This cultural profile is a compilation of information existing on EthnoMed. Some is from a small structured interview survey of patients at the Harborview Refugee Clinic conducted by Carey Jackson, MD et al in 1990.
In Cambodia, only symptomatic individuals are treated, and outside of major cities chest x-rays and medication may not be available. Many Cambodians will have had exposure to Western medicine during the 2-10 years spent refugee camps prior to immigrating to the United States, and during the refugee screening process. Thus they may have had some familiarity with skin testing and chest x-rays in the diagnosis of tuberculosis.
Translation or Language Equivalents
The Cambodian word for tuberculosis is “robeng”, which is understood to be a communicable disease characterized cough and weight loss. In a survey of Harborview Refugee Clinic patients we asked people if they could name the major symptoms of an illness, and beyond that if they had any biomedical notions associated with causation or disease process. The Cambodian patients could identify TB appropriately in only about 1/3 of the cases, and only 13% of the Cambodians could elaborate on the pathology and etiology of TB.
Cultural Knowledge and Traditional Treatment
Tuberculosis is differentiated from asthma or pneumonia by the nature of the cough and by lack of acute shortness of breath as occurs with asthma. Tuberculosis is recognized as a communicable disease with a cough that is particularly severe at night and productive of a green, sticky mucous. More stigma is associated with tuberculosis than with asthma or pneumonia, to the point that the entire family fears ostracism and isolation when a family member is diagnosed with TB. And for individuals, especially the elderly, fear of isolation from the family as a result of disease or treatment can be significant. Most Cambodians believe that Western medicine can cure tuberculosis.
Screening for TB with a skin test may seem alien to Southeast Asians because in many areas infant vaccination with BCG has made TB skin testing ineffective. In most areas of Asia, Africa and Central America children are given BCG vaccine at birth and may be boosted later on in life. Many Cambodians will have received BCG during their school age years. The BCG produces a positive PPD up to 4 years. In addition, conversion to a positive PPD from exposure to TB occurs at a rate of 2-3% per year. By age 20, the majority of population is PPD positive. In these circumstances, the PPD loses its effectiveness as a screening test for TB and is not used in developing countries.
This also has implications for prophylactic therapy with INH. In developing countries such as Cambodia, resources are available only for treating those with TB disease. Therefore when a provider tells a Cambodian patient that the skin test is positive but the chest x-ray is normal and therefore medication is required, the patient may be confused by the seemingly contradictory information and be less adherent to therapy.
In a study of “non-compliance” among Cambodian patients in our clinic, Shimada (1995) found that Cambodian patients were often concerned that medication was too strong for them (43%). Cambodian patients will often complain of being “ahh kaamlang” (without strength) a condition by itself or in association with other illnesses. This complaint refers to more than just being out of strength, it means losing balance in a way that has left them without adequate “internal strength” to sustain their health. When someone feels “ahh kaamlang” the solution was to adjust the medication or discontinue it altogether.
Recommendations for Providers
- Be extra careful to respect patient privacy and confidentiality.
- Emphasize the treatable nature of tuberculosis.
- Reassure patient that during and after treatment family life can continue as normal without isolation.
- Take time to explain the difference between tuberculosis infection and tuberculosis disease.
- Especially during the first few weeks of treatment, solicit feedback on side effects and tailor the regimen to the patient’s needs.
- Encourage the use of a nutritious diet and traditional therapies to better tolerate the side effects of Western medication.
References and Further Reading
Shimada J, Jackson JC, Goldstein E, Buchwald D. “Strong Medicine”: Cambodian views of medicine and medical compliance. J Gen Int Med 1995;10:369-374.