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Health of Vietnamese‐American Refugee Adults: A Summary of Health in the Context of the

Introduction 1975 in part to escape persecution by the Vietnamese‐ are a quickly new Communist government.2 Most were growing minority group in the United professionals and highly‐educated States. The 2010 Census identified the immigrants. The Second Wave came after current population of Vietnamese as the , commonly called “boat 1,548,449, a number that grew by over people” due to their main transportation 400,000 since the year 2000.1 However, out of Vietnam to temporary camps in information on the health status of this nearby , , , and group is not readily available, especially in other countries. Many people from this comparison to other Asian‐American wave gained citizenship after their arrival, subgroups that have longer historical and they form a large portion of patterns of migration to the , Vietnamese‐Americans. The Third Wave such as the Chinese and Japanese. In this followed after 1979 with the United document, we will explore the health status Nations’ approval of the Orderly Departure of Vietnamese‐American adults, focusing Program, which granted a legal method of particularly on the health of refugees of the immigration for Vietnamese refugees.3 Vietnam War. With continual immigration Since this time, many older Vietnamese to the United States and an influx of have migrated with political refugee status.2 refugees from other regions of conflict, it is imperative that we learn from historical Distribution and Heterogeneity precedent and adapt accordingly. Since Vietnamese populations tend The goals of this document include: to cluster in certain areas, it is important for • Presenting information on physical health issues their local health providers to understand of older Vietnamese‐Americans specific challenges. hosts the • Presenting information on mental health issues largest population of Vietnamese with of older Vietnamese‐Americans • Indicating how we can learn from the 581,946 individuals, a number greater than heterogeneity of the Vietnamese population the combined next nine states with large • Informing on the health experience of refugees Vietnamese populations (including • Suggesting policy mechanisms to better serve with 210,913).1 Within California, these marginalized communities immigrants cluster primarily in Orange, Santa Clara, and County. Due to Population and History the magnitude of the populations in these Many Vietnamese immigrants came areas, understanding the health status of to the United States in the years shortly this uniquely distributed group is critical. before the fall of Saigon in 1975 or left Working with heterogeneous Vietnam in the years following the war’s populations is changing the way we provide end. We can describe the pattern of access to and deliver health care in the Vietnamese immigration as a series of United States. With this perspective, we can waves. The First Wave, including mainly analyze the Vietnamese population in the South with connections following two ways. First, they are distinct to the US government, came shortly before Dang 2 from other Asian‐American subgroups and to higher rates of overweight and diabetes.4 carry particular health issues, attitudes, and While prevalence of obesity is low, beliefs. Second, the refugee experience, as Vietnamese‐American immigrants have defined by the three waves of immigration, more than double the rate of overweight also affects how Vietnamese‐Americans when compared with native Vietnamese interact in the United States. who never left.5 Fu et al. note that these differences are the effects of “immigration Health Issues and Disparities and acculturation, not to selection.” As Vietnamese‐Americans adults face hypothesized by adoption of a more higher rates of diabetes and high blood Westernized lifestyle, immigrants who have pressure compared to non‐Hispanic whites, been in the US longer have poorer BMI while facing comparable rates of heart outcomes. However, immigrants who were disease.1,2 However, most troublingly, fluent in both Vietnamese and English had Vietnamese‐Americans have a much greater better outcomes. The authored explained need for assistance with mental health this as disengagement with American problems, a situation further complicated society (not speaking English) correlating by lack of communication about such with poorer outcomes. The study controlled concerns with health care providers. for education and socioeconomic status by controlling occupational status, noting that Physical Health Issues there are “better opportunities for educational attainment among immigrants” Diabetes and Obesity after their arrival. While there have not been comprehensive assessments of the Cultural Notes prevalence and incidence of diabetes Many Vietnamese immigrants who amongst Vietnamese‐Americans firmly embrace traditional cultural beliefs specifically, national data suggest that on health have misconceptions about the Asians have higher diabetes‐related causes and treatment of diabetes. Mull et morbidity and mortality than non‐Hispanic al. note that “most patients mentioned whites.4 A study by Mull et al. in Orange worry and […] stress” as the cause of their County (home to over 140,000 Vietnamese) disease.4 Attitudes toward treatment create indicates county rates for diabetes amongst barriers that health care providers can Asians comparable to national data. address through tailored, culturally‐ Notably, the prevalence of obesity amongst competent care. One concern is distrust of Vietnamese‐Americans is quite low Western medicine because it could compared to the rest of the US population.5 potentially upset “hot‐cold balance,” (the However, for a better grasp of this issue, we idea of interplay between characteristics of must also consider the effects of migration. substances introduced to the body) with its “hot” chemicals. Another concern is Migration‐Related Notes exclusive faith in Eastern herbal medicine. Like other groups, Vietnamese immigrants have tended to adopt a higher Hypertension and Heart Disease calorie diet and a less active lifestyle, two Cardiovascular disease is a leading risk factors that could potentially contribute cause of death worldwide, and amongst Dang 3

Vietnamese women, accounts for 31% of all Hispanic white population, yet whites were deaths.6 One large risk factor that more than twice as likely to have had a contributes to hypertension and heart discussion with a medical provider about disease is smoking, and literature reviews of mental health concerns.2 Notably, this smoking practices of Vietnamese people phenomenon is present across other have somewhat mixed results. In some country’s Vietnamese refugee populations, areas of California, rates among women are including in Australia. as low as 0.4%, yet rates in other states climb to nearly 20%.6 In general, rates are Migration‐Related Notes higher among men (up to 42%). In a separate study distinct from the obesity research detailed earlier, Fu et al. Migration‐Related Notes looked at the mental health of Vietnamese In terms of factors contributing to immigrants compared to never‐leavers and heart disease, Coronado et al. found that returnees.7 The researchers concluded that spending over 20 years in the US was migration and related experiences of inversely related to fruit and vegetable uprooting and readjustment contributed to consumption. Additionally, longer times in mental health issues more than selection the US correspond to a greater likelihood of factors. The political climate in Vietnam smoking, despite also correlating with adds additional complexity to refugee receiving recent blood pressure and mental health. Birman et al. found that ex‐ cholesterol checks.6 political detainees had experienced more than double the number of traumatic Cultural Notes events on average compared to other There is a cultural perception that refugees, yet these detainees did not have smoking is generally unacceptable for higher rates of depression.8 However, the Vietnamese women because it is a sign of context of refugee and re‐education camps, low status, reinforcing higher rates of involuntary migration, and difficulties with smoking among men. adapting to new cultures as potential tends to consist of high‐glucose starches contributors to stress and anxiety are still based off of white rice, dishes with high relevant to keep in mind. sugar content, and dishes with high sodium content as well, all of which can contribute Cultural Notes to greater risk for hypertension and heart Birman et al. also found that disease, particularly in combination with Vietnamese behavioral acculturation was adoption of other less healthy parts of the associated with increased life satisfaction, Western diet.2 yet also predicted anxiety – participation in Vietnamese culture provided access to Mental Health Issues community activities, yet also led to alienation in American culture. Birman et al. Summary of Challenges found that English language competence In a survey of over 14,000 did not contribute to feelings of alienation; Vietnamese‐Americans, 21% were found to behavior and participation in society were have needed help for mental health more relevant. problems compared to only 10% in the non‐ Dang 4

Public Policy Implications and of immigrants in America – all residents can Recommendations serve as a form of social support crucial for The unique migrant experiences creating a safety net. described in this document highlight the One crucial implication is to need to develop culturally‐competent care challenge the idea that refugees experience to bring about positive health outcomes in certain health outcomes due to often‐ the Vietnamese‐American population. In assumed factors, such as prior trauma and particular, health care providers must language barriers. There is a rich complexity address linguistic and cultural barriers that of factors that contribute to the immigrant make navigation of the US health care experience, and taking a perspective with a system difficult. Increasing the availability multifaceted approach is a potential avenue of interpreters and translated documents to better serve these populations. It is will serve to put Vietnamese patients more important to remember that at ease. Similarly, engraining health workers generalizations of the health status of with a mindset of cultural humility (an open Vietnamese immigrants may not be mindset with regular self‐reflection) is accurate – length of residence, wave status, critical to designing appropriate, culturally and many other factors can potentially have tailored interventions. This can include an impact on health outcomes. holding focus groups of Vietnamese‐ While this document provided a Americans to address knowledge gaps, concise picture of the physical and mental access issues, and other factors that can health status of older Vietnamese adults, affect health outcomes. further research is necessary to better From a more generalized understand how we might best stage standpoint, creating an atmosphere for the interventions to develop the positive immigrant experience in the host country outcomes we desire. Links are provided that reduces feelings of isolation and stress below for additional information on the can protect against both physical and Vietnamese population and their health mental health issues. It is not just clinicians status in the US. that must be more cognizant of the needs

Other Links Immigration and Health: http://geriatrics.stanford.edu/ethnomed/vietnamese/index.html History of Immigration: http://www.asian‐nation.org/exodus.shtml Distribution and Demographics: http://www.migrationinformation.org/usfocus/display.cfm?ID=691

About the Author

Tim Dang is a junior majoring in Human Biology at Stanford University with a concentration in Preventive Medicine and Community Health. He is the son of two First Wave South Vietnamese immigrants from Saigon and grew up in Orange County, California, the county with the largest number of Vietnamese‐Americans in the US. Dang 5

1 US Bureau of the Census. The Vietnamese Population in the United States: 2010. , DC: US Bureau of the Census; 2010. 2 Sorkin D, Tan AL, Hays RD, Mangione CM, Ngo‐Metzger Q. Self‐reported health status of vietnamese and non‐ Hispanic white older adults in california. J Am Geriatr Soc. 2008;56(8):1543–1548. 3 Periyakoil VJ. Health and Health Care of Vietnamese American Older Adults. Stanford University School of Medicine eCampus Geriatrics; 2010. 4 Mull DS, Nguyen N, Mull JD. Vietnamese diabetic patients and their physicians: what ethnography can teach us. West. J. Med. 2001;175(5):307–311. 5 Fu H, Vanlandingham MJ. Disentangling the Effects of Migration, Selection and Acculturation on Weight and Body Fat Distribution: Results from a Natural Experiment Involving Vietnamese Americans, Returnees, and Never‐ Leavers. Journal of immigrant and minority health / Center for Minority Public Health. 2012 6 Coronado GD, Woodall ED, Do H, et al. Heart disease prevention practices among immigrant Vietnamese women. J Womens Health (Larchmt). 2008;17(8):1293–1300. 7 Fu H, Vanlandingham MJ. Mental health consequences of international migration for vietnamese americans and the mediating effects of physical health and social networks: results from a natural experiment approach. Demography. 2012;49(2):393–424. 8 Birman D, Tran N. Psychological distress and adjustment of Vietnamese refugees in the United States:Association with pre‐ and postmigration factors. Am J Orthopsychiatry. 2008;78(1):109–120.