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West J Med. Nov 2001; 175(5): 312–313.
PMCID: PMC1071604
Commentary

Health beliefs about diabetes: patients versus doctors

Cecil G Helman, Associate professor1

This interesting and innovative article examines the health beliefs of 40 Vietnamese patients with type 2 diabetes mellitus and 8 Vietnamese health practitioners in southern California. It illustrates how patients' beliefs about diabetes often differ from those of their physicians, and it discusses the implications of this difference for effective clinical practice.

Many patients in the study explained their diabetes within the social context of their daily lives. For example, most blamed their illness on the worry, stress, and sadness of immigrant life. Others emphasized how a lack of balance—such as in physiologic states, diet, or treatment— could lead to diabetes. As with many other cultures, Vietnamese patients explained how an imbalance between “hot” and “cold” could be a causative factor. Some patients considered insulin to be a hot substance that was undesirable and that could lead to imbalance and subsequent illness. Other key findings were the difficulty faced by patients in adapting the traditional Vietnamese diet to a diabetic diet and patients' recourse to both plant remedies and to the herbs of traditional Chinese medicine. Some of the study findings echo those of our own study in London of Bangladeshi immigrants with type 2 diabetes.1,2 These immigrants, for example, also saw perspiration as beneficial to health and explained their diabetes as being due to a lack of sweating in Britain's cold climate.

Because about 800,000 Vietnamese immigrants currently live in the United States, the article underlines the importance of understanding and respecting patients' beliefs about their own health, even if they are rooted in cultural traditions unfamiliar to their primary care physicians.

Articles such as this one highlight 2 of the key problems in contemporary medicine: how to deliver effective primary health care to an increasingly diverse patient population, with a variety of health beliefs and practices; and how to deal with the increased incidence of chronic diseases, such as diabetes, hypertension, and coronary heart disease, in patients from nonindustrialized countries undergoing relatively rapid exposure to a western diet and lifestyle.

In discussing these problems, the authors could have referred more to the theories and research findings of medical anthropology—the cross-cultural study of health, illness, and medical care.3 This increasingly influential subject studies the range of beliefs found worldwide on a variety of issues in health and healing (see box). It aims to make health care effective—and culturally sensitive— while always avoiding cultural stereotypes and victim blaming.

Table 1

Range of beliefs and health practices studied in medical anthropology
  • Beliefs about the etiology of physical and mental illness
  • Beliefs about the structure and function of the human body
  • The use of self-treatment and traditional healers
  • Dietary beliefs and taboos
  • Patterns of infant feeding and child-rearing
  • Attitudes to pain and human suffering
  • Practices related to fertility, pregnancy, childbirth, and bereavement
  • Beliefs about the major diseases such as AIDS [acquired immunodeficiency syndrome], tuberculosis, and malaria

The use of the word “ethnography” in the article's title is misleading because in anthropology this term usually refers to detailed and long-term observational studies, also known as “participant observation.” These involve the researcher living within a community for a lengthy period, observing its daily life, its beliefs, and its practices, with the aim of understanding the worldview of its members. These days, ethnography is often combined with the use of semistructured and open-ended questionnaires, focus groups, video and audio recordings, the collection of personal narratives, and other qualitative research methodologies.

A more detailed follow-up study would be welcome, especially of the role of the Vietnamese immigrant experience in causing disease. It would also be valuable to gather further data on patients' explanations for the origin of their condition (including both “natural” and “supernatural” explanations3); their beliefs about bodily structure, function, and the pathogenesis of disease4; their recourse to self-treatment and traditional healers; and their food classifications and dietary practices.3 As with British Bangladeshis,1 it is possible that the practice of large extended Vietnamese families eating together at a communal meal may make it difficult for individual diabetic patients to adapt both the timing and composition of their own food intake to the recommendations of their nutritionists.

Overall, this article contributes toward a growing understanding of the limitations of the strictly biomedical model.5 It also points to the need—in an increasingly diverse, multicultural society—for a new type of practitioner: reflexive and culturally competent and able to combine the roles of a skilled and empathic physician with those of an applied social scientist.

Notes

Competing interests: None declared

Author: Cecil Helman is a family physician in London and a medical anthropologist. His textbook (Culture, Health, and Illness) explores medical anthropology in both primary care and international health.

References

1. Greenhalgh T, Helman C, Chowdhury AM. Health beliefs and folk models of diabetes in British Bangladeshis: a qualitative study. BMJ 1998;316: 978-983. [PMC free article] [PubMed]
2. Chowdhury AM, Helman C, Greenhalgh T. Food beliefs and practices among British Bangladeshis with diabetes: implications for health education. Anthropol Med 2000;7: 209-226.
3. Helman CG. Culture, Health and Illness. 4th ed. London: Arnold; 2000.
4. Ito KL. Health culture and the clinical encounter: Vietnamese refugees' responses to preventive drug treatment of inactive tuberculosis. Med Anthropol Q 1999;13: 338-364. [PubMed]
5. Helman CG. Limits of biomedical explanation. Lancet 1991;337: 1080-1083. [PubMed]

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