Perceptions of Asthma
Culture Influences Treatment Adherence
By Tracy L. Schmierer
The medicine men of the Nacirema culture work in an imposing temple, or latipso, where they perform elaborate ceremonies to treat the sick. Supplicants entering the temple are stripped of all their clothes. The latipso vestals insert magic wands in the supplicant’s mouth and force him to eat substances, which are supposed to heal. The medicine men jab magically treated needles into their flesh. That these temple ceremonies may not cure, and could kill, in no way decreases the people’s faith in the medicine men.1
Wondering where you find this strange culture? Nacirema is actually an anagram of American; latipso means hospital.
Some cultural medical practices aren’t as foreign as they first appear.
Clinicians need to realize that traditions and beliefs can form patients’ perceptions about their asthma. And although not every person with an ethnic background believes in every aspect of a culture’s views on medicine, if they do follow these traditions you can improve compliance. Incorporate these differences into your care plans along with prescribing spacers, peak flow meters, metered dose inhalers and corticosteroids.
“The highest prevalence of childhood asthma is in the mainland Puerto Rican population,” reports Lee M. Pachter, DO, director of the Pediatric In-patients Unit at St. Francis Hospital and Medical Center, an inner-city Hartford, Conn., center with a pediatric patient pop-ulation of mainland Puerto Ricans, African Americans, West Indians and Caribbeans. A sense of balance is extremely important to this community, in which many believe illness causes disharmony in the body.
In a recent study, Dr. Pachter found that an astounding 25 percent of mainland Puerto Rican mothers said they have a child with asthma. “So it’s a very common illness, and therefore not surprising that a lot of beliefs and practices have grown about this common idiom of distress in the community.”
Of the 117 families with asthma that Dr. Pachter studied, 20 percent said they give a home remedy, in addition to medication, during an attack. “That’s one in five of my patients that are using something I don’t know about,” he says. (See table above.)
Dr. Pachter discovered that many families use the same remedies, such as Siete jarabes (seven syrups), whether they’re prepared at home or bought in botanicas, Puerto Rican community stores. He made sure these remedies weren’t harmful and investigated their efficacy, especially because they’re out-of-pocket expenses.
“In general, they’re relatively harmless. I found these remedies didn’t do anything in regards to anti-inflammatory or bronchodilating effects.”
He probed further and asked families why they were using the syrup. Every parent said an important part of asthma is the mucus and phlegm that forms in the body, Dr. Pachter recounts. “And when you look at the specific treatments and remedies, some are expectorants, some are cathartics and some are laxatives. So if you look at it from the family belief system, when parents give the remedy, the child either coughs, vomits, or has loose bowel movements, so they’re getting the mucus out.”
Dr. Pachter says this discovery was “eye-opening” for him because it reminded him that it is crucial for clinicians to inquire as to why patients do certain things. However, he says, knowing about ethnic beliefs can be “a tightrope between being sensitive to the beliefs and practices of cultures, but not stereotyping.”
Knowing Siete jarabes’ powers helped him when a mother said she gave it to her son for asthma attacks and followed up two hours later with a nebulizer treatment. He told her to give both Siete jarabes and the nebulizer at the same time so they could work together. “I created a therapeutic ally instead of an opponent,” he says.
This is the most important thing Dr. Pachter has learned through his experiences with ethnically diverse groups: There always can be a compromise.
“A lot of traditional and longstanding beliefs are passed down from generation to generation and from family to family,” he said. “But it’s never an either/or situation. People don’t believe totally in the biomedical or ethnomedical (folk) medicine model.”
And, tradition isn’t always an obstacle, he reminds. “The center of the Hispanic community is the family, and children are the center of the family.” As such, “Inner-city families pull out carpets and use air filters.” As well, even in a community with the highest smoking rates for childbearing-age women, “if you work through what’s best for the children, sometimes you get families to change bad health behaviors.”
Although twice as many in the Puerto Rican community have asthma, African Americans are the next most prevalent group, Dr. Pachter reports.
A fear of inhaled steroids is prevalent in some of this population’s asthmatics, says Perla Vargas, PhD, instructor at the Center for Applied Research and Evaluation (CARE) at Arkansas Children’s Hospital in Little Rock. Many low-income African American parents of children with asthma have a steroid “phobia.”
Dr. Vargas also worked on African American studies at Johns Hopkins department of pulmonology and critical care medicine in Baltimore.
Her studies showed a very low adherence to preventative medicine among inner-city African Americans. “They’re afraid of the side effects and afraid to get hooked,” Dr. Vargas says. “Often they have so many competing needs, they put the effort into medications that have an immediate effect.”
Barbara Goergen, NP, Allergy and Asthma Medical Group and Research Center in San Diego, agrees. “Asthma is definitely high in the black culture. I find that along with compliance issues, they tend to take more rescue medicine than preventative. When they feel good, they tend to quit their medicines. But they’re feeling good because of those medicines,” she explains.
CHINESE CULTURAL BELIEFS
In the heart of San Francisco’s Chinatown, Angela C. Sun, MPH, director of the Chinese Community Health Resource Center, works with the Asian community on many issues such as perinatal and geriatric health. The center also offers asthma management programs, where she’s enlightened on how little this population knows about the disease.
“They’re very poor in using peak flow meters and their inhalers,” Sun reports. “And I would say that there are not very many Asian asthmatics using spacers. I’ve found that many of the participants don’t know about … the whole spectrum of environmental control.”
The language barrier is a possible contributing factor. Clinicians need to explain medications in more detail, Sun says. “I found some patients who don’t know the difference between corticosteroids and bronchodilators … they use steroid-based medications when they have asthma attacks.”
Some patients may refuse to use steroids altogether because of their fear of side effects, which they interpret as being harmful to their health. One of the main side effects they fear is getting a “moon face,” which refers to a swollen and round face.
Herbal remedies also must be taken into consideration when treating patients in the Chinese community. In a study of 43 asthmatics and 32 caregivers, Sun found that most participants used herbs along with their prescribed medicines. Eleven percent believed their bodies weren’t compatible with Western medicine and that it would make them sicker.
Some follow a strict diet regimen, adhering to the theory of Yin and Yang, the balance of “hot” and “cold” in Chinese medicine. Some participants believe that their asthma attacks are triggered by “cold” foods such as soymilk, sprouts, tomato, and some fruits, specifically honeydew and bananas. “Hot” foods in the Chinese culture include grains, garlic and legumes.
“If clinicians or dieticians don’t know the cultural background, they may prescribe eating fruits like bananas for lunch and tomatoes with dinner. A Chinese patient who believes in cold foods as triggers will stay away from these recommendations,” Sun says.
Overall, the less privileged face the majority of health issues. “Asthma is an endemic in the inner city and amongst certain ethnic populations,” Dr. Pachter says. “Most health care in the inner cities, especially with asthma, takes place not in the primary care physician’s office, but the ER.”
As such, he says it’s necessary to integrate the emergency system with the primary care system through computer databases so ER doctors are aware of the patient’s asthma history.
Sometimes those living in the city are more fortunate than those in rural areas, Dr. Vargas reports. In Arkansas, many patients with asthma living in rural areas have no access to emergency services or asthma specialists. The main emergency services are based in Little Rock and other locations, which are not easily accessible. “So they’re in a worse situation sometimes than inner-city populations.”
And for chronic conditions like asthma, medical expenses can be overwhelming. “Sometimes we think a low co-payment shouldn’t be a barrier. But for some, $5 is a lot of money when they have other needs too,” she says.
Experts agree that the key to overcoming cultural barriers is community education, but it’s difficult to obtain funding. Sun’s center collaborates with health organizations like the American Lung Association and the American Health Association because of their reputation, credibility and resources.
“As an education coordinator, I try to get free spacers and peak flow meters from manufacturing companies,” and give them as incentive items for answering questions correctly in the group meetings, she says.
Dr. Vargas, who focuses on compliance issues in under-served populations, is developing a grant to establish an asthma research and education program with primary care providers to disseminate the NHLBI asthma management guidelines and to make providers aware of the needs and problems of rural patients with asthma.
Meanwhile, clinicians should continue to educate themselves on different cultures’ beliefs. Dr. Pachter says knowledge about ethnic views has changed his practice and helped him to provide better care for his asthmatic patients.
“It shows that the medical care we provide is just one part of families’ total health care. It’s a sort of negotiation–finding a way to bridge the ethnomedical and biomedical beliefs and practices.”
1. Miner, Horace. Body Ritual among the Nacirema. American Anthropologist. 1956;58:503-507.
Tracy Schmierer is assistant editor of ADVANCE.
Awareness Assessment Negotiation Model
Dr. Pachter recommends clinicians take the following steps when discussing asthma with patients of different cultures:
1. Take a health belief history. Be sure to write down the patients’ responses in their own words so you get a better feel for their perspective.
2. Ask patients if they’ve heard of any home remedies, and if so, ask if they use any. Make sure not to stereotype people because of their ethnicity.
3. Investigate if the home remedy is harmful. If not, learn how to
incorporate the home remedy into their asthma program through
negotiating a plan with your patient.