The NASW Connect to End COVID-19 nationwide initiative strives to provide accurate information to social workers about COVID-19 and COVID-19 vaccines, which includes vaccine safety and effectiveness, barriers to vaccination (such as mis/disinformation, logistical challenges, psychosocial and social care considerations, etc.), as well as the role of social workers in supporting clients in informed decision-making about COVID-19 vaccination.
As part of the Connect to End COVID-19 initiative, the NASW-CA Asian Pacific Islander (API) Social Work Councils of Northern and Southern California are collaboratively providing appropriate information and education to social workers who work with clients and consumers who identify as Asian American, Native Hawaiian, and Pacific Islanders (AANHPI), a group of diverse languages, cultures, and ancestries (Green, 2021). This article will overview research about diverse AANHPI community perceptions and responses to western medicine, then focus on COVID-19 vaccine associations with western medicine and the implications it may have for vaccine confidence and culturally-responsive interventions in AANHPI communities.
Mistrust and Negative Attitudes toward Western Medicine in AANHPI Communities
As one case study of mistrust and negative attitudes towards western medicine in AANHPI communities, Anne Fadiman’s book (2007) The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures follows the journey of a Hmong refugee family with a daughter, Lia Lee, born in 1982 in Merced, California who suffered from severe epilepsy. Fadiman describes that within Hmong culture and belief systems, Lia’s soul was taken from her body by a dab (a bad spirit) that also availed her body to be a host for a neeb (a healing spirit)–a great honor within the culture and considered a blessing. Lia was seen by a Western provider and was prescribed medication to control her seizures. Yet the Lee family deemed that the provider showed little or no respect towards traditional Hmong ways of healing and then refused to administer the medication to Lia. Ultimately, the Lee family’s mistrust towards western medicine tragically led to Lia slipping into a coma after experiencing a tonic-clonic seizure at age four and the Hmong ritual neeb ceremony taking place to bring Lia’s soul back into her body.
Lack of trust of western medicine occurs in many South Asian communities. According to Asim (2021), South Asian communities are less likely to trust conventional medicine, which includes the COVID-19 vaccine. During the smallpox eradication campaigns in the 1970s and the polio campaign of the past 20 years, the World Health Organization’s (WHO) representations had difficulty mobilizing willing participants and volunteers in the interiors of South Asia, and WHO representatives even experienced resistance on religious grounds from local people (Deb Roy, 2018). The WHO responded strictly, such as closely surveilling villages and searching house-to-house, which contributed to a climate of mutual suspicion (Deb Roy, 2018). Mistrust and distrust of western medicine continued in South Asian communities when in 2011, the United States’ Central Intelligence Agency (CIA) used fake hepatitis vaccinations in Pakistan to locate Osama bin Laden, in which blood was drawn from children and tested for a DNA match to the pan-Islamic militant organization Al-Qaeda leader–resulting in increased suspicion towards all vaccination campaigns in Pakistan and Pakistani communities (Asim, 2021).
In listening sessions among Asian Americans in Michigan conducted by Ford, Bessire, Rainville, and Wu (2022), the COVID-19 pandemic illuminated the correlation of Asian Americans’ lack of trust in western medicine and the susceptibility of Asian Americans to higher infection rates. Several Asian American participants in these listening sessions identified the mass vaccination sites of COVID-19 as a barrier to Asian Americans with limited English fluency due to their distrust of police and military presence. Participating young Yemeni mothers reported hesitancy to the COVID-19 vaccine resulting from distrust of medical professionals, such as Yemeni participants suspecting an ulterior motive (e.g., mind control) when witnessing healthcare places promote COVID-19 vaccine with money (Ford et al., 2022).
Cultural Beliefs, Practices, and Other Remedies
AANHPI medicines and practices come in many forms, and AANHPI community members’ traditional ways of healing have existed and continued for a long time in their culture(s) of origin. For example, Fadiman’s (2007) book The Spirit Catches You highlights Shamanism as integral in traditional Hmong healing processes. One of the scenes in The Spirit Catches You describes a Shaman preparing the household with incense, rice, a sacrificed chicken, and an egg to call out for the spirits. In this ritual healing practice, shamans go into a trance with the rhythm of the gong in the background and jump on a bench to be transported to the spiritual world; while in this world, they are assisted by spirits to negotiate with evil spirits to get the bodies of sick people back to their healthy state (Moua, 2020).
Many Asians conceptualize health based on Traditional Chinese Medicine (TCM) (Green, 2021). Thousands of years old, TCM underscores the mind-body connection and values addressing root causes of illness instead of symptom management, according to Green (2021). TCM practitioners utilize a variety of psychological and/or physical treatments (such as acupuncture and tai chi) and herbal products to address health issues (National Center for Complementary and Integrative Health, 2019). The basic concept of TCM derives from a vital energy of life called qi that travels through the body to give vitality to every cell (John Hopkins Medicine, n.d.). As a component of TCM, acupuncture is a technique in which practitioners activate specific points on the body, usually by inserting thin, sterile, disposable metal needles through the skin to alleviate symptoms of disease and restore balance to body functions (Cleveland Clinic, 2022). In addition, TCM includes Chinese herbal remedies that can be in the form of capsules, liquid solutions, or formulas, which are commonly used to treat health problems like allergies, digestion issues, and menstrual or endometriosis pain (Cleveland Clinic, 2022). Finally, tai chi is a martial arts-based form of exercise consisting of slow movements and deep breathing methods that intend to energize and balance the qi (Cleveland Clinic, 2022).
Cultural beliefs, practices, and other remedies differ in South Asian communities. According to Asim (2021), many South Asians engage in traditional cultural practices by relying on natural methods or home remedies when treating illnesses, such as using homeopathy to heal the body. Such practices can range from single herb dispensing practitioners, bone setters, exclusive physicians of poisonous bites, and the generalists and specialists with longer years of training and scholarship (Sujatha, 2020).
Beyond the different kinds of practices and approaches to healing, it is important to recognize they are sometimes grounded in different understandings, beliefs, and values regarding the etiology of illness (NetCE, 2021). In some cases, AANHPI community members believe that suffering is a part of life and that medical interventions are not necessary. In other cases, it could be possible that some community members hold the belief that illnesses are attributed to:
- Organic problems, such as a weakening of nerves
- An imbalance of yin and yang
- An obstruction of chi/qi (life energy)
- A failure to be in harmony with nature
- Being cursed by an offended spirit
- Punishment for immoral behavior
Community Interventions for Education, Adherence, and Cross-Cultural Collaborations
Social workers must approach AANHPI communities with great humility and in a culturally-responsive manner in order to reduce racial divides in healthcare, especially as many members were scapegoated throughout the COVID-19 pandemic for the rise in infected cases (Asim, 2021). In the United States, there has been a long history of using diseases to justify xenophobia and racism against AANHPI community members (Chia-Ming Liu, 2020). To build trust within AANHPI communities, social workers must recognize these dynamics and learn and respect the diverse cultural practices that have been-long standing in their respective cultures.
Accurate and Culturally Inclusive Information
Accurate information and preventive efforts are key to countering misconceptions and myths about the COVID-19 vaccine. In the listening sessions among Asian Americans in Michigan conducted by Ford et al. (2022), participants shared misconceptions and myths about the COVID-19 vaccine when they expressed fears of adverse side effects of the COVID-19 vaccine (e.g., the vaccine allegedly destroying the immune system and then making one highly susceptible to sickness), fears of long-term effects, inadequate knowledge on the science of the vaccine, objections using religion (such as a Bangladeshi participant claiming protection from God or a higher power), and suspicions of an ulterior motive behind the government’s promotion of the vaccines. Some Asian Americans felt confused about who to trust due to mixed messages; local radio stations broadcasted doubts about COVID-19 vaccines while public health departments, hospitals, and local Asian American community organizations promoted reliable information about COVID-19 vaccines (Ford et al., 2022). However, there was immense success when AANHPI community organizations and healthcare professionals (including doctors and community health workers) who knew the language and cultures, collaborated together and promoted COVID-19 vaccination messaging through strategies like disseminating success stories, flyers and infographics translated in native Asian languages, and providing gift card incentives from community sources rather than government or business sources to earn trust from community residents (Ford et al., 2022). To address fear and distrust of vaccine safety, Center for Health Disparities Innovations and Studies of Eastern Michigan University collaborated with community-based organizations to host mobile COVID-19 vaccine clinics at locations AANHPI community members were familiar with and trust such as mosques and community centers (Ford et al., 2022).
Cross-cultural collaborations are crucial interventions to the lack of trust of western medicine in AANHPI communities. According to Green (2021), engaging adult children in healthcare decision-making for older family members can help overcome barriers to preventive care, such as lack of familiarity with and distrust in Western medicine, gaps in understanding between patient and provider, language and cultural barriers in the healthcare setting, and low health literacy in managing chronic illness. A community-based clinic in San Francisco’s Chinatown provides a holistic set of services for publicly insured patients, in which doctors and nurse practitioners provide medical care along with nutritionists, health educators, and physicians licensed in forms of traditional Chinese medicine such as acupuncture (Green, 2021).
Holistic Approaches to Healthcare
Utilizing holistic healthcare systems in AANHPI communities can be significantly effective in not only increasing trust of COVID-19 vaccines but also bridging eastern and western medicine. Fadiman’s (2007) book The Spirit Catches You centers on the reality of the Hmong population in Merced, California, describing experiences at Mercy Medical Center, a Dignity Health hospital. According to Bion (2020), Mercy Medical Center is the only hospital in the United States to create a Hmong shaman certification program as a culturally and linguistically responsive intervention for meeting the health needs of the Merced’s local Hmong community–any patient at Mercy Medical Center can request the shaman services. Furthermore, Mercy Medical Center uses cross-cultural diversity by incorporating community leaders to teach healthcare providers, and the hospital broadcasts health education programming on the Hmong television channel (Bion, 2020).
Cultural Values & Beliefs
Overall, when working with AANHPI community members at an individual level, it is important to consider their cultural values and beliefs. By explaining the patient’s ailment in words that are culturally relatable, Western medical care may be more acceptable to Asian views about the etiology of disease. It can be beneficial to thoroughly and fundamentally explain the diagnostic procedures and treatment plan in order to allay the concerns that many Asians have regarding Western diagnostic methods and therapies. Because some AANHPI community members are unfamiliar with Western views of anatomy, physiology, and germ theory, treatment explanations may need to include these explanations (NetCE, 2021).
With considerations of the case regarding the Lee family, critical community articles, and ethnic community research, below are our Councils’ recommendations for social workers:
- Understand the historical context of medical mistrust in many of the AANHPI communities as a barrier to improving confidence in vaccine safety and effectiveness.
- Practice cultural humility by continuously learning about various AANHPI cultural, religious, and spiritual practices and having meaningful conversations with AANHPI clients about their personal beliefs as ways to improve treatment adherence and dispel misunderstandings toward medical recommendations and vaccines.
- Collaborate with AANHPI community leaders to innovate linguistically-appropriate and culturally-responsive strategies for addressing the multitude of factors that contribute to vaccine hesitancy and promoting health literacy across contexts for AANHPIs.
Social workers have the ethical responsibility to do their best to understand and connect with the clients that they serve and promote treatment and care that is for their best interests and with their self-determination. Within the context of the COVID-19 pandemic, it is necessary for us social workers to be better equipped with sociocultural and historical knowledge along with knowledge of accurate information about COVID-19 to promote health and wellness in the communities that we serve. It is important to note that this article does not comprehensively capture the entirety of the diverse cultural practices and beliefs of AANHPI communities.
The NASW-CA API Councils will be hosting two recorded webinars to further our understanding of community outreach efforts and engagement strategies for COVID-19 vaccine series in the AANHPI communities in July and August. We encourage all social workers to join and improve their skills in promoting COVID-19 vaccine series in diverse communities.
Connect to End COVID-19: What Social Workers Can Learn From AANHPI Community Leaders Webinar
Learn how you can raise awareness and promote COVID-19 vaccine series among the AANHPI communities! Hear from community-based organizations and their efforts in promoting vaccine series, and how social workers can apply those strategies to their respective practice settings. The recording of the webinar is now available on our YouTube Channel.
- Asim, I. (2021, February 24). Why South Asians Don’t Trust Conventional Medicine: A Colonial Experiment. Burnt Roti. Retrieved from https://www.burntroti.com/blog/why-south-asians-dont-trust-conventional-medicine
- Bion, X. S. (2020, February 27). Hmong Community Planted Spiritual Roots in Merced Hospital. California Healthcare Foundation. Retrieved from https://www.chcf.org/blog/hmong-community-planted-spiritual-roots-merced-hospital/
- Chia-Ming Liu, M. (2020, February 14). The Coronavirus and the Long History of Using Diseases to Justify Xenophobia. Washington Post. Retrieved from https://www.washingtonpost.com/nation/2020/02/14/coronavirus-long-history-blaming-the-other-public-health-crises/
- Cleveland Clinic (2022, June 3). What is Traditional Chinese Medicine? Cleveland Clinic. Retrieved from https://health.clevelandclinic.org/chinese-medicine/
- Deb Roy, R. (2018). The Untold Story of Modern Science is One of Empire and Colonial Exploitation. QZ. Retrieved from https://qz.com/india/1247577/the-untold-story-of-modern-science-is-one-of-empire-and-colonial-exploitation
- Fadiman, A. (2007). The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus and Giroux.
- Ford, O., Bessire, R., Rainville, A. J., & Wu, T.-Y. (2022). Utilizing Listening Sessions to Assess COVID-19 Vaccine Acceptance among Asian Americans in Michigan. Healthcare, 10, 2284. https://doi.org/10.3390/healthcare10112284
- Green, S. (2021). Improving Health and Healthcare of Asian Americans. Dartmouth Geisel School of Medicine News. Retrieved from https://geiselmed.dartmouth.edu/news/2021/improving-health-and-healthcare-of-asian-americans/
- John Hopkins Medicine. (n.d.). What is Chinese medicine? John Hopkins Medicine. Retrieved from https://www.hopkinsmedicine.org/health/wellness-and-prevention/chinese-medicine
- Moua, J. (2020). Shamanism: The Healing Tradition of Hmong People, Writing Waves, 2(2), 11. https://digitalcommons.csumb.edu/writingwaves/vol2/iss2/11
- National Center for Complementary and Integrative Health. (2019). Traditional Chinese Medicine: What You Need to Know. National Center for Complementary and Integrative Health. Retrieved from https://www.nccih.nih.gov/health/traditional-chinese-medicine-what-you-need-to-know
- NetCE. (2021). Providing Culturally Responsive Care to Asian Immigrants. NetCE. Retrieved from https://www.netce.com/coursecontent.php?courseid=2287
- Sujatha, V. (2020). Globalisation of South Asian medicines: knowledge, power, structure and sustainability. Society and Culture in South Asia, 6(1), 7–30. https://doi.org/10.1177/2393861719883063
Other Helpful Resources
The COVID-19 vaccine confidence in Native Hawaiian and Pacific Islander communities and its impact in these communities can be explored further in our previous article here.
The Connect to End COVID-19 initiative is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services as part of a financial assistance award totaling $3.3 million with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS, or the U.S. Government.