Methods
The following section describes beliefs and practices relating to tuberculosis among Vietnamese residing in the U.S. It is based upon (1) the transcripts of Vietnamese focus groups held in California and (2) interpretation of this data by the Advisory Panel on TB and Vietnamese Culture, convened in Honolulu in 1997.
Causes of TB
Vietnamese believe tuberculosis to be caused by a variety of factors. Some members of the focus groups mentioned the germ theory of disease, but many other causative factors were mentioned. Among these were the following: malnutrition, overwork, excess stress, alcohol, cigarettes, poor hygeine, unsanitary neighborhoods, polluted environments, heredity, exposing the chest to cold, supernatural causes.
Cultural Advisory Panel members also noted that many believe tuberculosis to be caused by humidity or by dusty environments.
Regarding the germ theory, some participants noted that TB develops when the body is weakened by factors such as those listed above. Such a view is consistent with modern biomedical views on the cause of tuberculosis.
It was also stated that “everybody” has the TB germ, perhaps reflecting the high prevalence of TB infection in Vietnam. Given this experience, patients from Vietnam may not consider a positive PPD as a matter for concern, and extra time may need to be taken to explain the unfamiliar concept of TB preventive therapy. Some patients may believe that the BCG vaccination, commonly used in Vietnam, will protect them from TB infection (Carey et al., 1997).
Symptoms and Progression of TB
Focus group participants identified the medically recognized symptoms of TB, as follows: Coughing, Weight loss, Fever, Fatigue.
They also noted that people with TB experience: Bloody vomit, Muscle aches and pains, Difficulty sleeping, Depression, Suffering and death.
A physician in the Cultural Advisory Panel noted that patients often associate middle, upper-back pain with TB.
While some focus group participants maintained that TB is a silent disease which can’t be detected early, others maintained that it can be found early, and that the mild stages of TB can be treated. Similarly, a survey of recent Vietnamese refugees found that while most respondents understood that TB disease is not inevitable following infection, a minority of those respondents (29%) incorrectly thought that the development of disease inevitably followed infection. “Such a belief could lead to a view that chemoprophylaxis is useless” (Carey et al., 1997).
Focus group comments indicate that tuberculosis is not clearly differentiated from other respiratory conditions in the popular health belief system. Thus it is believed that TB can become cancer, that TB can cause other “lung diseases.” It is also believed that the person with TB easily develops colds and flu.
Contagion and Social Stigma
The focus group participants viewed TB as contagious, that it can be spread by:
- Coughing, sneezing, spitting
- From mother to child during pregnancy
- Sharing eating utensils, blankets, bed sheets, towels
Focus group participants indicated ways to prevent the spread of the illness: “Separate active TB, severe cases, to cure and prevent spread,” and “Don’t get too close or use their things.”
This belief that TB is extremely contagious leads to isolation of the sufferers of TB and their families. In Vietnam, “TB in the family is social humiliation, jeopardizing marriage contracts and work.” There are stories told about Vietnamese families in the U.S. where planned marriages were called off due to a family history of TB (Cultural Advisory Panel). In the U.S., TB is seen as having “highly adverse social consequences,” including job loss, deportation, family and community stigmatization (Carey et al., 1997).
Significant stress and mental anguish can result from the stigma associated with TB and the resulting isolation of TB sufferers and their families. Vietnamese patients are most likely to express these stresses somatically, often as fatigue or body aches. Since fatigue and body aches are also potentially symptoms of TB disease, or side effects from medication, health practitioners may not have an easy time sorting through cause and effect.
The Western concept of psychiatric illness is different from that of Vietnamese culture and medicine. Severe mental illness is recognized, although families will rarely send a mentally ill relative to an institution, “preferring to hide him at home ” (Cultural Advisory Panel). The concept of an apparently functional person suffering from mild or moderate psychiatic illness, however, is not familiar. Thus a suggestion to seek counseling is equivalent to labeling a Vietnamese patient as “crazy.”
Health practitioners who attempt to label symptoms as psychiatric and refer the patient out for therapy, especially on the first visit, are likely to be met with anger and/or noncompliance. They are advised to focus initial efforts on agreed-upon symptoms and problems, to build a relationship with the patient over several visits (“just get them talking”), gradually provide education regarding therapy, and then attempt a referral for behavioral therapy (Cultural Advisory Panel).
Treatment Beliefs
Consistent with the belief that TB is caused by various factors, focus group participants and advisory panel members believed that there are multiple factors involved in healing the sufferer of TB.
Changes in the environment and exposures
- Change the living environment: avoid areas with mildew and mold
- Change the weather conditions: living near the ocean is beneficial
Correcting imbalances in the body
- Improve personal nutrition, hygeine, and health habits
Western medicine, combined with the health-promoting behaviors listed above, is generally believed to be the best treatment for TB (AAPCHO TB focus groups, Cultural Advisory Panel, Carey etal., 1997). Focus group participants expressed doubt that traditional or herbal medicines, acupuncture, or praying would cure TB. Cultural Advisory Panel members stated that while many Vietnamese believe that certain illnesses are best treated with either Chinese medicine or Vietnamese treatments (such as coining or cupping,) that most believe Western medicine is needed to cure TB. Carey et al. found all respondents listed a Western physician as the most appropriate person to consult for TB treatment.
There may, however, be Vietnamese patients who believe in the efficacy of Eastern treatments, and may choose to utilize them in addition to biomedical treatment. Some may even choose to resort to such methods exclusively.
It may be difficult to get Vietnamese patients to go along with particular aspects of the biomedical approach to TB. Many Vietnamese believe that exposure to X-rays kills their blood cells and makes them tired or makes their skin turn yellow. In Vietnam, nurses will often advise their patients to eat meat and eggs to compensate for the effects of X-rays. Traditionally, it is believed that the body has a finite amount of blood, and that withdrawing blood causes an irreversible decrease. This makes many Vietnamese patients very reluctant to consent to drawing blood. Some mention the number of bowls of rice needed to make up for the effects of drawing blood.
Recommendations for Providers
- TB infection: Address possible patient assumption that “everybody” has TB germs in the body, and for those under 25, take time to explain the significance of a positive PPD and the rationale for preventive therapy.
- Blood tests and X-rays: It may be helpful to educate patients that the body constantly makes new blood cells. If a patient seems concerned about harmful effects of x-rays or blood tests, stress may be alleviated by asking,” What have you found that helps strengthen your body when it feels weak? If the response is something non-harmful, such as eating a “cold” food, or eating extra meat, encourage them to do a bit more of this strengthening activity, “even though the x-ray/blood test is quite safe and should not cuase any problem.”
- Psychosomatic illness: An internist advises: “If I tell a Vietnamese patient,’you may be depressed,’ they will say ‘What are you talking about?’ If I say this, especially on the first visit, they get angry, they think I am saying they are lying. In dealing with psychosomatic cases, let them somatize, get them talking, consider them a ‘future referral’ and after a couple months slowly, slowly introduce the concept of psychiatric care.”
References and Further Reading
Carey, J.W., Oxtoby, M.J., Nguyen, L.P., Huynh, V., Morgan, M., Jefferey, M. “Tuberculosis Beliefs Among Recent Vietnamese Refugees in New York State.” Public Health Reports. 1997;112:66-72.
Compliance with INH Prophylaxis for Tuberculosis
Linguistic and Cultural Aspects of Tuberculosis Screening and Management for Refugees and Immigrants
Cross Cultural Tuberculosis Guide: This guide is available through the Association of Asian Pacific Community Health Organizations (AAPCHO) and identifies the cultural influences on TB related Beliefs and Practices of Filipinos, Vietnamese, Chinese, and Koreans.
Patient Education Material
There are a number of sites that have TB patient education materials in other languages including Somali. See external resources in the Infectious Disease Patient Education section.