Vietnamese diabetic patients and their physicians: what ethnography can teach us.

OBJECTIVES: To describe the cultural context of type 2 diabetes mellitus among Vietnamese immigrants in the United States, including people's ideas about cause and proper treatment; and to suggest ways in which better control of the disease can be achieved in this population. DESIGN: The method was ethnographic. A native speaker used a structured interview guide to talk with 38 Vietnamese patients, and family members of 2 other patients, being treated for type 2 diabetes. In addition, 8 Vietnamese health providers--5 physicians, 2 nurses, and an herbalist--were interviewed. SETTING: A low-income area of southern California populated by a large number of Vietnamese. PARTICIPANTS: Forty patients being treated for type 2 diabetes and 8 health practitioners. RESULTS: Three quarters of the patients had not achieved good control of their diabetes. Ideas about the cause and proper treatment of the disease were culturally shaped. Many patients used eastern (herbal) medicine and described a strong aversion to insulin injections. Patients stopped taking their oral medications when using eastern medicine, and a quarter lowered their dose whenever they felt "out of balance." Almost two thirds had used traditional home remedies for diabetes. Two had received nonstandard medical care from neighborhood physicians trained in Viet Nam; 1 of these patients died during the study. CONCLUSION: The Vietnamese community and physicians serving that community need culturally appropriate education about type 2 diabetes and modern therapy for the disease.

Pica during pregnancy in low-income women born in Mexico.

OBJECTIVE: To describe pica behavior (ingestion of nonfood items) in pregnant low-income Mexican-born women in Mexico and the United States. DESIGN: A convenience sample of informants was interviewed with a questionnaire containing open-ended and closed-ended questions. SETTING: A low-income community on the outskirts of Ensenada, Mexico, and clinics serving low-income people in southern California (Santa Ana, Bakersfield, and Los Angeles). PARTICIPANTS: Of a total of 225 Mexican-born women, 75 (33%) were interviewed in Ensenada, and 150 (67%) were interviewed in southern California. RESULTS: The prevalence of pica during pregnancy was 44% (n = 33) in the Ensenada group and 31% (n = 46) in the southern California group. Those who reported pica behavior more commonly had a relative who also practiced pica. CONCLUSION: The high reported rate of pica in this sample indicates that pregnant Mexican-born women should be screened for pica and educated about the potentially serious effects on the fetus and mother.

Innovation and behavior change. Applied anthropology strategies for international health and cross-cultural medicine.

Most international health programs depend on individual behavior change. Cleverly catalyzing such change in populations requires knowledge of preprogram health behaviors and the web of culture in which they are suspended. This article reviews general medical anthropology perspectives and cases from the field. The current methods for defining baseline health knowledge, attitudes, and practices are reviewed to facilitate the development of benchmarks against which successful programmatic change can be measured.

Insights from community-based research on child pneumonia in Pakistan.

Although pneumonia is a major cause of death in Pakistan, little is known about community beliefs and practices surrounding the disease. In this study, 35 mothers and four self-trained allopathic practitioners were interviewed in Karachi squatter settlements and rural Punjab. The findings indicate that maternal ideas about chest anatomy and the cause of pneumonia (principally "coldness") are very different from biomedical concepts. Further, mothers judge fast breathing impressionistically and tend to attribute it to fever alone. Nevertheless, they know that it is abnormal and most also link chest indrawing with pneumonia. Only mothers lacking other options take their children to government health facilities. Instead, most turn to private (frequently unlicensed) practitioners, although observation shows that such individuals are unable to diagnose pneumonia correctly and that they build their practices around the indiscriminate use of antibiotics. The study demonstrates that the target of ARI education in Pakistan should extend beyond government doctors to mothers and private practitioners as well.

PIP: In Karachi squatter settlements and in rural Punjab in Pakistan, in-depth interviews with 35 mothers and grandmothers of young children and 4 self-trained allopathic practitioners were conducted for a medical anthropology study of acute respiratory infections (ARIs), especially pneumonia. Most mothers were familiar with chest indrawing as a danger sign of pneumonia. Most regional languages distinguished between the upper and lower chest, which should make it easier to educate mothers about the seriousness of fast breathing and unusual movement of the lower ribs and the area right below the ribs during breathing (i.e., chest indrawing). Mothers tended to associate fast breathing with fever alone. Utilization rates of government health facilities was very low (e.g., 16% during 1982-1983). Mothers would take their children to government health facilities only if other practitioners failed to successfully treat pneumonia. Most mothers would seek medicine from private (mainly unlicensed) practitioners. Yet, some of these practitioners do not count the child's breathing rates or examine the chest for indrawing. They even consider a fast pulse more dangerous than fast breathing. They overprescribe antibiotics. These findings suggest that the Pakistani government should include mothers and licensed and unlicensed allopathic practitioners in addition to its physicians in ARI education.

Mothers' perceptions of severe pneumonia in their own children: a controlled study in Pakistan.

In 1992, 320 mothers were interviewed in a Rawalpindi hospital to identify which of the signs and symptoms they saw in their own children were most consistently linked with a clinical diagnosis of pneumonia as opposed to common cold. A related goal was to determine whether mothers could correctly judge the actual presence or absence of two major pneumonia signs--fast breathing and chest indrawing. The mothers were predominantly poor and 43% were illiterate. The study sample was composed of four matched groups: (1) mothers of 80 children with pneumonia, most with severe disease, interviewed after the child was referred to the ward; (2) mothers of 80 such children interviewed in the outpatient clinic prior to any discussion of the pneumonia diagnosis; (3) mothers of 80 children with common cold; and (4) mothers of 80 'well' children. Results showed that when mothers were interviewed in the clinic, their perception that a child had fast breathing and/or chest indrawing was highly correlated with pneumonia (sensitivity 64%, specificity 90%). Mothers were even more likely to say that a child had these signs after the pneumonia diagnosis had been conveyed, suggesting that interaction with doctors influenced their views. Fast breathing was better recognized than chest indrawing, and accurate diagnosis of both signs was better among mothers having prior experience with childhood pneumonia. The data suggest that even in the absence of formal ARI education, a majority of Pakistani mothers attending hospitals in indigent areas can recognize these two signs in their own children. However, the seriousness of the signs and their connection with pneumonia should be stressed in education campaigns since a high percentage of children had chest indrawing (a late sign of severe disease) by the time they were brought to the hospital.

Cross-cultural communication in the physician's office.

Physicians are increasingly called on to provide care for patients whose cultures differ from their own. I describe strategies, attitudes, and investigative methods that will enhance the experience of cross-cultural medicine for both patients and physicians.

Maternal perceptions of pneumonia and pneumonia signs in Pakistani children.

Fifty mothers of children attending a hospital outpatient clinic with non-severe pneumonia (fast breathing but no chest indrawing) were interviewed in depth. Maternal perceptions and practices with clinical significance were documented. Results showed that most mothers initially tried "heat-producing" home remedies designed to counter the "coldness" of the disease, allowed only 2 days for any particular allopathic medicine to work, and did not go to the same practitioner twice. When mothers were asked what had alarmed them enough to come to the hospital, the symptoms named most frequently were persistent severe cough and high fever, inability to sleep and excessive crying. Fast breathing was spontaneously mentioned by only a few, although when questioned, 32/50 said that they had noticed it. The mothers who had prior experience with child pneumonia were more likely to notice fast breathing and also came to the hospital earlier than those who were inexperienced. Relatively higher levels of maternal education and income were suggestively associated with bringing a female child rather than a male child for pneumonia treatment. Fewer than half of the mothers knew where air goes when a person breathes in and where the lungs are located. Most held treatment preferences at odds with the protocols proposed for the national ARI program currently being initiated in Pakistan, e.g. they said that a doctor should use a stethoscope, should prescribe suspensions rather than tablets and should give injections. This study provides baseline data on attitudes and behaviors that can either be built on in that program or addressed through public education campaigns.

Cow dung, rock salt, and medical innovation in the Hindu Kush of Pakistan: the cultural transformation of neonatal tetanus and iodine deficiency.

In mountain villages of Chitral District in northwestern Pakistan, dried cow dung is used as Westerners would use talcum powder when babies are swaddled and rock salt is consumed in tea and other foods. Both substances are esteemed as conveying beneficial 'heat' and 'strength'. Unfortunately, however, cow dung sometimes contains a bacterium that causes neonatal tetanus, and the resulting toxin may enter through the baby's unhealed umbilical cord and cause death. Further, rock salt contains no iodine, and Chitral's soil is so iodine-deficient that goiter is very common. Thus local health workers advocate use of talcum powder rather than cow dung, immunization against tetanus, and replacement of rock salt by powdered iodized salt. The present report documents widespread community acceptance of these innovations despite the fact that the biomedical model of tetanus and goiter was not well understood and indigenous concepts of the causes of the diseases remained virtually undisturbed. Most of the villagers were Ismaili Muslim followers of the Aga Khan; their receptivity to such health messages was influenced by the high value that their religion places on advancement through 'education' and was correlated with their proximity to Ismaili health workers whom they trusted. A major implication of this research for primary health care programs is that when one is attempting to change existing health practices, explication of biomedical models should not be the only focus of concern. Attentiveness to the context in which behavior changes are introduced and interpreted is at least equally important. Further, the fact that new knowledge was added to the old without replacing it illustrates the complexity of human cognition and points to limitations in the KAP (knowledge-attitude-practice) model of health belief and behavior. This report adds to a small but important body of literature documenting the dynamic nature of medical pluralism in the developing world.

Culture and 'compliance' among leprosy patients in Pakistan.

In Pakistan approx. 30% of the 18,000 known leprosy patients have dropped out of their treatment programs. To investigate reasons for such widespread noncompliance, 128 diagnosed leprosy patients--59 outpatients and 69 inpatients--were interviewed in Karachi. More than half of the 'noncompliant' outpatients denied having the disease. Denial was found to be an understandable coping mechanism in view of the severe stigma associated with leprosy. The presence of close-knit extended families, in which joint decision-making was the norm and in which such a dread diagnosis could spell the end of job and marriage prospects for even distant relatives, contributed to the likelihood of denial. In such a setting, the very term 'noncompliant' appeared to be an oversimplification since it covered so many different types of culturally-constrained behavior. In addition, many of the patients who initially seemed most 'compliant' by virtue of being long-term hospital inpatients in fact owed their hospitalization to the fact that they had been markedly noncompliant in the past. Thus the usual view that adherence to a biomedical treatment regimen constitutes 'compliance' and that nonadherence to such a regimen constitutes 'noncompliance' proved inadequate for understanding the health behavior of these Third World leprosy victims. The study also showed that many patients had initially consulted traditional healers, inadequately-trained physicians, and/or untrained medical practitioners for treatment of their symptoms, which resulted in lengthy delays before they were correctly diagnosed. Further, even after the diagnosis was made and appropriate medications were prescribed by trained personnel, most patients were not told what had caused their leprosy and how the drug regimen worked to combat it: when questioned, only 4% of the 128 respondents attributed the disease to infectious organisms. In addition, patients were usually not warned in advance of the possibility of undesirable side effects from their leprosy medications, which led to further 'compliance' problems. The findings of this study emphasize the need for better training of physicians and other health care providers in early diagnosis of leprosy and better health education of diagnosed patients. To be truly effective, the treatment of leprosy must include counseling of extended families and education of the public at large as well as enhanced communication with the patients themselves.

Mothers' concepts of childhood diarrhea in rural Pakistan: what ORT program planners should know.

Diarrhea is the leading cause of infant and child death in Pakistan. Appropriately, the development of oral rehydration therapy (ORT) programs has become a major priority of the Pakistan Ministry of Health and of international funding agencies. Paradoxically, however, there is virtually no published anthropological literature on diarrhea-related traditional health beliefs and practices among the rural and illiterate people who make up 90% of the nation's population. The study reported on here focuses on these matters and suggests important implications for the multimillion-dollar ORT programs currently being launched. Mothers' ethnomedical models of diarrheal disease and concepts of appropriate treatment are discussed, as are practical problems relating to the effective implementation of ORT in such a setting. The results underline the need for anthropological studies as an adjunct to health interventions involving behavioral modification.

A visit with a curandero.

One author visited a Mexican-American folk healer in the Los Angeles area, not as a patient but as a fellow health professional. Information was obtained from this healer, a curandero, regarding his background, his clientele, the illnesses he treats, the therapeutic techniques he uses and his relationship with the official health care system. This information was generally consistent with statements about curanderismo that have appeared in the social sciences literature. It also provided additional insight into practices that have been alluded to in that literature but not described in detail. With few exceptions, curanderos would seem to be talented healers whose efforts often benefit their patients and whose continued popularity has important implications for physicians, especially those serving large numbers of people of Mexican descent.