Ethnographic Study among Seattle Cambodians: Fever

Methods

Participants

Three bilingual Cambodian interpreters and twenty-six Cambodian speaking informants participated in the study. Twenty-one were women and eight were men. The interpreters have worked at least three years with non-English speaking Cambodians. Three informants had a high school education in the USA. Most had little to no education in Cambodia. All of the informants lived in Cambodia until at least 17 years of age. Most were raised in rural and urban provincial towns. Two came from the capital city. Their ages ranged between 31 to 71 years. The informants were identified through the Refugee and Children’s clinics, and the Community House Calls Program, which provides services to the Seattle Cambodian community.

Data collection

Two focus groups of bilingual Cambodian interpreters were conducted in English. The initial focus group provided primary terms and definitions used in translation for fever and dizziness. The final one assured the quality of translation, reviewed and validated the findings.

Two focus groups and seventeen semi-structured interviews were held with non- English speaking Cambodians. The interviews were done in English with paraphrased and summary interpretation by an interpreter who was trained in interview techniques. The focus groups and the interviews lasted approximately one and a half hours. Handwritten notes were taken and an audiotape was made with informed consent from the informants. Transcripts of the tapes were made. They were edited by the interviewer and the interpreter to verify linguistic and cultural information.

The informants were asked to describe fever and dizziness, their causes, common symptoms associated with fever and dizziness, symptom management, and their worries and fears. The informants associated both fever and dizziness to a syndrome called “wind illness,” or known in Cambodian as khyol (pronounced khyol). It was decided that in order to understand fever and dizziness” in the Cambodian cultural context, the study needed to explore the association between fever, dizziness, and wind illness.

Analysis

Analysis for themes, linguistic and cultural contents was done by the principal investigator, the interviewer, and the interpreter. After the preliminary analysis, the findings were reviewed and validated in focus groups of non-English speaking Cambodians and bilingual interpreters. The methods are summarized below.

Initial Interpreter focus group
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Semi-structured interviews
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First focus group with non-English speaking informants
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Semi-structured interviews
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Second focus group with non-English speaking informants
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Final interpreter focus group

Results

Translation and Language Equivalents

Fever was translated into Cambodian as krun. However, krun did not always mean fever as medically defined. In this paper the terms “krun” and “fever” will be used interchangeably. They imply the Cambodian cultural meaning of fever. When the terms “having a temperature” or “high fever” are used, they imply the medical meaning of fever. The informants in this study described krun in four ways: 1) “Feeling ill,” as when a person did not feel well; they might say “I have krun.” Krun did not always mean that the person had an elevated body temperature. 2) “Feeling hot and cold,” or “feeling like fever” which was described as a sensation that the body temperature was out of balance. It may or may not be associated with an elevated body temperature. 3) “Feeling hot” or “having a hot body,” as when a person felt like the body temperature was warmer than normal. The lips were dry and they felt warm in the eyes and the mouth, and on the forehead. Feeling the forehead was a common method of determining if a person had an elevated body temperature. Using a thermometer was not a common practice. 4) “Having a specific illness.” When krun was used with other illness terms, it described specific symptoms. For example, krun door mok pii tjiak is fever from ear infection.

Clinical Features

The following are different kinds of fever (krun) found in this study: hot fever (krun kdaow); malaria fever (krun jang); shaking fever (krun ngiah); fever with identifiable sources (krun door mok pii); feeling hot and cold (krun sriew sran); common cold or flu (krun pradas sai).

1. Hot fever, feeling hot (krun kdaow)
   Krun kdaow implied that the temperature of skin was hot, and the body and forehead were warm. Children didn’t eat and play. Their faces were red and their heart beat was fast. According to some informants, the temperature ranged from 96 to 103 F. Some informants would use krun kdaow to explain that one is feeling hot without any change of body temperature.
2. Malaria (krun jang)
   Krun jang presented as a very hot fever and a shaking body (chill). The high fever came at a certain time of the day. It was very geographically specific, happening only in certain areas in Cambodia. It was caused by mosquito bites. In general there was no krun jang in the USA, except when people traveled back to certain areas in Cambodia, they could carry krun jang back..
3. Shaking fever, big fever (krun ngiah )
   Krun ngiah was described as a fever with a very hot body temperature which caused the body to shake. The interpreters called krun ngiah a “big fever.” Krun ngiah is one of the symptoms associated with malaria. Pneumonia was also reported to cause krun ngiah. Some people used krun ngiah and krun jang interchangeably. However, not every krun ngiah is krun jang. Children with krun ngiah could have seizures, and damage their brain.
4. Fever from identifiable sources (krun door mok pii)
   Krun door mok pii or krun door referred to fevers with identifiable sources, such as from inflammation, infection, injury, chicken pox, measles, teething, crying and playing too much. A 48-year-old mother explained, “krun door happens when you are already sick, like you have eye pain, toothache, you fall down and hit something and you are injured, then you have fever, krun door.” Fever from chicken pox is krun door mok pii ut svay. Fever from a wound is krun door mok pii dambao.
5. Feeling hot and cold (krun sriew sran)
   Krun sriew sran described a feeling of unbalanced body temperature and restlessness. The body felt a little hot and a little cold. Sometimes it felt hot on the face or in the mouth. One interpreter said with a smile, “it’s a `small fever’ as opposed to a `big fever’ like krun ngiah.” However, if a “small fever” was left unattended, it could turn into a “big fever.”
6. Common cold, flu ( krun pradas sai )
   Krun pradas sai described a person with fever, runny nose, stuffy nose, and headache. In children, sometimes the temperature was high and the body was hot. They didn’t want to eat or play. It could be transferred to other children and adults. The focus group informants agreed that among all kinds of krun, krun pradas sai was the easiest to identify based on symptoms described above.

Concerns Associated with Fever

The informants described the following problems as requiring extra caution or sometimes immediate medical attention.

1. Persistent high fever
   The interpreters and informants agreed that parents worried the most about persistent high fever (krun ngiah) in children. For example, if children had a fever of 105° F for a long time, it would affect their brain, and cause convulsions. They would become unconscious, paralyzed, or retarded.
2. Bathing after coining or when having fever
   After a traditional treatment – coining – a person wore warm clothes or wrapped himself/herself with a blanket. This maintained the heat and avoided cold air. The body was not to be exposed to cold air or water. A bath after coining could bring harm. Some believed that the cold element from the water could get in and block the flow of the khyol, or cause sudden shock to newly retrieved body heat. It could worsen the existing symptoms, cause pneumonia, seizure or death. Likewise, when a person had a temperature, a cold bath had to be avoided in order to prevent water from getting into the body and causing similar problems mentioned above.A 31-year-old mother advised, “you can coin and take Tylenol at the same time but don’t take a bath for one or two days. You are cold and chill when you have khyol. After coining you begin to get the heat back. When you take a cold bath, you feel shaken and shocked and you can die.”A 48-year-old mother disagreed with soaking a feverish child in water. She recalled a story about her friend in the Southwest. “A boy was very sick and at the hospital they put him in the water. He had a seizure and died immediately. The mother was very upset.”
3. Fever accompanied by difficult breathing, fast heart beat, diarrhea, vomiting, excessive cough, inability to eat and sleep.
   Cambodians called fever that comes with severe diarrhea and vomiting ar-sun- na-rook. Ar-sun-na-rook is a disease that one can die from quickly. The patients throw up and have diarrhea and it is considered an emergency. It happens during the ripe mango (hot and dry) season in Cambodia. One informant talked about her brother who died from severe krun , “during the Communist ruling, my four-year-old brother had krun. They did the coining and everything, but they did not help. He had severe fever, diarrhea, and vomiting. He died. They did not know he died from krun or khyol.”
4. Fever in Infants and Toddlers
   Cambodians would bring newborns and toddlers who had fever immediately to a doctor. People have learned from doctors in the past 15 years that many serious illnesses could happen to them.

Cambodian Concepts of Fever

Health Practices for Wind Illness, Fever, Dizziness

Health practices for fever, dizziness and wind illness were interchangeable.

Multiple health practices were used by study informants and were consistent with complex cultural meanings of fever, dizziness, and wind illness. They included traditional, self, medical, and dual treatments.

Traditional Treatments

The traditional treatments did not aim to treat only specific symptoms such as fever or dizziness, but rather symptom complexes of the illnesses. The treatments were used to “balance” khyol, so therefore treat fever and dizziness. Coining was the most commonly used treatment. Others were pinching and cupping, and home supportive treatments.

For more information about coining and cupping, go to  Ethnographic Study among Cambodians in Seattle: Wind Illness.

Self-medication

Tylenol was the most common self-medication used to reduce temperature, treat dizziness or headache. It was often available at home or could be obtained over the counter or at the clinic. When fever was perceived not to be serious, the informants used Tylenol once or twice and waited for a couple hours. They were likely to seek medical attention if Tylenol self-medication and other home treatments failed. In fever, often Tylenol was used with a sponge bath to the forehead to treat a hot body temperature. A 36-year-old mother said, “the head is important, so put a wet cloth on the forehead. Not too much water, just a little bit. I learn from a doctor. I believe in doctor… If not high fever, I will give them Tylenol at home.”

Another mother expressed her concern in using Tylenol. She was afraid of using too much medicine, “if give Tylenol too much, it can make them too cold. When the fever is high I am afraid to give Tylenol because the medicine can reduce body temperature too much. The body will be cold and chill. It’s cold outside but still hot inside. I may give too much medicine so I am afraid to give.”

The informants had a general knowledge of Tylenol. They knew that Tylenol was for fever, dizziness, headache, and body ache. Although the informants said they used Tylenol according to the directions, many of them were not able to read. They relied on their children for interpretation which was not always accurate. Most children had very limited Cambodian language skills. Taking or giving the right dose of home medication was still a concern for many households.

Medical Treatments

Some informants seek medical treatments when traditional treatments for krun failed. Others used medical treatments simultaneously with traditional treatments. A few prefer medical treatments as their first choice of treatment. The informants and interpreters described experiences and beliefs about medical treatments as follows.

1. Use of fever and pain medication
   Tylenol was a medication that the informants received and were familiar with by name. Others such as Advil or ibuprofen were less known by names. When a doctor prescribed Tylenol, it could be interpreted that the illness was not severe. A 32-year-old woman said, “If the doctor saw that fever is not bad they just gave Tylenol and sent the patient home. I did not mind if the doctor only gave Tylenol. But if my child is not better I will take him back. They are doctors so they know. I just followed the doctor’s advice.”The informants acknowledged that they’d learned how to use Tylenol from the doctor. For example, they learned that if after giving Tylenol every six hours for a couple days, the child is not better, they should call or bring the child back to the clinic.
2. Treatments for specific problems
   The informants knew that when fever or dizziness came from specific illnesses, they needed to take care of the problems. Taking only Tylenol would not help. For example, when dizziness was associated with anemia, or high blood pressure, they seek medical help. A 71-year-old man said, “if you have fever from toothache you have to pull the tooth out. If you have ear and eye problems the doctor will give medicine for ears and eyes. When the eye and ear pain goes away, the fever will go away.”
3. Beliefs about western medicine
   “Expected to be treated, not just to be told that they are OK.” was the consensus among interpreters of Cambodian patient expectations when they came to see doctors. They expected some medicine. “When they come with fever, they usually get Tylenol, or Ibuprofen. It does not matter what it is, give them something so they don’t walk away with empty hands… at least somebody does something.” Another interpreter gave an example of some of the patients he translated for, “They were sick for a week and waited for three hours and the doctor told them to go home, get rest, and drink a lot of water. They don’t want water, they want medicine!””Give something else but not Tylenol.” Some patients might expect to get different kinds of medicine if they had already tried Tylenol and did not get better. The interpreters suggested, “something like Advil or ibuprofen. They think the new medicine is very good, and they feel good.” Some people believed Ibuprofen worked quickly and was stronger than Tylenol. Sometimes the interpreters were caught in the middle of patient-doctor negotiations. One interpreter laughed while recalling his experience, “usually doctors don’t know (what patients want) so they just say … take this medicine, it will help you with ache and pain. Whether patients were satisfied or not they did not say anything to the doctor. After the doctor left they complained to the interpreter. They complained that they only got Tylenol, fever and pain medicine. They expected something like an antibiotic.””Avoiding blame for not seeking care.” A 48-year-old mother took her children to the doctor knowing they would get the same medication. “After giving Tylenol and it did not help, I went to a doctor. I knew that they were going to give Tylenol, but I still took them. I tried what I supposed to do. In case something happened, I would not get blamed.”
4. Dual treatments
   Many informants in this study combined traditional with medical treatments. A 41- year-old woman with pneumonia took antibiotics and used coining. She said, “if you just follow American ways you don’t get better. You coin and take medicine. Coining helps get rid of the body ache and the sickness.” The most common dual treatment for fever, dizziness, and wind illness was coining and taking Tylenol or Advil. There were two approaches to this particular dual treatment: taking medicine simultaneously with coining or right after it; or waiting a few hours after coining to take medicine in order to prevent an adverse interaction between coining and medicine.

Discussion

Patients’ experiences of illness often differed from those of health care providers, and has shaped how they explain illness etiology, pathophysiology, treatment, and/or prognosis. In our study, the Cambodian term krun described feeling ill, feeling hot and cold, feeling hot, or having specific illnesses that may or may not have been accompanied by elevated body temperature. krun is not equivalent to the biomedical use of the term fever. The common interpretation from Cambodian to English of the term krun as “fever” is of concern in a biomedical setting. Krun, interpreted as “fever,” could result in unnecessary medical tests and observation, especially in a pediatric setting where a history of fever in an infant often results in many cultures and blood tests.

Other authors have noted that “fever” or “hot” in Southeast Asians may not mean an elevated body temperature, but none have documented the specific terms used. (1) One author, of a review on Cambodian health care beliefs, lists several common words used in a biomedical medical setting that lead to misunderstandings when working with Cambodians, but fever or krun are not included. (2) He does note that “hot” may mean that a patient has a fever but can also mean that the patients believe they have a “hot” illness according to Chinese medicine traditional classification of illness as “hot” or “cold” conditions. None of our informants specifically associated krun with the “hot”/”cold” system of illnesses, but we did not ask directed questions about this belief system.

Our own experience with other Southeast Asian ethnic groups and translation problems suggests that a similar misunderstanding of a generic sickness term for the biomedical concept of “fever” often occurs in medical interviews in Vietnamese, Lao and Thai. This may be a more common issue in Asian ethnic groups. One recent study comparing concepts and beliefs about fever between ethnic groups found that among Vietnamese parents who named health professional as their main source of information about fever, one-third stated that their beliefs differed from those of their health care provider compared to only 4% of Hispanic African American parents and 5% of Caucasian parents.(3)

Fever (krun) and dizziness (vilmuk) were both clearly associated with the folk concept of wind illness or khyol. (See Folk Illness)

Conclusion and Practical Implications

1. Provider Education
   Providers need to be aware that when taking a history from a Cambodian patient, the patient’s concept of fever may be very different than the biomedical concept of fever. The patient is describing an illness condition with a range of symptoms which may or may not include an elevated body temperature. It is important to ask about the specific symptom of the body feeling hot to touch. Few Cambodians, not educated in the West, will use a thermometer to take a body temperature.
2. Interpreter Education
   Cambodian interpreters should be instructed to translate krun as “illness” rather than as “fever.” Or, if krun is translated as “fever” must give a full explanation of what patient means by “krun “. This will help prevent confusion with the biomedical concept of fever and encourage the provider to explore the patient’s experience of their illness in greater depth.Western providers also need to be aware that when Cambodians complain of dizziness and fever, they often believe that they have wind illness, a folk illness syndrome common throughout Southeast Asia. Coining is the most common treatment for this condition among Cambodians.
3. Patient Education
   Cambodian cultural beliefs and practices about fever provide a good framework for counseling about home treatment and triage. Educational approaches should emphasize the following points with patients:
   • Western doctors are worried about forms of krun where the body feels hot and the person does not eat well and don’t do their normal activities. Tell the doctor about these specific features of krun.
   • Tylenol, like coining, helps to “adjust and balance” body heat so the body will feel relaxed and comfortable. Tylenol should primarily be used when the body feels hot, aches, or there is localized pain.
   • Western doctors do not think there is any harm in using Tylenol and coining together. It is important to not delay giving Tylenol if the body feels hot.
   • Traditional practices such as avoiding bathing, wrapping in light blankets, and eating warm rice soup for illness are helpful.
   • Encourage the cultural practice of seeking medical attention for severe krun like krun ngiah (shaking/high fever); krun that comes from a specific cause such as an ear infection or is associated with pain, or krun with trouble breathing.
   • Encourage home treatment for colds with the following points: Cold and flu (krun pradas sai) are very common. If there is no pain in the ears or other areas of the body, and no trouble breathing, home treatments are helpful. It can be treated at home with Tylenol, coining and eating warm rice soup.
   • Western doctors may not be familiar with wind illness, or khyol, but if you think your illness is due to khyol, explain this to the doctor and what you think may be causing khyol in you at this time.

References

1. Muecke MA. In Search of Healers-Southeast Asian refugees in the American health care system. West J Med 1983;139:835.
2. Kemp C. Cambodian refugees health care beliefs and practices. J Comm Health Nursing. 1985;2:41.
3. Limbas MP, Grover G, Bartlett C, Berkowitz C. Cross-cultural beliefs about fever. From Ambulatory Pediatric Assoc meeting 1997. Abstract No. 77, Poster No. 316.