Understanding cultural barriers in hepatitis B virus infection

Belief systems and attitudes toward health care

An immigrant patient’s religious beliefs and cultural attitudes toward Western medicine may pose difficulties in successfully managing disease. Many Asian Americans are Buddhists, who may believe that suffering is an integral part of life; proactively seeking medical care may not be imperative for them. Confucianism, the worship of ancestors and the subjugation of the self to the well-being of the family, is a common belief system among Asians that may inhibit the desire to seek needed medical care. For example, a family elder may instruct a young man not to seek medical care for his HBV infection because this would jeopardize his siblings’ marriage prospects. Taoism involves the belief that perfection is achieved when events are allowed to take the more natural course. Intervention is therefore frowned upon.

Some belief systems may impede care because they incorporate indifference toward suffering. Many Hmong believe that the length of life is predetermined, so lifesaving care is pointless. Cultural value may be placed on stoicism, discouraging visits to health care providers. A belief that disease is caused by supernatural events rather than organic etiologies is another perception that serves as a barrier to seeking medical care.

Distrust of, or unfamiliarity with, Western medicine may delay care, and the resulting poor outcomes may be falsely attributed to Western medicine itself. In some cultures, there is a pervasive belief that a physician can touch the pulse and identify the problem. Some Laotians believe that immunizations are dangerous for a baby’s spirit, and therefore forgo immunization against HBV when it is indicated.

The patient’s relationship with his or her health care provider is an important determinant of quality of care and willingness to continue to receive care. The best possible scenario is concordance in language and culture. Asian cultures emphasize politeness, respect for authority, filial piety, and avoidance of shame. Because Asian patients often view physicians as authority figures, they may not ask questions or voice reservations or fears about their treatment regimens; instead, they may express their agreement with physicians’ advice, but with no intent to return or follow instructions.

Infection with HBV carries a stigma about the mode of transmission that can interfere with patients’ daily lives. A study of attitudes about HBV found that HBV-infected patients feel less welcome to stay overnight or share the same bathroom at friends’ or relatives’ houses, that noninfected persons fear that the disease may be passed to them by HBV-positive friends, and that HBV-infected patients are concerned about whether their choices may have led to the infection.¹¹

OVERCOMING BARRIERS

Sensitivity to cultural attitudes may enhance communication and the likelihood that patients will accept physicians’ recommendations. Several office visits may be necessary to confirm that a patient is receptive to the health care provider’s instructions and is adhering to them. Referral to access programs can aid communication. For example, most cities have community centers where patients can seek medical advice from physicians who speak the patients’ language; these centers also may provide native-language materials and interpreters.

Offering reassurance to patients in their own language and in a culturally sensitive setting will help break down barriers and improve care. Patients who are educated about HBV transmission and the availability of an effective vaccine may be instrumental in preventing transmission of the disease to household members.

Cultural sensitivity training will benefit health care providers and staffs whose patients include Asian Americans. Educational programs should be specific to the needs of the community, as different subpopulations have different needs. Resource materials are available for such training; for example, the federal government’s Office of Minority Health Web site (https://www.omhrc.gov/) offers links to resources for cultural training. In addition to educating themselves and their staffs, health care providers have a responsibility to advocate for funding and equal access to care, and for the creation of more cultural and community health centers that can serve as resources to overcome cultural barriers.

DISCUSSION

Robert G. Gish, MD: How often are herbal remedies tried for chronic HBV infection in the patients you see, especially in the Vietnamese population?

Tram T. Tran, MD: Once patients are diagnosed with chronic HBV infection, the use of herbal remedies is very high; it approaches 80% in my practice. Patients may not admit to it unless you ask them specifically, because they know herbal remedies may be somewhat frowned upon by Western physicians. If you are careful and ask very gently about their use of herbals, they will tell you that they do believe in herbal medicines pretty strongly.

Morris Sherman, MD, PhD: I’d like to emphasize the need to be able to communicate with patients in their own language. In Toronto, 50% of the population was born outside of Canada. We have a huge immigrant population; given the nature of hepatology, we have many patients from Southeast and South Asia, and from all over the world, who don’t speak English. My hospital has a multilingual interpreter service, which we use freely. Scarcely a day goes by without two or three interpreters coming to the clinic to talk to patients, and as a result it’s rare that I can’t make myself understood. Maybe what I’ve said hasn’t been accepted, but patients can at least understand what I’m saying.

William D. Carey, MD: I interview many applicants for our medical school, and many of them are Asians, including Hmong and Vietnamese. With the high value that most of these groups put on education and their success with educational attainment, is their access to care improving? Are we doing a better job of training nurses, allied health personnel, and physicians to deal with this problem?

Dr. Tran: I think so, yes. For instance, the Southeast Asian immigrant population arrived in two different eras. The Vietnamese who immigrated in 1975 have been in the United States longer and in general have been able to attain a higher level of education than those who came later. The group that arrived earlier is therefore more likely to have health insurance, and it has been easier to get them into the health care system. More recent immigrants have had more difficulty navigating the system. In general, their socioeconomic status and therefore access to care is directly related to how long they’ve been in the country.