Existing Belief System and Barriers to Health Care
By Tam Thu Tran, M.D.
According to a concise report on women’s health in Primary Care this May, “An estimated 12,800 women received a diagnosis of Invasive Cervical Cancer, and more than one third of them (4,800) died of the disease. Deaths from cervical cancer might be reduced by as much as 60% if all women with an intact cervix underwent regular screening examination.”
For us, it is heart-breaking to note that the National Cancer Institute’s latest statistics show that Vietnamese-American women have the highest rate of cervical cancer of all ethnic groups. And a survey of Vietnamese in California has shown that “Vietnamese are less likely to receive cancer screening tests when compared to the general population.”
These reports tell us that we need to look into this issue more seriously to find an effective way to change the fate of our Vietnamese-American women. No woman should die of this preventable disease, especially here in the United States in the year 2000, given the advanced techniques that exist for early detection and more effective treatment. During an 11-year practice in Vietnam, working closely with women, I cannot count how many times I was frustrated to see a patient waiting for death from a disease that could have been cured if it had been detected early. At the time, I blamed it on poverty, lack of awareness and lack of accessibility to the health care system. But now, practicing in the U.S., I see that there are still some Vietnamese-American women who are not taking the measures necessary to escape a preventable death.
Why do Vietnamese women have such a low rate of cervical cancer screening? Studies conducted in California as well as my own experience in caring for Vietnamese provide some explanations.
1. Traditionally, Vietnamese attribute illness to yin/yang imbalance. When they are sick, they try Chinese herbal (thuoc Bac) medicine or Southern Herbal Medicine (thuoc Nam) or some other kind of treatment, such as “coin rubbing” (cao gio), herbal sauna (xong hoi), or acupuncture (cham cuu) before seeking care from a western doctor. The thinking is that Vietnamese try everything that they consider “natural” before using western medicine, which they view as too hot, too strong, and too prone to side effects. These perceptions make Vietnamese reluctant to seek early screening and treatment.
2. “If I have no obvious symptoms, that means no serious problem.” As we know, women cancers can be detected early if patients come for screening, as recommended by the guidelines.
3. “I don’t want to see a doctor because he will find something wrong with me.” Remember that “the problem” will show up sooner or later. If a doctor finds it early, we can treat it before it’s too late.
4. “Cancer is a death sentence. There is no way to escape. Cancer is always detected at the late stages.” That is not true for cervical cancer, since early detection saves patients lives.
5. “Many of our grandmothers and mothers never had any treatment, but they were still okay.” Back in Vietnam in the old days, we did not have any statistics to know the prevalence or mortality rate of cervical cancer, nor any diagnosis of the cause of death for many women (no awareness).
As a matter of fact, in recent years with better information, Vietnamese-Americans pay more attention to the screening guidelines for cervical cancer. However, some obstacles to health care accessibility remain.
1. Poverty, resulting in lack of insurance.
2. The chances for a person to receive preventive health care service is low if that person does not have a regular doctor who will follow up on her condition.
3. Lack of English and ignorance play important roles in preventing Vietnamese patients from having early screening. Most patients do not understand fully, so they do not follow advice and are not aware that they are missing preventive care.
4. Southeast Asians including Vietnamese are used to a “crisis-oriented” system of care. They do not pay much attention to preventive medicine, and only come to see the doctor when they have a problem. Most women have a pap smear only when they are pregnant or when they have to be checked for a gynecological problem.
5. Early surveys show women who were Chinese-Vietnamese or who had a Vietnamese male physician were less likely to be up-to-date regarding screening. Possibly out of embarrassment, neither the physician nor the patient brings up the patient’s GYN history or a possible check-up (GYN, Rectal exam).
6. The older generation tends to avoid screening, which they view as ridiculous and shameful, such as a GYN check-up with Pap smear or rectal exam.
7. “Just too busy,” is an excuse I often hear.
8. “No means to access the Health Care system.” This is the case of women who cannot drive or who are elderly. They must rely on other family members to bring them to see the doctor.
To overcome the barriers to accessing the health care system, we need to create a comprehensive network exclusively for preventive care.
1. For women who have insurance, we need campaigns from the insurance companies to remind their members to get cervical screening according to their age, and to remind their primary care doctor either to do the screening or to refer patients to get it done.
2. For women who have no insurance, we need to ask for government funding assistance for screening tests.
3. We must use any effective way to remind Vietnamese women to come in for screening (radio campaigns, TV education, their own associations).
In my experience, the best way is constant reminding. Our Vietnamese people are just not familiar with the need for cancer screening, and just let it go!