Vietnamese Americans





Behavioral Objectives


After reading this chapter, the nurse will be able to:



  • 1.

    Identify communication barriers a Vietnamese American may encounter when using the U.S. health care system.


  • 2.

    Identify beliefs about space that may influence how Vietnamese people feel about care given to females.


  • 3.

    Describe the organization of the Vietnamese family.


  • 4.

    Articulate ways the nurse might modify instructions to a Vietnamese-American client based on differences in time perception.


  • 5.

    Discuss briefly the basic yin and yang theory of Chinese medicine and how it is expressed in the cause and treatment of disease.


  • 6.

    Articulate at least three explanations for the causes of illness that influence traditional Vietnamese thinking.


  • 7.

    Discuss implications for care of the small body size of many Vietnamese Americans.










Overview of Vietnam


Vietnam is situated on the eastern coast of the Indochina peninsula, bordered on the north by China, with the Gulf of Thailand surrounding the Mekong Delta on the south. On the west, Vietnam is bordered by Cambodia (Kampuchea) and Laos and on the east by the South China Sea. The country is slightly smaller than Japan, with 127,000 square miles. Vietnam, along with Laos and Cambodia, is often referred to as Indochina or Southeast Asia. These three countries are strikingly dissimilar, with different languages, unrelated social roots, long histories of unique development, and varying sources of strife.


The northern part of Vietnam is mountainous, with deep valleys and the industrial Red River Delta. The central ribbon is a long, narrow corridor with a mountain range, coastal plain, and miles of beautiful white sand beaches. The southern part of Vietnam is mostly the flat Mekong Delta, the agricultural area where most of the rice for the country and for export is grown. Vietnam is considered a tropical country, although the north has four distinct seasons and the south has two seasons: rainy and dry.


The population of Vietnam is 93,423,835 (2014 estimate) ( ; ), which includes lowland people (often urban and more educated), rural village people (with varying degrees of sophistication and education), and mountain people (made up of at least 30 different groups or tribes with a culture all their own). Ethnic groups include Kinh (Viet), 85.7%; Tay, 1.9%; Thai, 1.8%; Muong, 1.5%; Khmer, 1.5%; Nun, 1.1%; Hmong, 1.2%; and others, 4.1% (2014 census) ( ). The mountain people number approximately 1 million ( ). The life expectancy is 72.91 years (2014 estimate), with an infant mortality rate of 18.99 deaths per live births. The literacy rate is 93.4% ( ; ).


Vietnam has a recorded history of more than 2000 years, with legends that cover an additional 2000 years. Earliest records are of dynasty rule and domination by the Chinese (111 b . c . to 938 a . d .). There were 900 years of independence until the French came in 1858. Throughout the French domination (until 1954), the Vietnamese continued to work toward independence.


The country was divided into the Communist north and the non-Communist south by the Geneva Accords in 1954, when it became clear that the “nationalist” movement in the north had been monopolized by leaders leaning toward Communist ideology. The struggle between the Soviet-assisted North Vietnam and the United States–assisted South Vietnam ended in 1975, when Vietnam was reunited under the victorious Socialist Republic of Vietnam. More than 30 years of war had physically, economically, and socially devastated the country. There was a great deal of turmoil and isolation during the next 15 years, as the Communists attempted to rebuild the country under a new philosophy. Floods and drought added to the crises and poverty. Thousands of people left the country for hope in the outside world, especially France, the United States, Canada, and Australia. By the late 1980s, however, the need and opportunity for economic exchange helped ease restrictions, and there was a pronounced influx of economic interests and business with countries around the world. By 1993, the country had a trade surplus and was the world’s third largest exporter of rice ( ). The years-long trade embargoes from the United States were lifted in 1994, and in 1995 the United States extended Vietnam full diplomatic recognition. The 25% unemployment rate of 1995 has decreased to an estimated 5.5% in 2012, and the Vietnamese have become less anxious to leave the country ( ). The 2013 estimate of the gross domestic product was $358.9 billion, with a per capita income of $4000 ( ). Some 12.3% of the people live below the poverty line (2013 estimate). Today, 56.8% of the labor force is agricultural, 37% is industrial, and 6.2% is service oriented. By 2002, “going back” to visit Vietnam was a common occurrence in most U.S. Vietnamese communities. Dollars carried in by friends still provide welcome help for improving the quality of life for many Vietnamese. Today, tourism provides many jobs for the people of Vietnam. The United States has become Vietnam’s top export market, with an annual trade totaling over $6 billion ( ).




Immigration to the United States


In 2009, 1,471,509 people (0.37% of the population of the United States) identified Vietnam as their country of origin. The Vietnamese population ranked as the fourth largest Asian American group, preceded only by Chinese, Filipinos, and Asian Indians ( ). Vietnamese make up approximately 11.0% of the total Asian American population.


Of the Asian Americans residing in the United States, 20.7% reside in the Northeast, 11.7% in the Midwest, 18.8% in the South, and 48.8% in the West ( ). The highest concentrations of Vietnamese Americans are in California, Virginia, Texas, and Florida. Approximately 84.0% of Vietnamese persons in the United States today were born in a foreign country ( ). Between 1980 and 1990, 69.7% of all Vietnamese residing in the United States were immigrants, compared with 27.1% between 1975 and 1979. The number of Vietnamese immigrants slowed somewhat between 1991 and 2009. In fact, while the Vietnamese population grew by 134.8% from 1980 to 1990, it was only 35.1% from 1991 to 2009 ( ; ). The median age for Vietnamese Americans is 37.5 years, compared with 35.7 years for the rest of the U.S. population ( ; ; ). Approximately 48.8% of Vietnamese Americans are females, compared with 51% for the total nation ( ).


First-Wave Immigrants


The first group of refugees, who began arriving in 1975, included lowlanders, professionals, ranking South Vietnamese military personnel, and those with close U.S. connections. This group also included those who had the means to get out of the country and those who stood to lose the most under the new regime. A high percentage of these immigrants were educated in Vietnam or abroad, and some spoke English. Many were young and single or married with small children. The children moved into the school systems and could soon speak English more fluently than their parents and in some cases more fluently than they could speak Vietnamese.


Some of these immigrants had been exposed to European cultures or to the American culture for years and had economic or vocational assets. They generally did not go through a long, stressful period of economic and psychological deprivation affecting their health. Of the 145,000 Vietnamese persons who came to the United States in 1975, 14% lived in single-family households, 42% were under 18 years of age, and 11.6% were over 44 years of age. Approximately 90% were employed 1 year after arrival ( ).


Second-Wave Immigrants


A higher percentage of the second-wave refugees (1979–1980) were Chinese-Vietnamese extended family groups who left Vietnam under duress and pressure from the government. These immigrants were educated and part of the business community in or near Saigon and had as much social status as was permitted under the existing regime. For many persons in the second wave of refugees, however, Vietnamese was a second language, and fewer spoke English than in the earlier group. These immigrants also included elderly persons and other extended family members who often had health needs.


Third-Wave Immigrants


Most of the Vietnamese refugees during the 1980s were “boat people,” who in many cases had lived through not only economic struggles but also political and social change while at home. In addition, the boat people had survived life-threatening situations for days at sea. Persons in the third wave often spent months or even years in refugee camps along the way, and these earlier experiences caused turmoil that needed to be dealt with once they arrived and got settled in the United States. Third-wave immigrants were even more diversified than those in the two former groups. Many were in poorer physical condition than those arriving earlier, and generally the adjustment was more difficult and more complex. Although many refugee education programs and school systems had organized programs to absorb the newly arrived children and adults in the first and second waves, these programs were not as effective with persons in the third wave. Life in camps did not encourage rigorous study habits or academic excellence, and many children in the third wave were not able to read or write well in either Vietnamese or English. For the boat people, education to assist in adjustment to the new environment needed to be much more comprehensive.


By 1986, nations surrounding Vietnam, Cambodia, and Laos had tightened laws for illegal travelers to their shores, and the traffic of boat people slowed down. At the same time, the government of Vietnam gave new economic life to the country by allowing the people some private marketing and land use. In 1989, the government agreed to voluntary repatriation of Vietnamese who had left the country, and during the next 3 years, with the United Nations’ help, more than 32,000 boat people returned from camps, especially from where they had been held in Hong Kong ( ). Foreign-born Vietnamese usually represent one of the three waves of immigration. In addition, it is helpful to know if the individual is first, second, or third generation in the United States, since these factors will influence adherence to cultural behaviors that are practiced ( ).




Communication


Language


In the United States, Vietnamese is the language of most of the 1,687,951 people who call or have called Vietnam their home. In 2013, 53.1% of all Vietnamese 5 years of age or older could not speak English well; 87.5% spoke a language other than English at home; and 12.5% spoke only English ( ).


Vietnamese is not mutually intelligible with any other Asian language. It is monosyllabic and disyllabic and polytonal (five to six tones), and so a syllable when spoken with different tones has an entirely different meaning. The language is flowing and musical, and for the most part, pronunciation is consistent and the grammar simple.


Until the 1960s, French was the language of educated Vietnamese people, along with Vietnamese; therefore, much of the scientific and technical vocabulary was borrowed from French or, more recently, English. After 1975 in Vietnam, English was more common as the choice for a second language in high schools and colleges. Three distinct dialects of Vietnamese separate the northern, central, and southern regions of Vietnam. Dialects identify the speaker’s origins and are understood by others regardless of region.


For many years before the Vietnam War, Vietnam had a large Chinese minority who had their own schools with classes conducted in Chinese. In the Chinese suburb of Saigon called Cholon, many older Chinese persons spoke only Chinese, and the children learned Vietnamese as a second language. This explains why many persons in the large Chinese–Vietnamese refugee group can speak both Chinese and Vietnamese or only Chinese. In contrast to this, the ethnic mountain people, or Montagnards, have their own tribal languages (usually of Austronesian type and, in the north, Miao-Yao type) and often do not understand Vietnamese.


Style


Respect is very evident in communication and is a cornerstone of Vietnamese society ( ). The proliferation of titles in the Vietnamese language is evidence of the cultural focus on respect. For example, when describing family relationships, English users have titles reserved for family members that include mother, father, sister, brother, uncle, aunt, cousin, grandmother, and grandfather . However, the language and style of the Vietnamese not only encompass family descriptors such as uncle but also designate which side of the family a family member represents (mother’s or father’s) and further indicate whether that relative is the eldest brother or sister. Grandparent titles also reflect paternal or maternal side. When a sister or brother is being described, the term used indicates if the sister or brother is younger ( em ) or older ( chi or anh ).


Context


The word yes is used in English to express agreement and does not reflect an attitude of respect or disrespect. For Vietnamese people, ya indicates respect and not necessarily agreement. Therefore, a troubling verbal communication between health workers and Vietnamese-American clients is the polite “ Ya, ya, Thua bà, ya, ya ,” response, which Americans interpret as “Yes, yes, I understand, and I’ll do it.” For the Vietnamese, the “yes” of ya is simply being respectful, indicating “I’m listening, and I respect what you’re saying” (even though the request may not be within the realm of possibility). Nurses often reflect later, “But he said, ‘Yes, yes,’ and agreed to . . . .” Noncompliance by Vietnamese Americans can often be traced to this misinterpretation of ya .


Vietnamese people often use personal pronouns to describe various roles held. For example, the speaker may refer to the self as con (referring to a child) when addressing parents and as em to the nurse or to any superior. However, the same individual may refer to himself or herself as thây (teacher) when addressing students. It is common for Vietnamese persons to use only the title of a person, such as “Uncle” or “Teacher” except with family and close friends. Especially when there is considerable distance between the speaker and the listener, the title alone is most correct. This custom is practiced even in the United States. For example, people often say “Madam Chair” or “Mr. President,” indicating that the title is more important than the name.


Two distinct features of the Vietnamese culture and consequently the language are moderation and caution ( ). Vietnamese people are taught from childhood to think before speaking. High value is placed on modesty of action and speech. A Vietnamese proverb suggests that “bragging reflects an empty soul.” There is also concern that a slip of the tongue may bring discord and be disruptive to harmony and respect. Ethnic Vietnamese lowlanders, as well as those from the mountain tribes, place high value on showing respect: communication should always be in a formal, polite manner ( ). Table 18-1 highlights some differences between Asian and American communication styles.



TABLE 18-1

Communication Style and Expression of Emotion

From Nilchaikovit, K., Hill, J., & Holland, J. (1993). The effects of culture on illness behavior and medical care. General Hospital Psychiatry, 15, 41–50.



















Asian American
Nonverbal Verbal
Subtle, indirect Open, direct
Serene, stoic, suppress negative emotions Expressive, spontaneous
Indirect expression of affection by fulfilling obligations, needs Direct verbal and physical expression of affection


Touch


Traditionally, the high value of emotional self-control and the general esteem for correct behavior have limited touch as a form of communication. Physical behavior, including backslapping, is not considered proper by the well-bred. The young people have been less formal, and in Vietnam in the 1970s it was not uncommon to see groups of Vietnamese boys jostling each other in the street or girls walking arm in arm on the sidewalk. Today in the United States, many Vietnamese youths are taking cues from their American counterparts. For some Vietnamese people, the head is considered the “seat,” and touching it, even in the process of giving care, may cause some vital force to escape ( ).


Kinesics


In the Vietnamese culture, respect is also conveyed by nonverbal communication. By the time standing is possible, the child is taught to cross the arms over the chest, lower the head, and bend the upper torso slightly forward when greeting an elder or a guest coming into the house. Nonverbal methods to communicate respect continue to be used throughout life. Deference to others shows a Confucian and Buddhist influence in that how something is done is often more important than what is done. Posture and manner of walking can be used to indicate self-concept ( ). Respect is also shown by avoiding eye contact when talking with someone who does not have equal standing in education, social standing, age, or gender. A student avoids eye contact with a teacher, an employee with the boss, a younger member of the family with the elders, and so on. Direct eye contact in these settings generally means a challenge or an expression of deep passion. Bowing the head slightly when entering the presence of an elderly person conveys respect. Using both hands to give something to or receive something from an adult, especially an elder, or person of higher status shows respect. The head may be considered sacred, and care should be taken in touching and patting. Feet are the lowliest body parts and should be kept on the floor.


A silent form of communication may also be used that relies heavily on implied understanding between people of the culture. Because of cultural norms, sometimes implicit concerns are not allowed to be discussed verbally. For example, it may be very unusual or could be considered improper for a son or daughter to discuss issues of death and dying with parents, yet concern by either of them may be expressed by nonverbal cues, such as bowing of the head or direct eye contact. When dealing with Western health care professionals, these understandings are not overtly stated. Unless the health care professional knows the culture well enough to address the unspoken, this valuable information is lost and often leads to misunderstanding of family–patient dynamics or lack of agreement with the plan of care ( ).


In contrast to the usual palm-up position used by persons in the dominant culture in the United States, Vietnamese persons beckon for someone to come by turning the palm downward and waving the fingers. The upturned palm is used to call a dog or other animal or as an insult. It is never proper to snap one’s fingers or wave violently to gain someone’s attention.


Except in private circumstances, open expression of emotions is considered in bad taste. Emotions interfere with self-control and can be considered weaknesses. Romantic overtures and demonstrative joyous expressions are reserved for home or other private settings. One exception to the usual restraint is the expected behavior of a widow at the grave for the burial of her husband, when she may wail or attempt to throw herself into the grave.


Implications for Nursing Care


Because respect and harmony are highly valued in relationships, there is a great desire in the Vietnamese culture not to disappoint, upset, embarrass, or cause another person to lose face. The desire to maintain harmony takes precedence over what the actual truth of a situation may be. When a Vietnamese-American client is confronted with a difficult or delicate question, particularly if the answer is negative, such as “Did you take your medication?” the client may choose not to give a direct answer in favor of the higher good of keeping peace with the nurse. In the Western culture, this avoidance might be considered an attempt to avoid the truth; however, in the Vietnamese culture the answer would be considered the correct way to handle a delicate situation.


The nurse should recognize that negative emotions or expressions of disagreement are usually conveyed by silence or a reluctant smile. For the Vietnamese a smile may express joy, but more often it is used to convey many other messages, such as stoicism in the face of difficulty or an apology for a minor social offense. A smile may be a proper response to a scolding to show sincere acknowledgment for the wrongdoing, as well as to convey that there are no ill feelings. A smile is also a way to respond when it is improper to say “thank you” or “I’m sorry” because of age or status. A smile is often present, regardless of the situation. Even if angry, feeling neglected, or in need, the Vietnamese-American client will rarely express this to the health care professional but rather will speak quietly and smile. Instead of asking questions that allow an answer, such as “Are you having pain?” or “Do you want something for pain?” the nurse should acknowledge the likelihood of pain and state, “Please let me get you something for pain.”


The nurse may experience difficulty with gathering information from Vietnamese-American clients. Vietnamese-American clients tend to be discreet and passive, quietly understanding problems and rarely expressing feelings. Usually there is even more difficulty obtaining information in the area of emotional problems or sexual difficulties because these topics are considered private and to be avoided in public ( ). In short-term relationships, it is crucial to have a same-sex Vietnamese interpreter; for the long term, the health professional should work toward a trusting relationship. For the Vietnamese client, a caring, accepting attitude helps bridge the gap to true understanding.


Because most Vietnamese American clients entering the health care system in the United States do not speak English, with many medical terms, an interpreter or bicultural medical translator can assist in accurate communication. It is important that the translator be culturally aware and conscientious to bridge the gap between the culture of the client and members of the health care team. Accurate translation can be assisted if the interpreter is Vietnamese because of the built-in cultural awareness. However, the Vietnamese interpreter may be hesitant to translate certain complaints that are unacceptable to Western practitioners, such as symptoms the client states are “caused by the wind,” a common expression. Other important factors are the effect of differences in social class between interpreter and client, the possible effect of a male interpreter with a female client, and the need for a female interpreter or companion when a physical examination is done on a female client. When an interpreter is unavailable, it is important for the nurse to choose vocabulary carefully, to keep instructions simple and brief, and to avoid medical jargon ( ) ( Box 18-1 ).



Box 18-1

Using an Interpreter


Unless there are large numbers of a specific cultural group, most hospitals or medical centers cannot afford professional interpreters. But with careful selection and guidance, good interpreters can be home grown.



  • 1.

    Find a good bilingual person in the Vietnamese community who lives near enough to be called upon to help, either in person or on the phone, when needed. Often Vietnamese can suggest suitable candidates. Except in real emergencies, avoid using the family’s 10-year-old daughter, friends, or “the cleaning lady.”


  • 2.

    Get to know the interpreter beforehand and practice saying the Vietnamese name correctly. Usually a title should be used.


  • 3.

    Be sure the interpreter understands the idea of confidentiality, “a commitment of all members on the health team.”


  • 4.

    Impress on the interpreter that you consider him or her a bridge between the two groups of people involved, the family and the health team, and in a special way an important member of both teams.


  • 5.

    If the terminology for the anticipated causes, symptoms, suspected diagnosis, and other matters is not routine or familiar, review it briefly with the interpreter so these can be looked up or clarified before the interview.



During the Interview




  • 1.

    The interpreter’s seat should be about halfway between you and the patient group. This helps communicate that the interpreter is a bridge, not a member of only the health team or of only the family.


  • 2.

    Greet the family, and then introduce the interpreter by name to the patient. If the patient is elderly, show respect by introducing the interpreter to the patient, but then also include the accompanying family, who likely will be doing much of the communicating.


  • 3.

    Always look and talk directly to the patient family group, not at or to the interpreter. Remember, the interpreter is the bridge, not the original messenger. (An exception is when you and the interpreter need to clarify something with each other.)


  • 4.

    To make it easier: Use short, direct sentences.




    • Plan questions carefully. Do not use double negatives. Focus on one item for yes–no questions.



    • Avoid technical jargon, idioms, and metaphors.



    • Avoid humor or jokes, which are often difficult to translate.



    • Be aware that questions related to the reproductive system or sexual behavior are sensitive areas.



  • 5.

    Be prepared to hear new names for familiar symptoms without showing surprise or scorn. One way of handling unfamiliar diagnoses can be to ask, “Can you tell me what I need to know about [the specific diagnosis mentioned]?” ( , p. 499).


  • 6.

    At the end of the interview, thank the family and specifically thank the interpreter.



The interpreter is not only bilingual but also bicultural. With sensitivity and respect in working together, the professional will be fortunate to come to depend on him or her not only to translate words but also to translate culture, raising the caution flag when the culture is being inadvertently violated in some way. Often the interpreter can come up with a good solution to the situation if the professional can be depended on for respect and understanding.


After the Interview




  • 1.

    Document the interpreter’s name on the medical record.


  • 2.

    Discuss any part of the interview that was problematic, and attempt to learn the cause and find possible options for the solutions.


  • 3.

    Validate any information or important decisions the professional understood had been made, including the plan of action.


  • 4.

    Thank the interpreter and check that the institutional plan for reimbursement is clear.




The nurse should be aware that English phonetic practices applied to Vietnamese names often result in pronunciations that are unintelligible to the Vietnamese. Nguyên Thi Hồng, who has been responding to approximately/Wee-un/Tee-hung/ for 23 years, can hardly be expected to appear at the clinic desk when she is summoned as /Hung Thigh Nugooen/. (In Vietnam, the family name—for example, Nguyên—is spoken first and always appears first on listings. In the United States the family name is always spoken last, although it appears first on listings.) In a clinic where clients must be called, it may be useful to have the clients take numbers because numbers are more readily understood. It is important for the nurse to appreciate that pronunciation may also cause difficulties with questions regarding addresses and phone numbers. It may be easier for the client to write answers to such questions. Such a client should be encouraged to carry instructions in written form.


A question about age may also be difficult for the Vietnamese-American client. A Vietnamese mother may be able to indicate the year a child was born but may not be able to state the child’s exact age. In Vietnam individual birthdays are not usually celebrated; rather, everyone becomes a year older at the beginning of each new year (Tết). Thus a newborn who arrives during the week before New Year would be considered 1 year old following the first Tết celebration. Another reason for confusion about age, especially for persons who immigrated as teenagers, is that new birth certificates may show an age adjustment of 2 or 3 years earlier. This adjustment may have been done in Vietnam to avoid the draft or in the United States to facilitate entrance into high school. (After 18 years of age, the student was not usually accepted into high school regardless of educational level attained in Vietnam.) The slight build of many Vietnamese persons facilitates this age adjustment. Elderly Vietnamese persons without birth certificates usually know the year of their birth and are officially assigned, on arrival in the United States, a birthday of January 1. Finally, the nurse should be cognizant of the fact that for many Vietnamese Americans the numerous questions asked by health professionals in the United States raise doubt about the competency of the health professionals. The nurse should attempt to communicate both acceptance of varying cultural practices and genuine concern in order to bridge the gap between the cultures and to increase the client’s trust in the caregivers.




Space


Intimate Zone


Beliefs about space are rooted deep in Vietnamese culture. For traditional Vietnamese persons, intimate-zone activities are confined to private settings. Holding hands in public, especially with members of the opposite sex, is considered in poor taste, and hugging or emotionally touching in public, even by close friends or family members, is embarrassing to the traditional Vietnamese.


Beliefs about space also influence how Vietnamese people feel about care given to females. Until the early 1900s, traditional practitioners were not to touch the bodies of their female clients except to take their pulse. Figurines were used for the female client to indicate where she was having problems. Today, many Vietnamese persons still emphasize virginity at the time of marriage, especially for the woman, and have strong feelings about unmarried young women having pelvic examinations.


Personal, Social, and Public Zones


Vietnamese individuals are likely to feel more comfortable with more distance during personal and social relationships than that required by persons in the dominant culture. Social exchanges generally do not involve physical contact other than handshaking, which may be practiced between men.


Living Space


In Vietnam, extended families live comfortably in relatively small areas. The moderate or warm climate allows many family activities to be carried on outside. Often the kitchen is separate from the rest of the house, and the two or three main rooms double as living rooms and bedrooms, with the mosquito nets neatly tied back during the day. Even in spacious homes, family members often prefer to spend much of their time in proximity to each other. In rural Vietnam, homes are typically arranged in communities and villages with several homes near each other.


Although many Vietnamese persons were used to living in close proximity, refugee camps brought a new kind of cramped and confined closeness. As refugees, many Vietnamese persons lived for several months or years with 8 to 10 persons occupying a one-room space, sometimes enclosed only by a blanket curtain. Special adjustment was required by most refugees when they received housing in the United States because many well-intentioned sponsors made an effort to provide single-home dwellings for the refugees because “they’ve been so crowded so long.” Unfortunately, this space lacked the familiar sounds, smells, and people and soon brought feelings of loneliness. Today, many Vietnamese Americans have homes with room for parents and additional family members and desire to have relatives and friends in close proximity.


Implications for Nursing Care


When caring for Vietnamese American clients, the nurse should be cognizant of the effect space may have on client care. For example, the nurse should be aware that if a pelvic examination is to be conducted, it is important for a female translator to explain carefully why it is necessary and what will be done and to remain with the client during the examination.


The nurse should also be aware that a back rub from a stranger could cause feelings of uneasiness. The nurse should use discretion in including a back rub as a routine part of nursing care.




Social Organization


Family


In Vietnam, the family is the basic institution of society and provides lifelong protection and guidance for the individual members. The roles and structure are well defined, with extensive terminology designating kinship relationships. The lineage is patriarchal, with the father considered the head of the household. The mother often handles much of the household responsibilities and management.


The immediate family includes the parents, unmarried children, daughters, sometimes the husband’s parents, and sons with their wives and children. In addition, the extended family includes other close relatives (usually with the same family name and ancestors) who live in the same community ( Box 18-2 ). The oldest son has the heavy responsibility of carrying on the family name, of taking over for the parents when they become elderly, of seeing to their care, and of following through with the religious and ancestral observances. The oldest daughter takes responsibility for the care of the household in the absence of the mother.



Box 18-2

Names


Many Vietnamese family names originated during the various dynasties that ruled in Indochina during the past 3000 years. There were about 100 family names for more than 56 million people, and of those 100 names, “only a score” are in common usage today ( ). Nguyên (near pronunciation is /Nwee-un/) is the family name for more than 25% of the Vietnamese family units in the United States and Canada. With so many persons having the same family name, it has limited usefulness in identification; therefore, given names are used.


Names in Vietnam are always written family name first, middle name (or names) second, and given name last—for example, “Nguyên Thi Hồng” or “Trần Văn Hai.” The same names may be used for males and females, and the middle name can be a clue as to gender. “Văn” used as a middle name usually indicates male gender (“Trần Văn Hai”) compared with “ ” (pronounced /Tee/), which is used for females (Nguyên Hồng). Sometimes several middle names are used, and therefore there is no gender indicator.


After marriage, a woman keeps her maiden name and does not combine it with her husband’s name. Informally she may be called by her given name or her husband’s given name (“Mrs. Hai”), but formally she uses her full maiden name preceded by “ Bà, ” which can be used as a respectful “Mrs.” Children take their father’s family name. Customs are changing in the United States, but to avoid confusion, many Vietnamese-American wives are adopting their husband’s family name. Either name may be used, depending on the setting, and children have interesting choices when asked for “mother’s name.”


Given names usually have special meanings, often describing the baby or expressing the hopes of the parents for the baby. Names can be chosen from virtues or from nature or music; for example, “Hồng” means “rose” and “Xuân” means “spring.” At home or in the village, people may be called by their number in the sibling ranking, rather than by their given names, which explains the nicknames of Nam (fifth) or “Bâỷ” (seventh).


Today, many babies born in the United States are given both an American name and a Vietnamese name. This is not a new practice for the Vietnamese. During the past half-century, for example, the Chinese Vietnamese were commanded by law to change their Chinese given names to Vietnamese names. These persons may also have taken a Christian name when they converted to Christianity. In this resettlement period, almost every Vietnamese child who has an English first name can also give a Vietnamese name if asked.


Except for close friends and coworkers, Vietnamese custom dictates that a person’s name is used with a title, never alone. An example of this in English would be “Mr. Bill,” “Mrs. Mary,” “Director James,” or “Uncle John.” Titles are important and therefore should be selected carefully by the speaker to convey appropriate respect as well as sometimes to place emotional distance between the speaker and the listener.



The family has been the chief source of cohesion and continuity for the Vietnamese for hundreds of years. In comparison with Chinese and other Southeast Asian groups, the Vietnamese family is seen “as the backbone of tradition and heritage” ( , p. 137), the center around which ancient traditions, customs, and ways of life continue ( ).


The crux of family loyalty is “filial piety,” which commands children to obey and honor their parents. According to , the worst insult a Vietnamese can receive is to be accused of failure to fulfill the obligation of filial piety. Along with the three major historical religions of Vietnam, “Honor your father and mother” is also commanded in the Christian faith (Exodus 20 : 12).


Parents consider it important to train their children, and this responsibility is usually shared by members of the extended family living in the household. Obedience and honor are shown in several ways: obedient behavior and attitudes, using the detailed kinship terminology for each person, and contributing to the family name through outstanding achievements. Personal interests and destiny are seldom considered outside the framework of the immediate and extended family. Behavior or misbehavior (juvenile delinquency, academic failure, mental disorders, and so on) reflects on the entire family and has great significance beyond the person involved. It has often served to curb antisocial behavior, especially among the young.


If personal feelings or ambitions do not contribute to the good of the family or cause disharmony, the individual is expected to bend toward the family and give up personal wishes. In a study using open interviews to understand Vietnamese culture, Laura, a 26-year-old, reflected on how parents or other older members of the family direct children in making life decisions:



Actually my older brother he really wanted to become a doctor. But my uncle said, “You can’t do that. You know that, you have to bring them (rest of the family) here, so you have to study something that take a short time. Engineering, something like that.” And my brother, he listened to my uncle. ( , p. 142)


As Vietnamese point out, Vietnamese family traditions began to change decades before immigration to the United States. With the years of war, the prescribed gender roles and decision making had to be taken on by the females of the family. Large extended families were less common or more scattered, or family homes were located in inaccessible territory. The intergenerational households in the United States create stress in the family, with young family members becoming acculturated into the American way of life, while parents and grandparents retain more traditional values ( ).


The Vietnamese concept of family and extended family that has existed across generations as a “super organic unit” is profoundly different from the individualism of the nuclear family in the United States in the beginning of the twenty-first century. And this disparity continues to strongly affect the stress levels of Vietnamese communities in the many pressures toward acculturation. Every culture has particular characteristics that help a member of the culture meet everyday life situations. When a cornerstone of the cultural structure is attacked, the cost of the resulting anxiety cannot be overestimated.


Socialized Role of Children


Children are socialized to their roles in the family at an early age. Children are to obey and respect all elders, address them by correct titles, and correctly cross their arms over the chest and bow slightly from the hips when introduced or coming into the presence of elders.


There is increasing concern noted in the literature with the practice in the West of equating the Asian concept of “training” with the Western ideas of “authoritarian” and “control” types of child rearing. noted that these terms may have entirely different implications for Asians because they are from a different cultural system, an American-European cultural tradition Asians do not necessarily share. The Asian concept of “training” describes the responsibility of parents to be highly involved, caring, and concerned. The mother as the central caretaker has major responsibility for promoting the success of the child, having the child physically near her, even through the night. Chao notes that Asian immigrant children do well in U.S. schools, often not true for the U.S. “authoritarian-type”–parented offspring.


examined “authoritarian” Asian parenting and the transmission of values. Again, control seemed to be less the determinant; rather the warmth, involvement, and kindness perceived by the child make the difference. Also, the importance of whether the culture is an individualistic or collectivistic culture and the dilemma of the immigrant parents (and African-American parents) raising children as minorities in a culture seen as a high-risk environment for the child personally and for the group. “Best values” may be best values for the whole group rather than simply the individual.


Although not mentioning Vietnamese specifically, in the article, “Understanding Context and Culture in the Parenting Approaches of Immigrant South Asian Mothers,” caution social workers against counseling these parents to accept Western culture, but rather establish support groups where parents support each other while finding their way as they “train” their children to survive in their new culture—and also survive in their old one.


Vietnamese children in the United States who are in school and learning English at a faster rate than their seniors at home are often placed in the role of translator. This situation, continued over a period of time, gives the child a sense of power in the family hierarchy that is difficult for both the child and the family.


Education


Before 1954, Hanoi was the educational center for Vietnam and contained most of the medical and dental schools. After the Geneva Accords, South Vietnam had its own educational centers in Saigon, Hue, and Can Tho, but the demand far exceeded the supply. The high demand and limited seats in the high schools and universities caused many students to delay their education, go abroad, or, for the men, be drafted.


Today in the United States, education continues to be highly valued in the Vietnamese community. The Vietnamese, like their other Asian-American counterparts, continue to excel in educational attainment. These data illuminate some interesting trends. For example, in 2013, among Vietnamese-American men 25 years of age and older, 73.3% were high school graduates, and 29.9% held a bachelor’s degree or higher. Similarly, among Vietnamese women 25 years of age and older, 69.7% were high school graduates and 27.0% held a bachelor’s degree or higher ( ).


Religion


Vietnam has a history of religious tolerance except for the period immediately before the French takeover, when Christians were suspected of being spies. More recently, the official government position is religious tolerance, with much of the governance being left to the local officials.


Three major religions from China have combined to strongly influence Vietnamese thought and practice and become an ingrained part of the culture during the past centuries: Buddhism, Confucianism, and Taoism. Buddhism is considered less an organized orthodoxy than a state of mind, using the Four Noble Truths taught by Buddha: (1) life is suffering, (2) suffering is caused by desire, (3) suffering can be eliminated by eliminating desire, and (4) to eliminate desire, one must follow the eightfold path.


Confucianism is a code of ethics and emphasizes hierarchy of society, worship of ancestors, and respect for age, customs, teacher, and family. Taoism from Tao, or “The Way,” originated in the sixth century b . c . and is a creative principle that governs the physical universe. When things are allowed to take their natural course, they move toward harmony and perfection. Therefore, individuals should attempt to blend into the natural world rather than try to conquer it ( ).


Two minor religious sects, Cao Dai and Hoa Hao (harmony), began in Vietnam during the past century, with a present combined following of about 3 million. Another belief system, Animism, continues to have a strong influence among the mountain tribal groups. It includes practices to deal with demons, evil spirits, angry gods, and elements of the natural world.


The first Catholic missionary arrived in Vietnam in 1513, and Jesuits arrived in the early 1600s. The Protestants came in the early 1900s. Today Christians number over 2 million. Buddhists (along with many Vietnamese who consider themselves Buddhists because of their practices relating to their ancestors) claim approximately two thirds of the country’s 79 million people. Many Vietnamese have turned to both Eastern and Western religions following the 1975 change of government.


Values


Respect and harmony are the two most important values in the Vietnamese culture and are based on the three major religious belief systems that have dominated the country. The strength of filial piety in the culture expresses the first value in many ways and throughout the life cycle.


Preserving harmony affects the lifestyle of a culture, from the highest government echelons to the most remote villages, from handling information to dealing with world conflicts. Specifically, it can affect health care decision making. Families may be less willing to share bad news with the group. Family members tend to be more likely to accept decisions made by the family, feeling the decisions were made for the overall good. Clients may be more willing to endure hardship or pain quietly to avoid causing problems or inconvenience for the family. When the belief values common to the Oriental or Eastern system found in Vietnam and those of the Occidental or Western system found in the United States are compared ( Table 18-2 ), the nature and extent of the tasks of acculturation faced by the Vietnamese who must mesh two systems are apparent.



TABLE 18-2

Comparison of Eastern and Western Value Systems

From Cao, A. Q. (1986). Linguistic and cultural issues in refugees. In The next decade: the 1986 Conference on Refugee Health Care Issues and Management. 1986 Refugee Health Care Conference Proceedings (pp. 70–75), University of Miami; Nguyen, D. (1988). Culture shock: a study of Vietnamese culture and the concept of health and disease. Journal of the Association of Vietnamese Medical Professionals in Canada, 98, 26–30.





































Eastern System Western System
Harmony with nature Mastery of nature (skyscraper)
Tradition Change, innovation
Hierarchy Mobility, upward or downward movement
Age Youth
Extended family (few family names) Nuclear family, small, individualistic
Convergent thinking Divergent thinking
Cyclical concept of time Specific point, schedules, clocks
Group orientation and reward Self-concept and self-actualization
Rote learning Discovery learning
Conformity Competition


The Asian and Pacific Islanders as a Group


Although many surveys handle Asian and Pacific Islanders (APIs) as a single group, it is imperative to keep in mind that the 2010 U.S. Census identified 30 Asian and 21 Pacific Islands groups in the API ( ). The label includes more than 30 distinct ethnocentric entities, each with its own languages and customs. With this diversity, unless the specific ethnicity of the individual is known, generalizations must be avoided.


The “model minority” is a good example of the extreme unevenness within the API designation. In 2009, there were many API immigrants with an annual income above $50,000, but even greater numbers had income at or below the poverty level. In education, the API group could boast the highest percentage of women age 23 years and older who had completed college in 2004 ( ). The disparity has been referred to as the “bipolar nature” of the API status, in which the successes of some API groups mask the severe problems of other API groups ( ). For example, noted that Asian immigrants as a whole are healthier than their U.S. counterparts; however, the pattern is not uniform, and data used to estimate the whole API population are deceptive. To ensure accurate research data, it is important to ascertain the specific ethnic identity of the test group and not to mix populations ( ).


In 2013, 66.1% of Vietnamese Americans participated in the labor force. Among Vietnamese Americans participating in the labor force, 32.6% held jobs in management, professional, or related occupations; 29.4% held jobs in service occupations; 16.5% held jobs in sales or office occupations, and 16.5% held jobs in production, transportation, or material-moving occupations ( ). In 2013, the median family income for Vietnamese Americans was $58,289 as compared with the rest of the general population at $52,250. Unlike other Asian Americans, the median family income and the median per capita income are both somewhat lower than the rest of the general population and are significantly lower especially for the median family income for other Asian Americans. The median per capita income for Vietnamese men was $40,940 as compared with $45,320 for the rest of the general population. Similarly for Vietnamese American women, the median per capita income was $30,924 as compared with $35,299 for the rest of the general population ( ).


Implications for Nursing Care


Because of the high priority placed on respect, harmony, filial piety, and material sharing found in most Vietnamese family systems, both immediate and extended family serve a significant role in providing emotional, physical, and economic support for the Vietnamese patient. A restriction to two visitors per patient in a hospital is incomprehensible to many Vietnamese, who may be used to large family gatherings in the home during illness. The feeling of support from the family outweighs any extra burden from the presence of additional family members and friends.


The culturally competent nurse will include family members in planning care and assisting with care whenever possible. If the client cannot speak English, the family will usually be appreciative if the nurse asks someone to stay with the client to serve as translator.


In most cases, communication about plan of care, legal documents needed, or preference of treatment options should be handled with a person designated by the family. Depending on the English proficiency within the family, the person speaking with the staff may be an interpreter. When an interpreter is used, adequate time should be given for the family to clearly understand treatment options. The value of respect and harmony can cause reluctance to tell family members of the client the true diagnosis or prognosis, especially if they are elderly. For example, a family may ask that the client not be told of a terminal diagnosis.


In addition to the potential to upset harmony in the group, it is sometimes believed that the diagnosis will hasten the death and cause the patient to give up prematurely. For many Buddhists, karma determines when death comes. This orientation makes the signing of informed consent and advance directives at best puzzling and, at worst, totally irrelevant. The nurse should appreciate that an elderly patient may delay signing papers until a designated family member arrives. Understanding the values of each individual client and family is essential to providing culturally competent care.




Time


The Vietnamese culture dates back thousands of years, and this antiquity is reflected in time orientation. Emphasis is placed on ancestors and their wishes, memories, and graves. Most Vietnamese people have been oriented to think of time in terms of cycles, events, or occurrences ( ). Since many Vietnamese individuals, even those who are not Buddhist, have some belief in reincarnation, time is less of a fixed point (here and gone) and more of a recurring reality. In other words, there was yesterday, there is today, and there will be tomorrow . . . which will in fact be today, followed by tomorrow . . . and so on. This belief results in a less stressful and less time-conscious pace than that commonly experienced in the West. Being late or early is not considered a problem.


As refugees, Vietnamese people practiced a present- and future-time orientation as they struggled to survive and focused on food, housing, employment, transportation, child care, and education. Today, Vietnamese Americans have goals and save for the future, and for many the motivation to live wisely may not only be to please the ancestors (past) but may also be connected with “the good life” (present) or the anticipation of heaven or reincarnation (future).


Implications for Nursing Care


The nurse should be aware that the concept of illness prevention requires both a future- and a present-time orientation. Illness prevention is a difficult concept if a person lacks a scientific understanding of disease processes. The nurse should also be aware that Vietnamese-American clients may believe that luck and fate play a significant role in suffering and that illness may easily be considered a result of spiritual failure or punishment. Agreeing to vaccinations for children, having a Pap smear or a mammogram, or even just the act of seeking medical care, is influenced by many factors, including time orientation.


Noncompliance with keeping appointments is often a result of factors other than time orientation. Some noncompliance can be traced to not understanding oral or appointment card communications or not being able to read the instructions. The nurse needs to review carefully the appointment card and any instructions given to be certain the client understands what is written. When a client is given a phone number to call for an appointment or for assistance, it is important to determine for sure that the client has a telephone available, knows how to use it, and has the correct clinic telephone number. Arriving at a clinic appointment on time can be a complex assignment for a Vietnamese American client, considering the usual work schedule of Vietnamese households, transportation by bus or subway, child care for those left at home, and the translation and challenges along the way.


Time orientation also contributes to the frustration of the nurse attempting to obtain a chronological sequence of the history of an illness. Especially rural Vietnamese may use life events such as births, marriages, or deaths rather than a specific date on the calendar to mark points of time. Sometimes the nurse can clarify historic events by referring to one of these events: “Did you start having these stomach pains before your husband died or since then?”




Environmental Control


Concepts of Illness


The medical system in Vietnam is a complex one, providing various options for health care from which the Vietnamese person may choose. Many traditional Vietnamese individuals tend to combine Chinese medicine with scientific techniques brought in from the West ( ; personal communication, 1989). For most, the choice is usually deliberate and purposeful but rarely rigid or restricted in any single direction. “The baseline is often a set of time-honored beliefs, customs, and usages that are faithfully followed by some, fiercely contested by others, but more or less consciously incorporated by the majority”.


; personal communication, 1989) divided the explanations of cause of illness into three types: naturalistic (folk medicine), supernaturalistic (animistic beliefs), and metaphysical (the theory of hot and cold). None of these theories excludes the others, and a client may explain illness by aspects of all three. A fourth explanation of germs as a cause of illness is gaining an increased following as Vietnamese interact with persons in Western cultures.


Natural Causes.


The naturalistic explanation for illness encourages a search for a natural or obvious cause of the symptoms, such as bad food or contaminated water or an obvious cause-and-effect relationship. To counteract the effects of these natural elements, an informal body of knowledge has been collected about indigenous medicinal herbs, therapeutic diets, and simple medical and hygienic measures. The information is usually transmitted orally and often treated with secrecy, remaining inside the clan or extended family. Vietnamese folk medicine may fall into the category of either thu c nam (southern medicine) or thu c b c (northern medicine), which more closely resembles Chinese medicine ( Box 18-3 ).



Box 18-3

Common Folk Practices




  • 1.

    gió (“rub-wind”: skin rubbing with a coin) is a folk practice used for diseases caused by wind entering the body, such as a common cold or flulike symptoms. A layer of balm or ointment is spread on the skin over the affected area—often the chest, upper back, or shoulders. A coin (preferably the size of a nickel or quarter) is pressed on the skin and drawn in one direction, and the coin is moved a short distance on the skin without breaking the skin. This is repeated several times, and if dark blood appears under the skin, the treatment is considered to be working. Often these ecchymotic stripes are continued in symmetrical rows down the back or chest. The purpose is to create areas where the offending wind or air may escape from the body. It is usually not a painful procedure for children or adults, and most report feeling improved by the procedure ( ).


  • 2.

    Bătgió (“catch-wind”: skin pinching) is a folk practice used for a headache. Fingers and thumbs are pressed on both temples in an attempt to move the blood across the forehead toward a spot between the eyes. After this has been repeated several times, the area on the forehead between the eyes is pinched between the thumb and forefinger and twisted slightly. If petechiae or ecchymoses appear, the treatment is considered successful. Skin pinching is also used on the neck for sore throat.


  • 3.

    Xông is a folk practice in which Vicks VapoRub or a similar agent or herb is stirred into scalding water. Depending on the reason for the treatment, the patient may simply inhale the vapor or may be treated under a blanket as in a steam tent.


  • 4.

    Inhalation of aromatic oils or liniments, such as menthol, eucalyptus, or mint-based aromatic oils, is used as a folk practice for symptoms such as motion sickness, indigestion, or cold or wind illness. The oils and liniments may be carried in vials in a pocket or purse for ready access and may be smelled when necessary; rubbed on the temple, under the nose, or on the abdomen; or taken internally in small amounts.


  • 5.

    Balm and medicated plasters are a folk practice involving direct application to the skin. Many common balms, such as Red Tiger Balm, Cù-Là-Mác-Su , or . Thiên-Du’ò’ng oil, are available in Asian shops, with certain balms obtainable only from an Asian pharmacy. Salonpas is a Japanese preparation (Hisamitsu Pharmaceutical Co., Tosu Sagu, Japan) with widespread availability and use. Many of the ointments have a mild “deep heat” quality on application and are used for bone and muscle problems as well as a variety of other ills.


  • 6.

    Herbal decoctions, soups, and condiments are used as a folk practice for a variety of symptoms and to maintain health ( ). The more complex, involving a variety of ingredients and combinations, are prepared by a pharmacist, whereas the simpler ones are prepared at home. The recipes may be generations old and have a mystical or secret quality about them. Many medicines are prepared to be given as soups. A familiar treatment is the use of garlic for hypertension. There is increasing interest and experimental evaluation of Eastern herbs in Western pharmaceutical firms.


  • 7.

    Giác ho’i (“cup-vapor”: cup suction) is a folk practice in which small, heated, cuplike forms applied to the skin cause a suction on the skin as the cups cool. The suction is used to remove unwanted wind or other elements from the body and is a favorite remedy for joint and muscle pains.


  • 8.

    String tying is a folk practice to control spirits. This practice is more common among the mountain people. Although the string, which stays on the arm, on the leg, or around the neck for long periods, may become dirty, it is relatively harmless and is a source of security for the wearer and significant others. Usually it can be left on without difficulty for anyone except health care workers, who may not understand the possible significance of this practice.




Supernatural Causes.


The supernaturalistic explanation for disease lays the blame on supernatural powers, such as gods, demons, or spirits. The illness is considered a punishment for a fault, for a violation of religious or ethical codes, or for an act of omission causing displeasure to a deity. In the supernaturalistic theory, disease may be caused by black magic or the evil incantation of an enemy who has bought the services of a sorcerer ( ).


The supernatural explanation for illness is the more likely choice of the mountain tribespeople or peasants from the rural areas. The Hmong (meaning “free”), for example, believe the individual’s spirit is the guardian of the person’s well-being. If the spirit is happy, the person is happy and well. A severe shock or scare may cause the individual’s spirit to leave, and the individual will become ill. The shaman then must come and call the spirit to return. Copper or silver bracelets, necklaces, or anklets lock the soul to oneself so that it cannot leave.


Metaphysical Causes.


A metaphysical explanation for illness may be found in areas of Vietnam heavily influenced by the Chinese ( Box 18-4 ). The metaphysical explanation is built on the theory that nature and the body operate within a delicate balance between two opposite elements: the Am and Duong (Vietnamese) or the yin and yang (Chinese), such as female and male, dark and light, or hard and soft. In medicine the opposites are expressed as “hot” and “cold,” and health is the result of a balance between hot and cold elements, which results in harmonious functioning of the viscera and harmony with the environment. An excess or shortage in either direction causes discomfort and illness.



Box 18-4

Chinese Medicine


Any attempt at probing into the nature of Asian health practices must begin with a search into the age-old philosophy from which they—and indeed all Eastern concepts of health and illness, cure, and death—evolved ( ).


Chinese medicine is a 5000-year-old system of medicine in which an 81-volume classic on the philosophy of life became the primary medical textbook. Body, mind, and soul are integrated and never separated. Man is seen in relationship to the environment. The system encompasses all of the following (in order of their importance as preventive concepts): philosophy, meditation, nutrition, martial arts, herbology, acumassage, acupressure, moxibustion, acupuncture, and spiritual healing ( ; ).


Part of the theoretical and philosophical basis for Chinese medicine comes from the Taoist concept that nature maintains a balance in all things and that as part of the universe, man interacts with this balance. The balance is measured in terms of energy and is articulated by the principle of yin and yang (negative–positive, dark–light, cold–hot, feminine–masculine, etc.).


An important difference between Chinese and Western medicine is the emphasis on prevention rather than disease and crisis intervention. This difference can be illustrated by the Chinese story of the “old days,” when people would go to their physician to have their energy balanced. The physician, knowing the client well, would prescribe the specific approach to life, type of meditation, exercise, diet, and occasional herbs to keep the client healthy. For this service the doctor would be paid regularly. If the client became ill, however, the client stopped paying, and the treatment was free of charge. This may not be as true for Chinese medicine today, but it does underline a major difference in approach from Western medicine.


Disease theory and “germs” are two other areas where the basic approach separates the two systems. Western medicine has spent the past 200 years identifying disease-causing organisms under the microscope and finding ways of destroying them, in many cases with dramatic success. The goal of the treatment is to destroy the microorganisms causing the illness.


In Chinese medicine, when illness results in an imbalance caused by faulty diet or strong emotional feelings, body harmony can be restored through self-restraint and the use of a corrective diet, often aided by herbs. Action is taken not to kill organisms but to restore a balanced state, countering the effects of unwise lifestyles or food. When the yinyang balance is disturbed, the body is more likely to become ill. Use of massage, steam baths, and the application of Tiger Oil are methods to protect health and prevent illness ( ).

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Dec 29, 2019 | Posted by in NURSING | Comments Off on Vietnamese Americans
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