected, but they have lost much of this status in the U.S., leaving many depressed and lonely. Older immigrants are less likely to have English skills which may increase the loneliness, isolation, and depression.
Many Vietnamese believe emotional pain to be a physical symptom and may resist referrals to mental health clinics. Mental illness is traditionally considered shameful, often feared and denied. In Vietnam, people with mental illness were hidden. Although many may suffer from anxiety, depression, and post-traumatic stress disorder (PTSD), they may not reveal these problems.
Due to the impact of the Vietnam War, children who were born to American soldiers often struggle with identity, as they may have been rejected by the Vietnamese community.
End of life
When discussing end of life issues with any patient, health care providers need to understand preferences based on personal and family views. Many Vietnamese people believe that suffering and illness are an unavoidable part of life. They feel that the length of one’s life is predetermined, and that prolonging life is futile. When a person is dying, family members take turns at the bedside and attend the body after death. Buddhists may ask a monk or elder to pray at the bedside. The family may object to autopsy and organ donation.
Arranging a proper funeral for a loved one is one of the most important things a Vietnamese person can do. It also helps the living grieve and go on with life. Death rituals provide the bereaved a chance to fulfill obligations and complete unfinished business with the deceased. Elaborate details of death rituals require extensive family and community involvement over a period of two to three years. The rituals communicate communal responsibilities and can recreate social order by conveying who will take the place of the deceased.
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