People of Indian Heritage, of Turkish Heritage and of Vietnamese Heritage.

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 1 Chapter 38 People of Vietnamese Heritage Susan Mattson and

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Larry D. Purnell Overview, Inhabited Localities, and Topography Overview Vietnam is located at the extreme southeastern corner of the Asian mainland, bordering the Gulf of Thailand, Gulf of Tonkin, and South China Sea, alongside China, Laos, and Cambodia. With a population of over 90 million in a land mass of 127,330 square miles (CIA World Factbook, 2011), it is relatively narrow in width, but its north–south length equals the distance from Minneapolis to New Orleans. Vietnam consists largely of a remarkable blend of rugged mountains and the broad, flat Mekong and Red River deltas, which mainly produce rice. Other features are a long, narrow coastal plain and other riverine lowlands, where most ethnic Vietnamese live. Much of the rest of the country is covered with tropical forests. Longevity for females is 74.92 years, and for males, 69.72 years. The fertility rate is a low 1.91 children per female (CIA World Factbook, 2011). Heritage and Residence The Vietnamese are a Mongolian racial group closely related to the Chinese. The population shares some characteristics with other Asian and Pacific Islander groups, yet many aspects of its history and culture are unique. Vietnam was under Chinese control from 111 BC to AD 939 (Huer, Saenz, & Doan, 2001). At that time, a variety of Chinese beliefs and traditions were introduced to Vietnam, including the religions and philosophies of Confucianism, Buddhism, and Taoism. In addition, the system of Chinese medicine was adopted widely. European merchants and missionaries arrived in Vietnam during the 16th century, and the French established a political foothold and instituted changes in government and education, including Western medical practices (Huer et al., 2001). The terms Indochinese and Vietnamese are not synonymous. Indochina is a supranational region that includes the countries of Vietnam, Laos, and Cambodia. Vietnam alone has eight different ethnic groups, the majority (86 percent) of whom are Viet (CIA World Factbook, 2011). One factor in providing proper health care to Vietnamese in America is understanding that they differ substantially between and among themselves, depending on the variant cultural characteristics of culture (see Chapter 1in this book). Clear differences exist among Vietnamese, Cambodians, and Laotians with respect to premigration experiences, which influence subsequent manifestations of psychological distress. Along with Asian Indians, Vietnamese immigrants have the highest proportion of children under the age of 18, with a median age of 33, yet the poverty rate is highest for Koreans, Vietnamese, and Chinese (13 percent). Within this population, Vietnamese immigrants have the highest proportion of naturalized citizens (50 percent), with the smallest proportion of those who were foreign born and not U.S. citizens at 21 percent; 30 percent are native born Americans. Forty-nine percent of the immigrants arrived before 1990, and 42 percent came between 1990 and 1999 (Office of Minority Health, 2007). Initial Vietnamese immigrants confronted a unique set of problems, including dissimilarity of culture, no family or relatives to offer initial support, and a negative identification with the unpopular Vietnam War. Many Vietnamese were involuntary immigrants, with their expatriation unexpected and unplanned; their departures were often precipitous and tragic. Escape attempts were long, harrowing, and for many, fatal. Survivors were often placed in squalid refugee camps for years. The first wave of Vietnamese immigration began in April 1975, when South Vietnam fell under the Communist control of North Vietnam and the Viet Cong. At that time, many South Vietnamese businessmen, military officers, professionals, and others closely involved with America or the South Vietnamese government feared persecution by the new regime and sought to escape. American ships and aircraft rescued some; many were temporarily located in refugee camps in Southeast Asia, and then sent to relocation camps in the United States. The 130,000 Vietnamese refugees who arrived in the United States in 1975 came mainly 1 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 2 2 Aggregate Data for Cultural-Specific Groups from urban areas, especially Saigon, and consequently had some prior orientation to Western culture. Many spoke English or soon learned English in relocation centers. More than half were Christian. Sixty-two percent consisted of family units of at least five people, and nearly half were female. They were dispersed over much of the United States, often in the care of sponsoring American families. One year after arrival, 90 percent were employed, and by the mid-1980s, their average income matched that of the overall American population. These first-wave immigrants adjusted well in comparison to the subsequent wave. By the 1970s,further events in Vietnam triggered a second wave of immigration. Many Vietnamese grew disenchanted with Communism and their decreased living standard. Great numbers had been forced into labor in new countryside settlements, and young men were often fearful of being called to fight against China or in the new war with Cambodia. Some left by land across Cambodia or Laos, commonly joining refugees from those countries in an effort to reach Thailand. For more than a decade, many others, known as the “boat people,” departed Vietnam in small, often unseaworthy and overcrowded vessels in hopes of reaching Malaysia, Hong Kong, the Philippines, or another non-Communist port. Half died during their journey. Many were forcibly repatriated to Vietnam or eventually returned voluntarily; others continued to languish in camps for years. Most of the second-wave refugees represented lower socioeconomic groups and had less education and little exposure to Western cultures. Most did not speak English. This wave of Vietnamese included far more young men than women, children, or older people, which disrupted intact families and normal gender ratios. Many spent months or years in refugee camps under deplorable and regimented conditions. The United States passed the Refugee Act of 1980 in response to this second wave and widened the scope of resources available to assist refugees or individuals who fled their native country and could not returen for fear of persecution and physical harm (Huer et al., 2001).When they finally arrived in the United States and Canada, many did not fit into American communities, did not learn English effectively, and remained unemployed or obtained menial jobs. These hardships contributed to physical problems, psychological stress, and depression. The contiuing persecution of individuals in Vietnam led to a third wave of immigration, beginning in 1979 with the creation of the Orderly Departure Program, which provided safe and legal exit for Vietnamese seeking to reunite with family members already in America. Former military officers and soldiers in prison or reeducation camps were allowed to come the United States with their families, resulting in the immigration of 200,000 individuals by the mid-1990s. The Humanitarian Operation Program of 1989 also permitted more than 70,000 current and former political prisoners to immigrate. Finally, the Amerasian Homecoming Act of 1988 allowed the children of Vietnamese civilians and American soldiers to immigrate to the United States. Many of the Amerasian children were orphans who had lived on the street, received no formal education, and had been subjected to prejudice and discrimination in Vietnam (Huer et al., 2001). Reasons for Migration and Associated Economic Factors Vietnamese, whether as immigrants or sojourners, have fled their country to escape war, persecution, or possible loss of life. Better-educated, first-wave immigrants from urban areas had professional, technical, or managerial backgrounds. Less-educated, second-wave immigrants from more rural areas were fishermen, farmers, and soldiers and had only minimal exposure to Western culture. Factors influencing the ability of displaced Vietnamese to obtain employment included a higher level of education and the ability to speak English on arrival. Thus, the second-wave immigrants were significantly more disadvantaged. Educational Status and Occupations Vietnamese place a high value on education and accord scholars an honored place in society. The teacher is highly respected as a symbol of learning and culture. In contrast to American schools’ emphasis on experimentation and critical thinking, Vietnamese schools emphasize observation, memorization, and repetitive learning. This style of learning is still predominant in Vietnam, including the universities with schools of medicine and nursing. Most Vietnamese men and women in America are very educationally oriented and take full advantage of educational opportunities when possible. Educational level and occupation continue to vary by the time of arrival in the United States, as described earlier in the discussion of the four waves of immigration. Communication Dominant Languages and Dialects The official language of Vietnam is Vietnamese, with English increasingly being favored as a second language, followed by French and Chinese (CIA World Factbook, 2011). Ethnic Vietnamese speak a single distinctive language, with northern, central, and southern dialects, all of which can be understood by anyone speaking any of these dialects. The Vietnamese language resembles Chinese and contains many borrowed words, but someone speaking one of these languages cannot necessarily understand the other. All words in Vietnamese consist of a single syllable, although two words are commonly joined with a hyphen to form a new word. Verbs do not change 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 3 People of Vietnamese Heritage forms, articles are not used, nouns do not have plural endings, and there are no prefixes, suffixes, definitives, or distinctions among pronouns. Contextually, the Vietnamese language is musical, flowing, and polytonal, with each tone of a vowel conveying a different meaning to the word. The language is spoken softly, and its monosyllabic structure lends itself to rapidity, but spoken pace varies according to the situation. Whereas grammar is mostly simple, pronunciation can be difficult for Westerners, mainly because each vowel can be spoken in five or six tones that may completely change the meaning of the word. Vietnamese is the only language of the Asian mainland that, like English, is regularly written in the Roman alphabet since it was introduced by the French in the 17th century. Although the letters are the same, pronunciation of vowels may vary radically depending on associated marks indicating tone and accent, and certain consonant combinations take on unusual sounds. When speaking Vietnamese, Westerners in particular will often use “hand signals” to indicate an upward inflection or a mark that should appear with the letter being spoken (personal observation, Mattson, 2005, 2007–2009). Even if someone learns how to pronounce and translate Vietnamese, problems may remain with respect to intended meaning of various words. One minor but perennial stumbling point with potential medical connotations is that the words for “blue” and “green” are the same. More important, the word for “yes,” rather than expressing a positive answer or agreement, may simply reflect an avoidance of confrontation or a desire to please the other person. The terms “hot” and “cold,” rather than expressing physical feelings associated with fever and chills, may actually relate to other conditions associated with perceived bodily imbalances. Various medical problems might be described differently from what a Westerner might expect; for example, a “weak heart” may refer to palpitations or dizziness, a “weak kidney” to sexual dysfunction, a “weak nervous system” to headaches, and a “weak stomach or liver” to indigestion (Muecke, 1983b). Most Vietnamese refugees, even those who have been in the United States for many years, do not feel competent in English. Although many refugees eventually learn English, their skills may not be adequate in certain situations. The important subtleties in describing medical conditions and symptoms, or the more abstract presentation of ideas during psychiatric interviews may be particularly difficult. Health-care providers may need to watch patients for behavioral cues, use simple sentences, paraphrase words with multiple meanings, avoid metaphors and idiomatic expressions, ask for correction of understanding, and explain all points carefully. Approaching Vietnamese patients in a quiet, unhurried manner, opening discussions with small talk, and directing 3 the initial conversation to the oldest member of the group facilitate communication. Cultural Communication Patterns Traditional Vietnamese religious beliefs transmitted through generations produce an attitude toward life that may be perceived as passive. For example, whenever confronted with a direct but delicate question, many Vietnamese cannot easily give a blunt “no” as an answer because they feel that such an answer may create disharmony. Self-control, another traditional value, encourages keeping to oneself, whereas expressions of disagreement that may irritate or offend another person are avoided. Individuals may be in pain, distraught, or unhappy, yet they rarely complain except perhaps to friends or relatives. Expressing emotions is considered a weakness and interferes with self-control. Vietnamese are unaccustomed to discussing their personal feelings openly with others. Instead, at times of distress or loss, they often complain of physical discomforts such as headaches, backaches, or insomnia. Vietnamese tend to be very polite and guarded. Sparing one’s feelings is considered more important than factual truth. The strong influence of the Confucian code of ethics means that proper form and appearance are important to Vietnamese people and provide the foundation for nonverbal communication patterns. For example, the head is a sacred part of the body and should not be touched. Similarly, the feet are the lowest part of the body and to place one’s feet on a desk is considered offensive to a Vietnamese person. To signal for someone to come by using an upturned finger is a provocation, usually done to a dog; waving the hand is considered more proper. Hugging and kissing are not seen outside the privacy of the home. Men greet one another with a handshake but do not shake hands with a woman unless she offers her hand first. Women do not usually shake hands. Two men or two women can walk hand in hand without implying sexual connotations. However, for a man to touch a woman in the presence of others is insulting. Looking another person directly in the eyes may be deemed disrespectful. Women may be reluctant to discuss sex, childbearing, or contraception when men are present and demonstrate this unwillingness by giggling, shrugging their shoulders, or averting their eyes. Negative emotions and expressions may be conveyed by silence or a reluctant smile. A smile may express joy, convey stoicism in the face of difficulty, indicate an apology for a minor social offense, or be a response to a scolding to show sincere acknowledgment for the wrongdoing or to convey the absence of ill feelings. Vietnamese prefer more physical distance during personal and social relationships than some other cultures, but extended Vietnamese families of 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 4 4 Aggregate Data for Cultural-Specific Groups many individuals live comfortably together in close quarters. Temporal Relationships Vietnamese religion and tradition place emphasis on continuity, cycles, and worship of ancestors. Traditional Vietnamese may be less concerned about the precise schedules than are European Americans. To cope with their changed situation, many Southeast Asian refugees concentrate on the present and, to some extent, on the future. Asians frequently arrive late for appointments. Noncompliance in keeping appointments may relate to not understanding oral or written instructions or to not knowing how to use the telephone. One other aspect of time involves the concept of age. Vietnamese people pay much less attention to people’s precise ages than do Americans. Actual dates of birth may pass unnoticed, with everyone celebrating their birthdays together during the Lunar New Year (Tet) in January or February. In addition, a person’s age is calculated roughly from the time of conception; most children are considered to be already a year old at birth and gain a year each Tet. A child born just before Tet could be regarded as 2 years old when only a few days old by American standards. Because the practice of determining age is so different in Vietnam, many immigrants who do not know their exact birth date are often assigned January 1 for official records. When a friend is invited on an outing, the bill is paid for by the person offering the invitation. When giving gifts, the giver often discounts the item, even though it may be of great value. The recipient of a gift is expected to display significant gratitude, which sometimes lasts a lifetime. Some may be reluctant to accept a gift because of the burden of gratitude. Vietnamese may refuse a gift on the first offer, even if they intend to accept it eventually, so as not to appear greedy. Format for Names Most Vietnamese names consist of a family name, a middle name, and a given name of one or two words, always written in that order. There are relatively few family names, with Nguyen (pronounced “nwin”) and Tran accounting for more than half of all Vietnamese names. Other common family names are Cao, Dinh, Hoang, Le, Ly, Ngo, Phan, and Pho. Additionally, there is little diversity in middle names, with Van being used regularly for men and Thi (pronounced “tee”) for women. Given names frequently have a direct meaning, such as a season of the year or an object of admiration. Family members often refer to offspring by a numerical nickname indicating their order of birth. This practice may increase the difficulty of modern record-keeping and identification of specific individuals. Therefore, use the family name in combination with the given name. Indeed, Vietnamese refer to one another by given name in both formal and informal situations. For example, a typical woman’s name is Tran Thi Thu, which is how she would write or give her name if requested. She would expect to be called simply Thu or sometimes Chi (sister) Thu by friends and family. In other situations, she would expect to be addressed as Cô (Miss) or Ba (Mrs.) Thu. If married to a man named Nguyen Van Kha, the proper way to address her would be as Mrs. Kha, but she would retain her full three-part maiden name for formal purposes. The man would always be known as Kha or Ong (Mr.) Kha. Some Vietnamese American women have adopted their husband’s family name. Children always take the father’s family name. Family Roles and Organization Head of Household and Gender Roles The traditional Vietnamese family is strictly patriarchal and is almost always an extended family structure, with the man having the duty of carrying on the family name through his progeny. Some families who are not accustomed to female authority figures may have difficulty relating to women as professional health-care providers, although this is changing in Vietnam. Today there are many physicians, dentists, and pharmcists who are women, with an increasing number of men choosing nursing as a career (personal observation, Mattson, 2007–2009). With the move into Western society, the father may no longer be the undisputed head of the household, and the parents’ authority may be undermined. Immigrant Vietnamese families frequently experience role reversals, with wives or children adapting more easily than men. A Vietnamese woman lives with her husband’s family after marriage but retains her own identity. Within the traditional family, the division of labor is gender related: the husband deals with matters outside the home, and the wife is responsible for the actual care of the home, and often makes health-care decisions for the family. While many Vietnamese and Vietnamese American women work outside the home, they also continue as the primary caretaker of the home. Although her role in family affairs increases with time, a Vietnamese wife is expected to be dutiful and respectful toward her husband and his parents throughout the marriage. Vietnamese refugees of all subgroups have experienced degrees of reversal of the provider and recipient roles that existed among family members in Vietnam. “Women’s jobs,” such as hotel maid, sewing machine operator, and food-service worker, are more readily available than male-oriented unskilled occupations; today more men are employed in these jobs. Role reversals between parents and children are also common because children often learn the English language and American customs more rapidly than their parents 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 5 People of Vietnamese Heritage and therefore, may be able to find employment more quickly. Vietnamese families in the United States experience a greater tendency toward nuclearization, growth in spousal interaction and interdependency, more-egalitarian spousal relations, and shared decision making than their traditional counterparts. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Traditionally, children are expected to be obedient and devoted to their parents, their identity being an extension of the parents. Children are obliged to do everything possible to please their parents while they are alive and to worship their memory after death. The eldest son is usually responsible for rituals honoring the memory and invoking the blessings of departed ancestors. This pattern may be ingrained from early childhood. Vietnamese children are prized and valued because they carry the family lineage. For the first 2 years, their mothers primarily care for them; thereafter, their grandmothers and others take on much of the responsibility. Parents usually do not discipline or place extensive limits on their children at a young age. Generally, Vietnamese do not use corporal punishment such as spanking; rather, they speak to the children in a quiet, controlled manner. Young people are expected to continue to respect their elders and to avoid behavior that might dishonor the family. As a result of their exposure to Western cultures, a disproportionate share of young people have difficulty adapting to this expectation. A conflict often develops between the traditional notion of filial piety, with its requisite subordination of self and unquestioning obedience to parental authority, and the pressures and needs associated with adaptation to American life. Ironically, successful relationships with Americans at school have placed Vietnamese adolescents at risk for conflicts with their parents. Conversely, failure to form such relationships with their American peers has sometimes appeared to be a precursor of emotional distress. Parents do, however, show relative approval for adolescent freedom of choice regarding dating, marriage, and career choices. The extreme bipolarities of the adaptation of Vietnamese youth are sometimes overemphasized. Members of one group, usually the children of the first-wave refugees, are often portrayed as academic superstars. At the other end of the social spectrum are the criminal and gang elements, who often direct their activities against other Asian immigrants. Most Vietnamese adolescents, however, fall between these two extremes and have the same pressures and concerns as other youths. Family Goals and Priorities The traditional Vietnamese family is perhaps the most basic, enduring, and self-consciously acknowledged 5 form of national culture among refugees, providing lifelong protection and guidance to the individual. The family, usually large, patriarchal, and extended, includes minor children, married sons, daughtersin-law, unmarried grown daughters, and grandchildren under the same roof. Other close relatives may be included within the extended family structure. The family is explicitly structured with assigned priorities, identifying parental ties as paramount. A son’s obligations and duties to his parents may assume a higher value than those to his wife, children, or siblings. Sibling relationships are considered permanent. Vietnamese self is defined more along the lines of family roles and responsibilities and less along individual lines. These mutual family tasks provide a framework for individual behavior, promoting a sense of interdependence, belonging, and support. The traditional family has been altered as a consequence of Western influence, urbanization, and the war-induced absence of men. Nevertheless, many Vietnamese continue to uphold this social form as the preferable basis of social organization in the United States. As mentioned in the previous section, exposure of the younger generation to American culture can become a source of conflict with considerable family strain as adolescents are influenced by the perceived American values of individuality, independence, self-assertion, and egalitarian relationships. Traditionally, older people are honored and have a key role in transmitting guidelines related to social behavior, preparing younger people for handling stressful life events, and serving as sources of support in coping with life crises. Older people are usually consulted for important decisions. Addressing a client in the presence of an older person, whether they speak English or not, instead of the elder, may be interpreted as disrespectful to the family. Homesickness and bewilderment are especially acute in older refugees when confronted with the strange Western culture and despair about the future (Fig. 38-1). Accustomed to considerable respect and esteem in their homeland, they may feel increasingly alienated and alone as the younger generations adopt new values and ignore the counsel and values of the elders. Living within the family unit facilitates the social adjustment of older refugees into American society. Traditional Vietnamese are class conscious and rarely associate with individuals at different levels of society. Traditional respect is accorded to people in authoritative positions who are well educated or otherwise successful or who have professional titles. However, class distinctions are sometimes blurred in the turmoil of war and resettlement. Two concepts govern the gain and loss of prestige and power, thereby maintaining face: mien, based on wealth and power, and lien, based on demonstration of control over and responsibility for moral character. For example, to smile in the face of adversity is to maintain lien and is considered of great importance. 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 6 6 Aggregate Data for Cultural-Specific Groups However, this emphasis is not a detriment to productivity in work habits, because a good work record and steady pay bring honor and prosperity to the family. The Vietnamese are highly adaptable and adjust their work habits to meet requirements for successful employment. Most Vietnamese respect authority figures with impressive titles, achievement, education, and a harmonious work environment. They may be less concerned about such factors as punctuality, adherence to deadlines, and competition. Other traditions include a willingness to work hard, sacrifice current comforts, and save for the future to ensure that they assimilate well into the workforce. Many seek the same material, financial, and status rewards that beckon native-born Americans. Issues Related to Autonomy Figure 38-1 Elders are honored in traditional Vietnamese culture, but the effects of American culture on immigrant families may sometimes be troubling to older adult Vietnamese Americans. Alternative Lifestyles The complex extended Vietnamese family in America is extremely vulnerable to change. Many young people, frequently unmarried couples, seek their own living accommodations away from the control of older generations. Unattached male refugees may join pseudofamilies, households made up of close and distant relatives and friends who share accommodations, finances, and companionship. These families form an important source of social support in the refugee communities. Because of the high regard for chastity placed on Vietnamese adolescents, the number of single-parent households is low, as is the divorce rate. Differing sexual orientation is difficult for Vietnamese to face because being gay or lesbian brings shame upon the family, causing many gays and lesbians to remain closeted (Miae, 1999). When questioning a gay or lesbian person about his or her sexual activity, an interpreter unknown to the family is an absolute requirement. Workforce Issues Culture in the Workplace First-wave immigrants adjusted well to the American workplace, and within a decade, their average income equaled that of the general U.S. population. Many later immigrants, who had less education and did not know English, ended up working in lower-paying jobs. However, some learned English and opened their own businesses and prospered. Traditionally, priority is given to the concerns of the family rather than to those of the employer. Confucianism and its stress on the maintenance of formal hierarchies within governmental, religious, and educational institutions; commercial establishments; and families have heavily influenced the Vietnamese outlook. This cultural background results in conformity and reluctance to undertake independent action. At the same time, the cultural outlook of company and family values superseding personal values creates a cohesive work group. Moreover, because many fear losing their job if they speak out about inequities, they are likely to be taken advantage of by some moreunscrupulous employers. Vietnamese quickly learn vocabulary for pragmatic communication but may have difficulty with complex verbal skills. Values related to their own culture discourage disclosure of inner thoughts and feelings. These barriers may adversely affect employment opportunities and limit their ability to communicate needs relative to social, psychological, and economic matters. Employers may need to allow extra time and provide visually oriented instructions and programs that enhance communications to promote increased harmony in the workplace. Biocultural Ecology Skin Color and Other Biological Variations Vietnamese are members of the Mongolian or Asian race. Although their skin is often referred to as “yellow,” it varies considerably in color, ranging from pale ivory to dark brown. Mongolian spots, bluish discolorations on the lower back of a newborn child, are normal hyperpigmented areas in many Asians and dark-skinned races. To assess for oxygenation and cyanosis in darkskinned Vietnamese, the health-care provider must examine the sclerae, conjunctivae, buccal mucosa, tongue, lips, nailbeds, palms of the hands, and soles of the feet. These same areas should be observed for 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 7 People of Vietnamese Heritage adverse reactions during blood transfusions, giving special attention to diaphoresis on the forehead, upper lip, and palms, which may signify impending shock. One of the first signs of iron deficiency anemia is pallor, which varies with skin tones. Dark skin loses the normal underlying red tones, so that Vietnamese patients with brown skin will appear yellow-brown. Petechiae and rashes may be hidden in dark-skinned individuals as well, but these can be detected by observing for patches of melanin in the buccal mucosa and on the conjunctivae. Jaundice can be observed in dark-skinned Vietnamese as a yellow discoloration of the conjunctiva. Because many dark-skinned individuals have carotene deposits in the subconjunctival fat and sclera, the hard palate should also be assessed. The Vietnamese are usually small in physical stature and light in build relative to most European Americans. Adult women average 5 feet tall and weigh 80 to 100 lbs. Men average a few inches taller and weigh 110 to 130 lbs. Although Roberts, Copel, Bhutan, and Otis (1985) reported no significant difference in birth weight between refugee babies and those of other parents, Vietnamese children are small by American standards, not fitting the published growth curves. The study by Vangen et al. (2002) of the birth weights for Vietnamese, Pakistani, Norwegian, and African American babies found that the mean birth weights were largely unrelated to perinatal mortality, which was lowest for the Vietnamese (8.2 of 1000; 95 percent confidence interval [CI]: 5.1 to 11.3). They concluded that the differences in perinatal mortality between ethnic groups were not explained by differences in mean birth weight. Paradoxical differences in birth weight–specific mortality rates could be resolved by adjustment to a relative scale. Thus, growth charts commonly used in America cannot provide adequate assessments for evaluating the physical development of Vietnamese children. Other parameters such as parental height and weight, apparent state of health, the energy level of the child, and progressive development over time need to be considered. Typical physical features of the Vietnamese include almond-shaped eyes, sparse body hair, and coarse head hair. Vietnamese also have dry earwax, which is gray and brittle. People with dry earwax have few apocrine glands, especially in the underarm area, and thus produce less sweat and associated body odor. Asians generally have larger teeth than European Americans, creating a normal tendency toward a prognathic profile. In addition, there may be a torus, bony protuberance, on the midline of the palate or on the inner side of the mandible near the second premolar. Hjertstedt et al. (2001) found that 23 percent of Vietnamese subjects in their study had mandibular tori, 13 percent had palatal tori, and 12 percent had both mandibular and palatal tori. Mandibular tori were more common in men, and palatal tori were more common in women. 7 Betel nut pigmentation may be found in some Vietnamese adults, resulting from the practice of chewing betel leaves (chau). This practice is common among older women and has a narcotic effect on diseased gums. Some older women lacquer their teeth, believing that it strengthens the teeth and symbolizes beauty and wealth. Diseases and Health Conditions Vietnamese women have the highest rate of cervical cancer of any female population in the United States that has been surveyed, approximately 43 per 100,000 or six times the national average (Wright, 2000). The prevalence of the disease is the result of lack of education, reluctance to seek early treatment, fear that nothing can be done, low utilization of annual Pap smears, and failure to follow up on abnormal Pap smears. Some evidence also implicates human papillomavirus (HPV), a sexually transmitted etiological factor, in the pathogenesis of cervical cancer. Cancer and other problems common to Vietnamese people may also be associated with the widespread application of chemical agents during the Vietnam War. Vietnamese Americans ages 56 and older are twice as likely as Caucasian Americans to report needing mental health care and also less likely to discuss such issues with a professional. Many of the problems are believed to be related to the Vietnam War and leaving the country in 1975. “They already had pre-war trauma, and they come to the U.S and it’s a new country, a new language and they have to find jobs. What we are finding is that 30 years after the war, there are still people having problems” (Sorkin et al., 2008, p.1). Mental-health research has indicated that Vietnamese refugees have disturbingly high rates of depression, generalized anxiety disorders, and post-traumatic stress associated with military combat, political imprisonment, harrowing events during escapes by sea, and brutal pirate attacks. Chronic personal and emotional problems often stem from post-traumatic stress experiences in this population (Hilton et al., 1997). Of immediate concern to health-care providers working with Vietnamese refugees is the treatment of infectious conditions that jeopardize both the refugee and the resident population. Some refugees suffer from malaria, parasites, and other problems associated with the tropics, although Catanzaro and Moser (1982) reported that the Vietnamese have a lower incidence of intestinal parasites, anemia, and hepatitis B antigenemia than other refugee groups. However, 69 percent of tuberculin tests return positive in the Vietnamese refugees, and this high rate of positive results correlates with their origins from crowded, poorly ventilated cities. Screening of second-wave refugees reveals a higher incidence of tuberculosis, intestinal parasites, anemia, malaria, and hepatitis B. Sutter and Haefliger (1990) reported an estimated 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 8 8 Aggregate Data for Cultural-Specific Groups annual risk of 2.2 percent for developing active tuberculosis in Vietnamese people and also noted that the disease was most likely present before arrival in refugee camps. Hepatitis B virus is hyperendemic in Indochina, with most people being infected during childhood and spreading the infection to others. Hepatitis B virus vaccination is recommended for all newborn refugee children. Other endemic diseases include leprosy (a rate of about 20 to 30 cases per 1000 population compared with a U.S. rate of fewer than 0.25 per 1000 population); high levels of parasitism, particularly the intestinal nematodes Ascaris (roundworm) and Trichuris (whipworm), which are associated with contaminated or poorly cooked foods, the liver fluke Clonorchis, which is introduced in raw, pickled, or dried fish (Dao, Gregory, & McKee, 1984), and Necator (hookworm); and malaria. To determine the presence of parasites, health-care providers must assess for symptoms of anemia, lassitude, failure to thrive, abdominal pain, weight loss, and skin rashes. In the first two waves of refugees, major health problems also included skin infections caused by fungus, impetigo, scabies, and lice (7 to 15 percent); infections of the upper respiratory tract and otitis media (20 percent); anemia including parasitic iron deficiency (16 to 40 percent), with a higher occurrence in young children; hemoglobin disorders (30 percent); chronic diseases (10 percent); and malnutrition and poor immunization status (Ross, 1982). Caution should be used before routinely diagnosing tuberculosis. Two clinical illnesses that may mimic tuberculosis, melioidosis and paragonimiasis, are also reported among refugees. Additionally, Sutherland, Avant, Franz, and Monson (1983) reported that 14 percent of the Vietnamese refugees in their Mayo Clinic study exhibited microcytosis, which can lead to an incorrect diagnosis of iron deficiency and inappropriate treatment with iron. Erythrocytic microcytosis in Southeast Asians is most likely a reflection of the presence of thalassemia or of hemoglobin E trait, conditions that are usually harmless and need no treatment. These disorders should be suspected in people with findings consistent with tuberculosis but with a negative purified protein derivative response (Ross, 1982). Screening immigrants for syphilis shows an incidence as low as 1 to 5 percent. Sporadic cases and limited outbreaks of cholera, measles, diphtheria, epidemic conjunctivitis, and typhoid fever fail to show a notable secondary spread (Ross, 1982). Observations at the Mayo Clinic reported that refugee populations are young and generally healthy, despite a prevalence rate of 82 percent for intestinal parasites (Sutherland et al., 1983). In addition, moderate to severe dental problems may occur in newer immigrants, especially children. The health-care provider should consider screening newer refugees and immigrants from Vietnam for nutritional deficits; hepatitis B; tuberculosis; parasites such as roundworm, hookworm, filaria, flukes, amoebae, and giardia; malaria; HIV; Hansen’s disease; and post-traumatic stress disorder. Recommended laboratory and other tests for refugees include a nutritional assessment, stool for ova and parasites, hemoglobin and hematocrit, and a chest radiograph for tuberculosis. Variations in Drug Metabolism Little pertinent drug research exists specifically on the Vietnamese. Clinical studies comparing other Asians with European Americans provide some idea of what might be expected. For example, the Chinese are twice as sensitive to the effects of propranolol on blood pressure and heart rate; experience a greater increase in heart rate from atropine; require lower doses of benzodiazepines, diazepam, and alprazolam because of their increased sensitivity to the sedative effects of these drugs; require lower doses of imipramine, desipramine, amitriptyline, and clomipramine; and are less sensitive to cardiovascular and respiratory side effects of analgesics (e.g., morphine) but are more sensitive to their gastrointestinal side effects. Asians require lower doses of neuroleptics (e.g., haloperidol) (Levy, 1993). Lin and Shen (1991) expressed concern about the lack of research on pharmacotherapy specifically related to major depressive and post-traumatic stress disorders in Southeast Asian refugees. They suggested that drug metabolism is comparable with that of other Asian groups with important common traits such as genetic, cultural, and environmental influences. Asian diets, for example, are similar in their higher carbohydrate-to-protein ratio, which significantly influences the metabolism of some commonly prescribed drugs. Also, because most Asians come from areas with similar degrees of socioeconomic development, exposure to various enzyme-inducing agents, such as industrial toxins, is likely to be similar. Conversely, the exposure of the refugees to war, trauma, starvation, and other adverse conditions could have an effect on the enzyme systems governing psychotropic medications. One precaution involves the continued extensive use of traditional herbal medicines by the refugees. Some of these herbal drugs have active pharmacologic properties that may interact with psychotropic drugs. For example, some may cause atropine psychosis when ingested concomitantly with tricyclic antidepressants or low-potency neuroleptics. Significantly lower dosages of psychotropic medications are prescribed in Asian countries than are common in Western countries. Low doses of antidepressant medications are often effective. Weight standards for neuroleptic dose ranges are significantly 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 9 People of Vietnamese Heritage lower in Asians than among white Americans (Levy, 1993). Because Vietnamese are considerably smaller than most white Americans, medication dosages may need to be reduced. Vietnamese generally consider American medicines more concentrated than Asian medicines; thus, they may take only half of the dosage prescribed. In addition, many Asian people are slow metabolizers of alcohol. Thus, Asians are more sensitive than European Americans to the adverse effects of alcohol, as expressed by facial flushing, palpitations, and tachycardia. High-Risk Behaviors Alcohol and tobacco use by Vietnamese in general has been reported to be relatively low. However, some adolescents have turned to alcohol, often drinking alone. Yu (1991) reported a substantial increase in smoking among Asian American women in general; traditionally there have been more men than women smokers. Jenkins, McPhee, Dordham, and Hung (1992) found the incidence of smoking among men in California was higher in Vietnamese than in Chinese or Hispanics. The prevalence of alcohol consumption is 67 percent among Vietnamese men and only 18 percent among women, versus 66 percent and 47 percent, respectively, in the general population. Binge drinking is reported by 35 percent of men. Among women, 89 percent say they had never heard of the Pap test; after this procedure is explained, 32 percent say they never had one (versus 9 percent of American women). Vietnamese women living in the United States have a cervical cancer incidence rate that is five times that of Caucasian women. Contibuting to this problem is the low rate of cervical cancer screening among this high-risk population (Solomon, DeJoice, Nguyen, Kwon, & Berlin, 2005).Recent U.S. data indicate that women of Vietnamese descent also have lower levels of Pap testing than Caucasian, Black, and Latina women. Regular Pap testing was strongly associated with having a regular doctor, having a physical in the last year, previous physician recommendation for testing, and having asked a physician for testing. However, women whose regular doctor was a Vietnamese man were no more likely to have recieved a recent Pap smear than those with no regular doctor. The authors of the study recommend that intervention programs should improve patient–provider communication by encouraging health-care providers (especially male Vietnamese physicians serving women living in ethnic enclaves) to recommend Pap testing (Taylor et al., 2009). Solomon et al. (2005) also found that knowledge about the importance of Pap tests was the most influential factor in contributing to why Vietnamese women may not seek a Pap test, and recommended print materials to include both English and Vietnamese translations. In addition, 28 percent of women never had a breast examination and 83 percent never had a 9 mammogram. Findings from a study of the Cancer Prevention Institute of California reveal that Asianborn women in the United States, particularly women from Vietnam, China, and the Philippines, have a much higher risk of dying from breast cancer than U.S.-born Asian Americans. The highest-risk group, women born in Vietnam, had a four times greater risk of dying from breast cancer than U.S.-born Vietnamese (Medical News Today, 2010). The incidence of lung cancer is 18 percent higher among Southeast Asian men than among European American men, most likely associated with smoking and exposure to environmental pollutants. Among Asian American men, lung and bronchial cancer are the leading causes of death (Medical News Today, 2010). Further, the incidence of liver cancer is more than 12 times higher among Southeast Asian men and women. The high rate of liver cancer is associated with the prevalence of hepatitis B (HBV) in Southeast Asian immigrants. Between 7 and 14 percent of Vietnamese American men are chronically infected with HBV (Medical News Today, 2009). Up to 60 percent of liver cancer from HBV can be prevented by immunization, but it was found that low socioeconomic status and use of traditional health care were associated with lower immunization rates (Medical News Today, 2010). High rates of gastrointestinal cancer may be due to asbestos that is used in the process of “polishing” rice in some parts of the world. Colorectal cancer is the fourth most common cancer in the United States, and the third most common among Vietnamese adults in California. Yet Vietnamese Americans have lower rates of screening for colorectal cancer compared to other Asian Americans and Whites (Medical News Today, 2010). Trichinosis risk is 25 times greater in Southeast Asian refugees than in the general population. This increased risk is related to undercooking pork and purchasing pigs directly from farms. Generally, young Asians are less sexually active than other groups and have a lower risk of AIDS. Similarly, Vietnamese also have a lower incidence of AIDS than do Japanese people (Cochran, Mays, & Leung, 1991). Possibly related to psychological pressures on refugees is the occurrence of sudden unexplained death syndrome (SUDS), a phenomenon reported mainly for the Hmong but also affecting Vietnamese and other Asian groups. Nearly all deaths involve physically healthy, young adult men who die at night or during sleep. The Centers for Disease Control and Prevention (1990) reported 117 cases from 1981 to 1988 and suggested that a structural abnormality of the cardiac conduction system and stress may be risk factors for SUDS. The exact cause of the deaths remains unknown. These deaths may be a form of unconscious suicide associated with nightmares brought on by intensive feelings of depression and survivor guilt (Tobin & Friedman, 1983). 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 10 10 Aggregate Data for Cultural-Specific Groups Health-Care Practices The Vietnamese approach to health care is one of ambivalence. Many Vietnamese immigrants are accustomed to depending on the family unit and traditional means of providing for health needs. They may be distrustful of outsiders and Western methods. Most are familiar with immunizations and diagnostic tests, and they do want to avoid health problems and are anxious to follow reasonable procedures. Newly arrived refugees are less likely to seek Western health care, but once established, Vietnamese are the most likely of the Southeast Asians to seek care and to do so earlier (Strand & Jones, 1983). Most Southeast Asian refugees want to go to a physician for an illness, but they rarely seek care when they are asymptomatic (for screeing and prevention services), and few are familiar with the appointment system. Some regard the most-convenient physician as the closest one not requiring an appointment and accepting medical coupons, which usually translates into a hospital emergency room (Muecke, 1983a). In contrast, the Vietnamese family may not seek outside assistance for illness until it has exhausted its own resources. The family may try various home remedies, allowing the condition to become serious, before seeking professional assistance. Once a physician or nurse has been consulted, the Vietnamese are usually quite cooperative and respect the wisdom and experience of health-care professionals. Hospitalization is viewed as a last resort and is acceptable only in case of emergency when everything else has failed. With respect to mental health, Vietnamese do not easily trust authority figures, including treatment staff, because of their refugee experiences. Nutrition Meaning of Food Meals are an important time to the Vietnamese, allowing the entire family to come together and share a common activity. Preparation is precise and may occupy much of the day. Celebrations and holidays involve elaborately prepared meals. Common Foods and Food Rituals Because of their size, the normal daily caloric intake of the Vietnamese is approximately two-thirds that of average Americans. Rice is the main staple in the diet, providing up to 80 percent of daily calories. Other common foods are fish (including shellfish), pork, chicken, soybean curd (tofu), noodles, various soups, and green vegetables. Preferred fruits are bananas, mangoes, papayas, oranges, coconuts, pineapples, and grapefruits. Soy sauce, garlic, onions, ginger root, lemon, and chili peppers are used as seasoning. The Vietnamese eat almost exclusively white or polished rice, disdaining the more nutritious brown or unpolished variety. Rice and other foods are commonly served with nuoc mam, a salty, marinated fish oil sauce. A meal typically consists of rice, nuoc mam and a variety of other seasonings, green vegetables, and sometimes meat cut into slivers. Chicken and duck eggs may be used. The Vietnamese prefer white bread, particularly French loaves and rolls, and pastry. A regular dish is pho, a soup containing rice noodles, thinly sliced beef or chicken, and scallions. Other Vietnamese dishes resemble Chinese foods commonly seen in the United States. Some of these include com chien (fried rice) and thit bo xau ca chua (beef fried with tomatoes). Perhaps the favorite of Americans is cha gio (pronounced “cha-yuh”), a combination of finely chopped vegetables, mushrooms, meat or bean curd, rolled into delicate rice paper and deep fried. If fried, it is also called a “spring” roll, while if left uncooked (the rice paper), it is a “summer” roll. It is served as part of elaborate meals or during celebrations; proper preparation may require many hours. Vietnamese eat three meals a day: a light breakfast, a large lunch, and dinner, with optional snacks. Meals are served communal style, with food being placed in the center of the table or passed around, with everyone taking what they wish. If in a restaurant, the various dishes are often brought out when they are prepared, not necessarily all at once. Children wait for their elders to pass each dish. Chopsticks and sometimes spoons are used for eating. Knives are seldom necessary at the table, because meat and vegetables are usually cut into small pieces before serving. Stir frying, steaming, roasting, and boiling are the preferred methods of cooking. Hot tea is the usual beverage. Dietary Practices for Health Promotion A predominant aspect of the traditional Asian system of health maintenance is the principle of balance between two opposing natural forces, known as am and duong in Vietnamese. As with medicines, these forces are represented by foods that are considered hot (duong) or cold (am). The terms have nothing to do with temperature and are only partly associated with seasoning. Rice, flour, potatoes, most fruits and vegetables, fish, duck, and other things that grow in water are considered cold. Most other meats, fish sauce, eggs, spices, peppers, onions, candies, and sweets are hot. Tea is cold, coffee is hot, water is cold, and ice is hot. Illness or trauma may require therapeutic adjustment of hot–cold balance to restore equilibrium. Hot foods and beverages, used to replace and strengthen the blood, are preferred after surgery or childbirth. During illness, certain foods are consumed in greater quantity, such as a light rice gruel (chao) mixed with sugar or sweetened condensed milk, and a few pieces of salty pork cooked with fish sauce. Fresh fruits and vegetables are usually avoided, being considered too cold. Water, juices, and other cold drinks are 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 11 People of Vietnamese Heritage 11 restricted. Nutritional counseling should take into consideration these factors and other aspects of the usual Vietnamese diet, because advice to simply eat certain kinds of American foods may be ignored. Nutritional Deficiencies and Food Limitations The traditional Vietnamese diet is basically nutritious, comparing favorably with U.S. federal guidelines for a diet low in fat and sugar, high in complex carbohydrates, and moderate in fiber. However, the prevalence of anemia in children may be associated with an iron deficiency (Goldenring, Davis, & McChesney, 1982), although many pregnant women have thalassemia β which may be genetically transmitted to their children. The Vietnamese diet may also be deficient in calcium and zinc but exceedingly high in sodium, with implications relevant to hypertension. Most Vietnamese adults and many children have lactose intolerance, which may cause problems in schools, other institutional settings, and adoptive families. Health-care providers may need to encourage the use of substitute milk products that are based on soybeans. Before 1975, immigrants encountered difficulty in preparing traditional dishes, especially in areas with no established Vietnamese community. Even then, the determined housewife could assemble most necessary ingredients through judicious selections at ethnic American, Chinese, Korean, and Indian groceries. Today, nearly all common Vietnamese foods are available at reasonable cost in the United States, except perhaps for certain native fruits and vegetables. In addition, Vietnamese Americans have changed their diet to a degree, often increasing their fat intake. Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy Indochinese women have children over a longer period of life than European Americans, evidenced by females aged 40 to 44 having a birth rate nearly 14 times that of their European American counterparts (Hopkins & Clarke, 1983). However, in Vietnam, the birth rate is down to 1.91 children per woman (CIA World Factbook, 2011). This is not true for Vietnamese immigrants. They have the highest fertility rate at 72/1000 births in the previous 12 months (Office of Minority Health, 2007). It has been suggested that the high fertility rate is an attempt to replace children lost during the attempts to leave Vietnam. Abortions are commonly performed in their homeland because pregnancy outside of marriage is considered a disgrace to the family. Contraception is also not practiced on a regular basis, and abortion is used as birth control. It is not uncommon for young women to have several abortions before she is in her 20s. While the period of the New Year (Tet) is regarded as a positive time for a marriage, it is not a desirable time to have a child born, so women will often have abortions if they believe they will deliver during this time (Mattson, personal communication, 2007). Fertility practices of the Vietnamese in America in this regard are relatively unknown After arriving in the United States, women often desire information on contraception but are afraid to ask. The problem stems in part from their cultural background and emphasis on premarital modesty and virginity. However, when contraception is addressed and information made available Vietnamese women choose some method of contraception. Providers should avoid forceful family-planning indoctrination on the first encounter, but such information is usually well received on subsequent visits. Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Prescriptive food practices for a healthy pregnancy include noodles, sweets, sour foods, and fruit but avoidance of fish, salty foods, and rice. After birth, to restore equilibrium and provide adequate warmth to the breast milk, women consume soups with chili peppers, salty fish and meat dishes, and wine steeped with herbs. In addition to hot (duong) and cold,(am), foods are classified as tonic and wind. Tonic foods include animal protein, fat, sugar, and carbohydrates; they are usually also hot and sweet. Sour and sometimes raw and cold foods are classified as antitonic. Wind foods, often classified as cold, include leafy vegetables, fruit, beef, mutton, fowl, fish, and glutinous rice. It is considered critical to increase or decrease foods in various categories to restore bodily balances upset by unusual or stressful conditions such as pregnancy. Whereas the balance of foods may be followed, the terminology is not consistently used. During the first trimester, the expectant mother is considered to be in a weak, cold, and antitonic state. Therefore, she should correct the imbalance by eating hot foods such as ripe mangoes, grapes, ginger, peppers, alcohol, and coffee. To provide energy and food for the fetus, she is prescribed tonic foods, including a basic diet of steamed rice and pork. Cold foods, including mung beans, green coconut, spinach, and melon, and antitonic foods, such as vinegar, pineapple, and lemon, are avoided during the first trimester. In the second trimester, the pregnant woman is considered to be in a neutral state. Cold foods are introduced, and the tonic diet is continued. During the third trimester, when the woman may feel hot and suffer from indigestion and constipation, cold foods are prescribed and hot foods are avoided or strictly limited. Tonic foods, which are believed to increase birth weight, are restricted to reduce the chances of a large baby, which would make birthing 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 12 12 Aggregate Data for Cultural-Specific Groups difficult. Wind foods are generally avoided throughout pregnancy, because they are associated with convulsions, allergic reactions, asthma, and other problems. This regimen may appear more complex and restrictive than it actually is in practice. Most women use it only as a general guide, commonly restricting, rather than totally abstaining from, the proscribed foods. A great variety of food, including rice, many kinds of vegetables and fruits, various seasonings, and certain meats and fish, is generally permissible throughout pregnancy. Intensive prenatal care is not the norm in Southeast Asia. Many women do not seek medical attention until the third trimester because of cost, fear, or lack of perceived need. Vietnamese women who are generally better educated seek early prenatal care more than other Southeast Asians (Hopkins & Clarke, 1983). For obstetric and gynecological matters, Vietnamese women feel more comfortable with a female physician or midwife. Traditionally, Vietnamese women maintain physical activity to keep the fetus moving and to prevent edema, miscarriage, or premature delivery. Prolonged labor may result from idleness, and an undesirable large baby may result from afternoon napping. Additional restrictive beliefs include avoiding heavy lifting and strenuous work; raising the arms above the head, which pulls on the placenta causing it to break; and sexual relations late in pregnancy, which may cause respiratory stress in the infant. In Vietnam, many consider it taboo for pregnant women to attend weddings or funerals. However, they often look at pictures of happy families and healthy children, believing that it helps give birth to healthy babies. In Vietnam, some rural children are delivered in a screened-off portion of the home or in a special birth house by certified midwives; more frequently though, more are born in hospitals with Western-trained physicians or midwives in attendance, especially in the cities and towns, although they may receive their prenatal care in the rural clinics. Southeast Asians generally dislike invasive procedures, such as episiotomies, cesarean sections, circumcisions, nasal oxygen, and intravenous fluids. However, unlike some women of other ethnic groups, Vietnamese women may ask for anesthesia during labor and delivery and epidurals are becoming popular if the woman can pay. Otherwise, once in labor, the Vietnamese woman tries to maintain self-control and may even smile continuously. Her period of labor is usually short, and there may be no warning of impending delivery. Although a special bed may be available, the mother may prefer walking around during labor and squatting during the birth process. This position is less traumatic than others, for both mother and baby, and results in fewer and lessserious lacerations. This is a deviation from normal birth practices in the United States and may need to be discussed with the attending physician or midwife prior to birth. Because the head is considered sacred, neither that of the mother nor that of the infant should be touched or stroked. Removal of vernix from the infant’s head can cause distress. The American practice of inserting intravenous devices into infants’ scalps can be particularly stressful to Vietnamese families. Health-care providers need to stress the importance and necessity of this invasive procedure and select other venous routes if possible. Customary practices include clearing the neonate’s throat using the finger, cutting the umbilical cord with a nonmetal instrument, quickly burying the placenta to protect the infant’s health, and ritually cleaning the mother in a manner that does not involve actual bathing with water. Because body heat is lost during delivery, Vietnamese women avoid cold foods and beverages and increase consumption of hot foods to replace and strengthen their blood. Ice water and other cold drinks are usually not welcome, thus the usual practice of offering a newly delivered mother a cold drink should be replaced with something hot—either water or tea is usually available. This can accomplish the nurse’s goal of replacing fluids and maintain the patient’s cultural heritage. Most raw vegetables, fruits, and sour items are taken in lesser amounts. Prescriptive foods include steamed rice, fish sauce, pork, chicken, eggs, soups with chili or black peppers, other highly seasoned and salty items, wine, and sweets. Because water is cold, women traditionally do not fully bathe, shower, or wash their hair for a month after delivery. Some Vietnamese women have complained that they were adversely affected by showering shortly after delivery in American hospitals. Others, however, have welcomed the opportunity to shower and seem willing to give up other traditional practices. Postpartum women also avoid drafts and strenuous activity; wear warm clothing; stay in bed, indoors, or both for about a month; and avoid sexual intercourse for months. In the past, postpartum women remained in a special bed above a slow-burning fire. This practice still continues with the use of hot-water bottles or electric blankets. Other women in the family assume responsibility for the baby’s care. In Vietnam, husbands would never be present at their child’s delivery. For Vietnamese in the United States, this varies and some men do attend deliveries. The mother’s inactivity and dependence on others may be incorrectly interpreted by health-care workers as apathy, depression, or lack of attachment to the baby. A newborn is often dressed in old clothes; it is considered taboo to praise the child lest jealous spirits steal the infant. The mother may be reluctant to cut the child’s hair or nails for fear that this might cause illness. The infant is generally maintained on a 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 13 People of Vietnamese Heritage 13 diet of milk for the first year, with the introduction of rice gruel at around 6 months. There is little formal toilet training; the child usually learns by imitating an older child. One can see mothers holding their naked babies away from them to urinate, and “whispering” in their ears to stimulate a bowel movement. The child is then cleaned and returned to his or her usual clothing. Breastfeeding is customary in Vietnam, but since resettlement, some variations on this practice have been instituted. Some Southeast Asian women discard colostrum and feed the baby rice paste or boiled sugar water for several days. This does not indicate a decision against breastfeeding. After the milk comes in, both mother and baby benefit from the hot foods consumed by the mother for the first month. Then, however, a conflict arises: The mother believes that hot foods benefit her health but that cold foods ensure healthy breast milk. Having the mother change from breastfeeding to formula can easily solve this dilemma; however, it is counterproductive to the medical and nursing community’s efforts to promote breastfeeding during the baby’s first year. If the mother cannot afford formula, she may use fresh milk or rice boiled with water, which may result in anemia and growth retardation. Some health-care professionals, concerned about these developments and their impact on the infant’s health, have recommended educational programs that might restore conditions conducive to traditional breastfeeding. Death Rituals Death Rituals and Expectations Vietnamese accept death as a normal part of the life process. The traditional stoicism of the Vietnamese, the influence of Buddhism with its emphasis on cyclic continuity and reincarnation, and the pervading association of current activities with ancestral spirits and burial places contribute to attitudes toward death Most Vietnamese have an aversion to hospitals and prefer to die at home. Some believe that a person who dies outside the home becomes a wandering soul with no place to rest. Family members think that they can provide more comfort to the dying person at home. Sixty percent of women in one survey said that if someone in their family were dying, they would not want that person told; 95 percent said that they would want a priest or minister with them when they died; and 95 percent indicated a belief in life after death (Calhoun, 1986). Ancestors are commonly honored and worshipped and are believed to bestow protection on the living. Southeast Asians tend not to want to artificially prolong life and suffering, but it may still be difficult for relatives to consent to terminating active intervention, which might be viewed as contributing to the death of an ancestor who would shape the fates of the living (Muecke, 1983a). Few Vietnamese families consent to autopsy unless they know and agree with the reasons for it. Older Vietnamese, on realizing the inevitability of death, sometimes purchase coffins in advance, display them beneath the household altar, and choose burial sites with a favorable position. Although Vietnamese custom is associated with proper burial practices and maintenance of ancestral tombs, cremation is an acceptable practice to some families. Responses to Death and Grief Vietnamese families may wish to gather around the body of a recently deceased relative and express great emotion. Traditional mourning practices include wearing white clothes for 14 days, the subsequent wearing of black armbands by men and white headbands by women, and the yearly celebration of the anniversary of a person’s death. Such observances, together with ritual cleaning and worship at ancestral graves, help reinforce family ties and are deeply woven into Vietnamese culture. Departure from Vietnam has greatly curtailed the observance of these practices, leaving a painful void for many refugees. Priests and monks should be called only at the request of the client or family. Clergy visitation is usually associated with last rites by the Vietnamese, especially those influenced by Catholicism, and can actually be upsetting to hospitalized patients. Sending flowers may be startling, because flowers are usually reserved for the rites of the dead. Spirituality Dominant Religion and Use of Prayer Although some Vietnamese refugees are Catholic, or have converted to other branches of Christianity, many Vietnamese follow Buddhist concepts. Buddhism on the whole is best understood not as a religion in the Western sense but more a philosophy of life and impacts profoundly on the health-care beliefs and practices of the Vietnamese. If one lives in adherence to the Buddhist path one can expect less suffering in future existences. Buddhsim stresses disconnection to the present, especially materialism and self-aggandizement. Thus pain and illness are sometime endured and health-seeking remedies delayed because of this belief in fate. Similarly, preventive health care has little meaning in this philosophy. Respect for and veneration of ancestors is associated with Buddhism and Confucianism. The prospect of burial away from ancestral burial sites is a source of significant distress to older Vietnamese. Difficulty visiting burial sites in Vietnam is also distressful (Rasbridge, 2004). 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 14 14 Aggregate Data for Cultural-Specific Groups Religions practiced by the Vietnamese are Buddhism (9.3 percent), Catholic, (6.7 percent), Hao Hao (1.5 percent), Cao Dai (1.1 percent), Protestant (0.5 percent), Muslim (0.1 percent), and none (80.8 percent) (CIA World Factbook, 2011). There are a number of other religions, including Taoism and Confucianism, which are basically offshoots and combinations of the major faiths. Animism is found mainly among the highland tribes. Many Vietnamese believe that deities and spirits control the universe and that the spirits of dead relatives continue to dwell in the home. Most Vietnamese who practice a religion are Buddhists, but some almost never visit temples or perform rituals. Others, both Buddhist and Christian, may maintain a religious altar in the home and conduct regular religious observances. In cases of severe illness, prayers and offerings may be made at a temple. Meaning of Life and Individual Sources of Strength Whereas the wish to bring honor and prosperity to the family remains a dominant force for most Vietnamese, some find meaning in life from the practice of Buddhism or other religions. Some are driven by the desire to learn, to relieve suffering, to produce beauty, to assist the progress of civilization, and to gain strength from participating in ethnic community activities. A tenet of Buddhism holds that the family unit is more important than the individual, with less emphasis on the “self.” Accordingly, health-care decision making is frequently a family matter. Concordantly, the family is typically involved in treatment. (Bankston & Zhou, 2000). The family is the fundamental social unit and the primary source of cohesion and continuity. Spiritual Beliefs and Health-Care Practices Vietnamese religious practices are influenced by the Eastern philosophies of Buddhism, Confucianism, and Taoism. Central to Buddhism is the concept of following the correct path of life, thus eliminating suffering that is caused by desire. Another tenet is that the world is a cycle of ordeals: to be born, grow old, fall ill, and die. In addition, people’s present lives predetermine their own and their dependents’ future lives. Confucianism stresses harmony through maintenance of the proper order of social hierarchies, ethics, worship of ancestors, and the virtues of chastity and faithfulness. Taoism teaches harmony, allowing events to follow a natural course that one should not attempt to change. These beliefs have contributed to an attitude that may be perceived as passive by Westerners, characterized by maintenance of self-control, acceptance of one’s destiny, and fatalism toward illness and death. Health-Care Practices Health-Seeking Beliefs and Behaviors The diagnosis of illness is frequently understood in three different, although overlapping models. The first, the least common, could be considered supernatural or spiritual, where illness can be brought on by a curse or sorcery, or failure to observe a religious ethic or belief. Traditional medical providers are common, both in the United States and Vietnam; some are specialists in the more magico-religious realm, and may be called upon to exorcise a bad spirit via chanting, a potion, or consultation from an ancient Chinese text. The use of amulets and other forms of spiritual protection is also commonly employed. For example, babies and children often wear bua, an amulet of cloth containing a Buddhist verse, or that has been blessed by a monk. It is worn on a string around the wrist or neck. Vietnamese traditionally do not have a concept of mental illness as discrete from somatic illness, and thus rarely utilize Western-based psychological and psychiatric services. Instead, most mental health issues such as depression or anxiety fall into this spiritual health realm and are treated appropriately. Similarly, somatization is common, and treatments overlap with Western treatments and metaphysical interventions described below. Second, a widespread belief is that the universe is composed of opposing elements held in balance; health is a state of balance between these forces, know as am and duong, based on the more familiar concepts of yin and yang in China. In health, these concepts are frequently translated as “hot” and “cold,” although they do not necessarily refer to temperature. Illness results when there is an inbalance of the “vital” forces; the imbalance can be a result of a physiological state, such as pregnancy or fatigue, or it can be brought on by extrinsic factores like diet or overexposure to “wind,” one of the body forces or humors first described by Galen. Balance can be restored by a number of means, including diet changes to compensate for the exess of “hot” or “cold” Western medicines and injections, and tradtional medicines, herbs, and medical practices. Naturalistic explanations for poor health include eating spoiled food and exposure to inclement weather. The natural element known as cao gio is associated with bad weather Third, most Vietnamese Americans also recognize the more Western concept of disease causation such as the germ theory. There is widespread understanding that disease can come from contaminants in the environment, even if full concepts of microbiology or virology are not grasped. Thus, through decades of French occupation 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 15 People of Vietnamese Heritage 15 and more recently the American influence, even the most rural Vietnamese has come to know the power of antibiotics. When Vietnamese enter the American health-care setting, they do so frequently with the goal to relieve symptoms; in general, the patient expects a medicine to cure the illness immediately. When something is not prescribed initially, the patient is likely to seek care elsewhere, either directly from a Vietnamese pharmacist or specialized “injectionists.” Newly arrived immigrants are used to receiving the medication directly from the doctor; the concept of a “prescription” written on a piece of paper to take to a pharmacy to be “filled” is foreign to them. They may feel that this piece of paper contains instructions for the patient, and not follow through with obtaining the medication. Vietnamese frequently discontinue medicines after the symptoms disappear; similarly, if symptoms are not perceived, there is no illness. Thus, preventive, long-term medications like antihypertensives must be prescribed with culturally sensitive education. It is quite common for Vietnamese patients to amass large quantities of half-used prescription drugs, even antibiotics, many of which are shared with friends and may be sent back to family in Vietnam. Additionally, Vietnamese commonly believe that Western pharmaceuticals are developed for Americans and Europeans, and hence dosages are too strong for more slightly built Vietnamese, resulting in self-adjustment of dosages. The Vietnamese hold great respect for those with education, especially physicians. The doctor is considered the expert on health; diagnosis and treatment should happen at the first visit, with little examination or personally invasive laboratory or other diagnostic tests. Commonly, laboratory procedures involving the drawing of blood are feared and resisted by Vietnamese, who believe the blood loss will make them sicker, and that the body cannot replace what was lost. Surgery is especially feared for this reason. Overall, as health is believed to be a function of balance, surgery would be considered an option of last resort, as the removal of an organ would alter the internal balance. Vietnamese view health and illness from a variety of different perspectives, sometimes simultaneously. It is not uncommon for a sick person to interpret their illness as an interaction of spiritual factors, internal balance inequities, and even an infective process. They will thus combine diagnostic and treament elements from all three models in order to get the maximum health benefits (Rasbridge, 2004). The belief that life is predetermined is a deterrent to seeking health care. For many Vietnamese, diagnostic tests are baffling, inconvenient, and often unnecessary. Procedures such as circumcision or tonsillectomy, which biomedicine considers simple, are generally unknown to the Vietnamese. Invasive procedures are frightening. The prospect of surgery can be terrifying. The fear of mutilation stems from widespread beliefs among non-Christians that souls are attached to different parts of the body and can leave the body, causing illness or death. Loss of blood from any route is feared, and the Vietnamese may refuse to have blood drawn for laboratory tests. The client may complain, though not to the health-care worker, of feeling weak for months. A Vietnamese client in America may feel that any body tissue or fluid removed cannot be replaced, and the body suffers the loss in this life as well as into the next. The concept of long-term medication for chronic illnesses and acceptance of unpleasant side effects and increased autonomic symptoms, which are standard components of modern Western medicine, are not congruent with traditional notions of safe and effective treatment of illnesses. Responsibility for Health Care In Vietnam, the family is the primary provider of health care, even in hospitals. This practice survives because of tradition and a shortage of professional personnel. Their own families attend hospitalized patients day and night. The importance of involving family members, including elder family members or clan leaders, in all major treatment decisions regarding physical and mental health must be stressed. Health care in Vietnam is crisis oriented, with symptom relief as the goal. Vietnamese typically deal with illness by means of self-care, self-medication, and the use of herbal medicines. Facsimiles of Western prescription drugs are sold over the counter throughout Southeast Asia, which may explain the increasing resistance of bacteria to several readily available antibiotics. Many Vietnamese believe that Western medicine is very powerful and cures quickly, but few understand the risks of overdosages or underdosages. Patients being treated for depression who fail to take their antidepressants evidence improvement after receiving instructions for taking their medication. Vietnamese patients may not follow prescribed schedules of medication for the treatment and prevention of tuberculosis. Extensive education, repetition of instructions, and home visitations are necessary. Unfortunately, most Vietnamese women who have abnormal Pap smears fail to return for follow-up care, thereby contributing to the shockingly high incidence of cervical cancer in the population (Wright, 2000). That problem has been associated with lack of organized language services and, thus, a failure by the women to comprehend the severity of the situation and the potential for recovery if regular treatment begins early enough. To increase follow-up visits and 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 16 16 Aggregate Data for Cultural-Specific Groups care, it may be necessary to carefully explain the problems that may result if they do not follow up after an abnormal Pap smear. Women should understand that lack of symptoms or pain may be only temporary and that experiences of acquaintances may not apply to them. Persistent reminding, as part of an overall effort to improve communication and information dissemination, has been suggested as the best way to encourage Vietnamese women to undergo regular cancer screening and follow-up treatment. Folk and Traditional Practices The forces of am (cold) and duong (hot) are pervasive forces in the practice of traditional Vietnamese medicine. Am represents factors that are considered negative, feminine, dark, and empty, whereas duong represents those that are positive, masculine, light, and full. These terms are applied to various parts, organs, and processes of the body. For example, the inside of the body is am, and the surface is duong. The front part of the body is am, and the back is duong. The liver, heart, spleen, lungs, and kidneys are am, and the gallbladder, stomach, intestines, bladder, and lymph system are duong. Am stores strength, and care must be taken not to use it up too quickly. Duong protects the body from outside forces, and if it is not cared for, the organs are thrown into disorder. Proper balance of these two life forces ensures the correct circulation of blood and good health. If the balance is not proper, life is short. Diseases and other debilitating conditions result from either cold or hot influences. For example, diarrhea and some febrile diseases are due to an excess of cold, whereas pimples and other skin problems result from an excess of hot. Countermeasures involve using foods, medications, and treatments that have properties opposite those of the problem and avoiding foods that would intensify the problem. Asian herbs are cold, and Western medicines are hot. A widely held belief among Vietnamese refugees is that Asian medicine relieves symptoms of a disease more quickly than Western medicine but that Western medications can actually cure the illness. Many prefer Asian methods for children. Reliance on traditional folk medicine is declining in the United States, partly because of the unavailability of suitable shamans and traditional herbs. The following are common treatments practiced in Vietnam and continued to some degree in the United States: Cao gio (or coining) literally meaning “rubbing out the wind,” is used for treating colds, sore throats, flu, sinusitis, and similar ailments. An ointment or hot balm oil is spread across the back, chest, or shoulders and rubbed with the edge of a coin (preferably silver) in short, firm strokes. This technique brings blood under the skin, resulting in dark ecchymotic stripes, so the offending wind can escape. Health-care professionals must be careful not to interpret these ecchymotic areas as evidence of child abuse. However, dermabrasion may provide a portal for infection. Be bao or bat gio, skin pinching, is a treatment for headache or sore throat. The skin of the affected area is repeatedly squeezed between the thumb and the forefinger of both hands, as the hands converge toward the center of the face. The objective is to produce ecchymoses or petechiae. Giac (or cup suctioning) another dermabrasive procedure, is used to relieve stress, headaches, and joint and muscle pain. A small cup is heated and placed on the skin with the open side down. As the cup cools, it contracts the skin and draws unwanted hot energy into the cup. This treatment leaves marks that may appear as large bruises. Xong(or steaming) relieves motion sickness or cold-related problems. Herbs or an agent such as Vicks® VapoRub is put into boiling water, and the vapor is inhaled. Small containers of aromatic oils or liniments are sometimes carried and inhaled directly. Moxibustion is used to counter conditions associated with excess cold, including labor and delivery. Pulverized wormwood or incense is heated and placed directly on the skin at certain meridians (Fig. 38-2) Acupuncture, acupressure, and acumassage relieve symptomatic stress and pain. Balms and oils, such as Red Tiger balm, available in Asian shops, are applied to affected areas for relief of bone and muscle ailments. Herbal teas, soups, and other concoctions are taken for various problems, generally in the sense of using cold measures to overcome hot illnesses. Eating organ meats such as liver, kidneys, testes, brains, and bones of an animal is said to increase the strength of the corresponding human part. Two additional practices in Vietnam are consuming gelatinized tiger bones to gain strength and taking powdered rhinoceros horn to reduce fever. At least 430 folk medicines used by Vietnamese contain ingredients from endangered, threatened, or protected species (Gaski & Johnson, 1994). Barriers to Health Care Barriers to adequate health care for Vietnamese people include 1. Subjective beliefs and the cost of health care 2. Lack of access to a primary health-care provider 3. Differences between Western and Asian healthcare practices 4. Caregivers’ judgment of Vietnamese as deviant and unmotivated because of noncompliance with 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 17 People of Vietnamese Heritage 17 Figure 38-2 Moxibustion is used to counter conditions associated with excess cold, including labor and delivery. Pulverized wormwood or incense is heated and placed directly on the skin at certain meridians. (From Ancient Way Acupuncture and Herbs. Klamath Falls, Oregon. Retrieved from www.AncientWay.com) medication schedules, diagnostic tests, follow-up care, and their failure to keep appointments 5. Inability to communicate effectively in the English language by recent immigrants who lack confidence in their ability to communicate their needs; failure of providers to communicate adequately or lack of an interpreter 6. Avoidance of Western providers out of fear that traditional methods will be criticized 7. Fear of conflicts and ridicule resulting in loss of face 8. Lack of knowledge of the availability of resources Additional barriers exist for Vietnamese people when seeking mental-health care. These include fear of stigmatization, difficulty locating agencies that can provide assistance without distorted professional and cultural communication, and reluctance to express inner feelings. Cultural Responses to Health and Illness Fatalistic attitudes and the belief that problems are punishment may reduce the degree of complaining and expression of pain among the Vietnamese, who view endurance as an indicator of strong character. One accepts pain as part of life and attempts to maintain self-control as a means of relief. A deep cultural restraint against showing weakness limits the use of pain medication. However, the sick person is allowed to depend on family and receives a great deal of attention and care. Many Vietnamese believe that mental illness results from offending a deity and that it brings disgrace to the family and, therefore, must be concealed. A shaman may be enlisted to help, and additional therapy is sought only with the greatest discretion and often after a dangerous delay. Emotional disturbance is usually attributed to possession by malicious spirits, the bad luck of familial inheritance, or for Buddhists, bad karma accumulated by misdeeds in past lives. The term psychiatrist has no direct translation in Vietnamese and may be interpreted to mean nerve physician or specialist who treats crazy people. The nervous system is sometimes seen as the source of mental problems—neurosis being thought of as “weakness of the nerves” and psychosis as “turmoil of the nerves.” To overcome these problems, Kinzie and Manson (1982) and Buchwald and colleagues (1993) developed a Vietnamese depression scale, which uses terms that allow an English-speaking practitioner to make a crosscultural assessment of the clinical characteristics of depressed Vietnamese patients. Health-care providers working with Vietnamese patients may find this scale useful when providing mental-health services. Physically disabled people are common and readily seen in Vietnam. Some are veterans or survivors of the Vietnam War, and others have been affected by congenital disabilities (often from environmental toxins) or birth injuries. To the extent that resources allow, they are treated well and cared for by their families and the government. In contrast, a mentally disabled person may be stigmatized by the family and society and can jeopardize the ability of relatives to find marriage partners. The mentally disabled are usually harbored within their families unless they become destructive; then, they may be admitted to a hospital. Blood Transfusions and Organ Donation Because many Vietnamese believe that the body must be kept intact even after death, they are averse to blood transfusions and organ donation. Many Vietnamese, even those whose families have long been Christian, may object to removal of body parts or organ donation. However, some staff in a rural hospital in Vietnam donated blood after learning that the body replenished its blood supply. The smaller size of Vietnamese adults makes many of them ineligible to donate a full unit of blood. Other Vietnamese people, who may prefer cremation, will donate body parts under certain circumstances. 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 18 18 Aggregate Data for Cultural-Specific Groups Health-Care Providers Traditional Versus Biomedical Providers Four kinds of traditional and folk providers exist in Vietnam. The first group includes Asian physicians who are learned individuals and employ herbal medication and acupuncture. The second group consists of more informal folk healers who use special herbs and diets as cures based on natural or pragmatic approaches. The secrets of folk medicine are passed down through the generations. The third group includes various forms of spiritual healers, some with a specific religious outlook and others with powers to drive away malevolent spirits. The fourth group is made up of magicians or sorcerers who have magical curative powers but no communication with the spirits. Many Vietnamese consult one or more of these healers in an attempt to find a cure. Whereas many Vietnamese have great respect for professional, well-educated people, they may be distrustful of outside authority figures. Most Vietnamese have come to America to escape oppressive authority. Refugees generally expect health-care professionals to be experts. A common suspicion is that divulging personal information for a medical history could jeopardize their legal rights. Respect and mistrust are not mutually exclusive concepts for Vietnamese seeking care from Western providers. Because of the need to build trust with a Vietnamese client, it is particularly important to acknowledge and support traditional belief systems. Traditional Asian male providers do not usually touch the bodies of female patients and sometimes use a doll to point out the nature of a problem. Whereas most Vietnamese may no longer insist on the use of this practice, adults, particularly young and unmarried women, are more comfortable with health-care providers of the same gender. Pelvic examinations on unmarried women should not be made on the first visit or without careful advance explanation and preparation. When such an examination is necessary, the woman may want her husband present. If possible, the practitioner and an interpreter should both be female. Women may not want to even discuss sexual problems, reproductive matters, and birth control techniques until after an initial visit and after confidence has been established in the practitioner. Status of Health-Care Providers Because of the shortage of physicians in Vietnam, medical assistants, nurses, village health-care workers, self-trained individuals, and injectionists practice Western medicine. Paralleling these approaches are the traditional systems of Asian and folk medicine. 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