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research-article2014

TCNXXX10.1177/1043659614523470Journal of Transcultural NursingNguyen

Research Department

Self-Management of Type 2 Diabetes: Perspectives of Vietnamese Americans

Journal of Transcultural Nursing 2014, Vol. 25(4) 357­–363 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614523470 tcn.sagepub.com

Anna Thao Nguyen, PhD, RN1,2

Abstract The purpose of this study was to explore diabetes self-management strategies and underpinnings of behaviors among Vietnamese with type 2 diabetes. Using Leventhal’s illness representation model, semistructured interviews were conducted with a convenience sample of 23 participants, 14 women and 9 men. NVivo 8 software was used for content analysis. Data revealed that participants constructed implicit theories of the identity, causes, consequences, timeline, and controllability of diabetes, which were inconsistent with the biomedical literature. Participants labeled diabetes by their symptoms of hypo-/ hyperglycemia, and they focused on the relief of these symptoms. However, the participants’ focus on symptomatology undermined their use of blood glucose monitoring to manage diabetes as a majority of the participants had diabetes-related complications. Participants integrated the continuum of Eastern and Western treatment belief systems to achieve a balance to create harmony between the two systems. Keywords Vietnamese adults, diabetes self-management, Leventhal’s model of illness representation

Introduction

Background and Significance

Diabetes has been a major contributor to increasing health care cost, and it has been associated with increased morbidity and mortality. According to the American Diabetes Association (ADA; 2008), diabetes was one of the nation’s most prevalent, debilitating, and deadly diseases. Type 2 diabetes accounts for 90% to 95% of diabetes cases in the United States (ADA, 2007). Type 2 diabetes refers to the impairment of insulin use rather than lack of insulin production, which is a hormone produced in the pancreas that enables body cells to absorb glucose and turn glucose into energy. If the body cells do not absorb the glucose, the glucose accumulates in the blood, leading to various potential medical complications. According to the American Association of Clinical Endocrinologists and the American College of Endocrinology (2003), the onset of these complications can be prevented or delayed with adequate management to normalize blood glucose levels. Once diagnosed with diabetes, individuals bear much of the burden of managing the disease by following a complex set of activities on a daily basis and preventing diabetic complications (National Diabetes Education Program & Department of Health and Human Services, 2004). The emphasis of treatment is on self-management, especially controlling glucose and reducing disease complications rather than cure. The purpose of this qualitative ethnography study is to explore the diabetes self-management strategies among Vietnamese adults and to explore the underpinnings of their behaviors on diabetes self-management.

Asian Americans (AAs) are one of the fastest growing segments of the U.S. population. Vietnamese comprise the fourth largest and fastest growing subgroup of AAs, constituting 11% of the Asian population (U.S. Census Bureau, 2010). As a result of recent normalization of relations between the United States and Vietnam, as well as continued high rates of poverty in Vietnam, it is expected that Vietnamese immigration to the United States will continue at a high rate (Povell, 2005). Because of this increase of Vietnamese immigrants, some communities in which they entered have been unprepared to provide culturally and linguistically appropriate health care. In addition, it is likely that Vietnamese migrated in large groups to always be surrounded by those who share the same language, culture, and beliefs. That immigrant practice likely resulted in the formation of ethnic enclaves that made it more difficult for these immigrants to become acculturated into the United States (Povell, 2005). Asian Americans are at high risk for developing diabetes (Office of Minority Health & Health Disparities, 2006), especially type 2 diabetes. According to the National 1

Oklahoma City University, Kramer School of Nursing, OK, USA The Children’s Center Rehabilitation Hospital, Bethany, OK, USA

2

Corresponding Author: Anna Thao Nguyen, The Children’s Center Rehabilitation Hospital, 6800 N.W. 39th Expressway, Bethany, OK 73008, USA. Email: [email protected]

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Diabetes Education Program & Department of Health and Human Services (2004), the incidence of diabetes is rising among AAs. McBean, Gilbertson, Li, and Collins (2004) found that the greatest increase in diabetes prevalence was among Asians as compared with Hispanics, Blacks, and Whites. In another epidemiologic study, McNeely and Boyko (2004) found that the prevalence of diabetes was 60% higher in AAs than in non-Hispanic White Americans. Mull, Nguyen, and Mull (2001) reported that the prevalence of diabetes was increasing among the Vietnamese population in the United States. Individuals from the Asian ethnic groups are significantly affected by diabetes and its debilitating long-term complications (Centers for Disease Control and Prevention, 2004).

Literature Review There are numerous studies on Caucasians, but only a few studies were found in the literature related to Vietnamese and diabetes. Many studies have focused on a categorical approach, describing attitudes, values, beliefs, and behaviors of AAs as a single entity. With the extreme heterogeneity of AA groups, there are influences such as cultural characteristics and the acculturation of socioeconomic status that could explain variability found within AAs. Thus, research findings of diabetes beliefs and management for AAs were not equitable or transferable to the Vietnamese population. In particular, the Vietnamese population has been understudied with respect to diabetes management, and they are not therefore adequately represented in intervention programs. Traditional Vietnamese beliefs about diabetes influenced the way diabetes is managed. Both Pham’s (2003) and Mull et al.’s (2001) research studies revealed that most of their participants believed that stress brought on worry and sadness and served as causes of their diabetes. In addition, participants in the study conducted by Mull et al. (2001) attributed diabetes to the decrease in perspiration in the United States as compared with that occurs in Vietnam in response to daily physical activities. Participants believed that perspiration was a desirable effect because it removed body toxins that could damage vital organs. This finding suggested that there were cultural influences on health and well-being and misconceptions of disease and illness among Vietnamese with diabetes, which might impede recognition of early warning signs and delay them in seeking medical treatments (Mull et al., 2001). The use of herbal products was not uncommon when it comes to seeking treatment for diabetes among Vietnamese individuals. Hughes (2002) reported more than a third of Vietnamese use herbal medicines as an alternative care. One of the dangers noted during periods of herbal usage was that some of these participants stopped taking their Western doctors’ prescribed medicines for fear of undesirable drug interactions.

Theoretical Framework: Leventhal’s Illness Representation Model The theoretical framework for this study was based on Leventhal’s illness representative model (Leventhal, Meyer, & Nerenz, 1980). The illness representation model was developed in an attempt to understand people’s cognitive representation of the nature of the threat. It was the illness representation model of self-regulation that provided the understanding of cognitive and perceptual factors in response to and management of a wide variety of chronic illnesses and other threats to health. People with chronic illnesses, such as diabetes, obtain new information about their condition and evaluate their attempts to cope with the disease, with new representations being developed and adopted or discarded based on their experiences. Leventhal et al. (1980) and Leventhal, Diefenbach, and Leventhal (1992) found that illness representations to be related to the decision to seek health care and to comply with medical advice. Thus, Leventhal’s model is used to assess the content of their diabetes beliefs and to understand how people’s cognitive representations of their illness influence both coping and adapting. Leventhal’s illness representation model has been effectively used to develop a better understanding of people’s adaptation and coping in Chinese immigrants. Jayne and Rankin (2001) used a qualitative design to evaluate the applicability of Leventhal’s illness representation model to Chinese immigrants with type 2 diabetes. The researchers found that Leventhal’s model was effective in describing the perceptions of diabetes among Chinese immigrants. This particular model had not been applied to Vietnamese individuals with diabetes. Thus, Leventhal’s illness representation model was used to provide a framework for guiding this research study with the Vietnamese population.

Research Design This study used a descriptive ethnography design. The focus of this study was to explore the illness perception of Vietnamese individuals with diabetes to answer the specific aims that are based on Leventhal’s illness representation: (a) identify the various labeling of diabetes as a health threat, (b) identify the perceived causal mechanism of diabetes, (c) elicit the believed consequences of diabetes among this population, (d) describe the diabetes timeline trajectory among Vietnamese adults with diabetes, (e) describe beliefs on the controllability of diabetes, and (f) describe the adaptive and coping decisions that Vietnamese adults use to manage diabetes. This study complied with the protocol for human subjects protection as obtained from the institutional review board.

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Nguyen

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Sample

perceptions of self-management according to the specific aims, which are presented below.

A sample of 23 Vietnamese adults with type 2 diabetes (ages 43 to 83, with a mean age of 64.7) was used in the study. The inclusion criteria for this project were Vietnamese men or women diagnosed with type 2 diabetes, who could speak English or Vietnamese, and were able to provide consent to participate. Individuals who were under 21 and women who were pregnant were excluded. Participants were recruited via mass media such as the local Vietnamese radio station and Vietnamese newspapers. They were also recruited at the annual Asian health fair, Vietnamese churches and temples, and word-of-mouth by community leaders and participants. Potential participants were screened for eligibility, and when eligibility criteria were met, informed consent was obtained.

Data Collection The method of data collection was face-to-face interviews, which were conducted using an interview guide comprising 6 sections and 23 questions. The researcher conducted all interviews using the semistructured interview guide, which lasts about 60 minutes. No further interviews were conducted after data were saturated. The data sources were field notes and audio-recorded interviews, which were transcribed verbatim by the researcher. Each interview was recorded with the participant’s consent. All participants had the option of being interviewed in Vietnamese or English, and they had the option of completing the consent and confidentiality forms in either language. The study consent form was translated from English to Vietnamese by the researcher and then back-translated from Vietnamese to English by another translator to verify congruence and accuracy in the consent documents.

Data Analysis Interviews conducted in Vietnamese were transcribed verbatim in Vietnamese, and then translated into English for coding and analysis. Content analysis was conducted using the NVivo 8 software. Prior to analyses of the transcripts, each transcript was read at least twice and compared with the recordings to ensure accuracy and completeness. To ensure trustworthiness, selected transcripts were reviewed and coded by two experienced qualitative researchers to ensure intercoder reliability. Once the themes and categories were clearly defined, a typology was created to serve as the basis of the conceptual framework that described the illness representation of Vietnamese with diabetes in Oklahoma.

Results Themes and categories identified were consistent with the major constructs in Leventhal’s model. The findings revealed

Specific Aim 1: Labeling of Diabetes All participants were asked, “What do you call your illness?” With dramatic consistency, all the participants used the general Vietnamese terms tieu duong (urine sugar) and benh tieu duong (disease of urine sugar) to label diabetes. Because participants labeled diabetes as a disease with sugar in the urine, they expected the diagnosed to be based on the presence of sugar in the urine. The participants equated that if these symptoms do not emerge then there is no diabetes present, as one participant described, “Some Vietnamese people told me that if ants don’t crawl around their urine, they don’t have diabetes.” Such perception may influences their diabetes self-management behavior or adherence lessened if their symptom identification was a signal for them to implement self-care behaviors. The participants perceived their condition is less severe if sugar was not found in their urine, and it may imply that the biomedical approach to management may be considered unnecessary if no sugar is present in the urine, creating a faulty appraisal of the diabetes status and the possibility of selecting less optimal management strategies. Data indicated that the study participants used symptomatology to label diabetes; they focused on the treatment and relief of their symptoms rather than being concerned with the serious complications of hypoglycemia and hyperglycemia. These findings may be problematic for the individuals who are guided by their sensory experiences of diabetes management.

Specific Aim 2: Perceived Causal Mechanism The majority of the participants attributed diet, eating too much white rice, as the cause of diabetes. Most of them expressed that they preferred rice, vermicelli, or noodle soup as a main dish. The following exemplar described the preference of rice and as being the causal mechanism: Vietnamese people eat a lot of rice. We eat that three meals a day, three bowls each meal. Eating too much rice is not good. Every time I eat a lot of rice, I test my blood sugar and it is always high.

The second most commonly reported cause of diabetes was family history, which was mentioned as a cause of diabetes by nearly half of the participants. They attributed their diabetes as being inherited, and they expressed a fatalistic view about diabetes because of their family history of diabetes. Another perceived causal mechanism was the high levels of stress due to relocation to the United States. They shared their past experiences including excessive manual labor at the Vietnamese concentration camps or stress of thinking

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and worrying at the workplace in the United States. The participants’ personal beliefs about the causes of their diabetes indicated a complex structure for causation that included environmental, physical, social, and cultural factors.

Specific Aim 3: Perceived Consequences The most frequently mentioned consequences to diabetes were blindness, damage to body organs, and limb amputation. As a predictor of amputations, the participants did not associate the immediate threat of having pain and loss of sensation in their feet. No one mentioned foot care as a part of their regimen as a strategy to prevent the long-term consequence of amputation. If individuals do not perceive pain and loss of sensation in the feet as an association with diabetes complications, they are guided by low perceived threat, which means that they are unlikely to take action. Participants identified multiple organ damage including the female reproductive system and the respiratory system, which were incongruent with the biomedical evidence of consequences of type 2 diabetes. There was a plethora of organs mentioned including the brain, heart, lungs, kidneys, gallbladder, intestines, eyes, pancreas, liver, muscles, and bones. The explanations by the participants regarding the pathophysiology of the complications were medically inadequate; participants understood the negative impact of diabetes and perceived it as a threat to their health. In addition to physical consequences, participants expressed that diabetes significantly affected their quality of life. The participants indicated they had to restrict their social activities and avoid gatherings in order to control their diabetes and sacrificed opportunities for socialization. They described social gatherings involve overeating and drinking, which cause their glucose to be out of control.

Specific Aim 4: Timeline Trajectory Participants who lived with diabetes 10 years or longer perceived that diabetes was “curable” or “no more diabetes.” Some participants hoped that the prescribed medications would “cure” their diabetes. Of the participants who believed diabetes is curable, they mentioned that exercise must be incorporated into the daily regimen of diabetes management. The data suggested curability is used interchangeably with diabetes management or glucose control as some participants believed that curability is based on the level of adherence of the individual with diabetes, “I don’t know how long it will last but I think it can be cured. If we exercise everyday, take the medicines every day, and eat just enough to keep the energy then it will go away some day.” Participants who perceived diabetes as acute and curable may have difficulty adhering to medication treatments. Some participants had a limited understanding of the permanent nature of diabetes and the importance of taking medications to manage the disease even when feeling no symptoms.

Three fourths of the participants viewed diabetes as a lifelong illness and that cure is unlikely. An important dimension of dealing with diabetes is realizing that diabetes is a chronic and persistent illness. The perception of diabetes as permanent in participants who were diagnosed with diabetes for more than 10 years suggested they have a better understanding regarding the duration of diabetes, and they have accepted the reality of a chronic timeline for diabetes. When people with diabetes do not adopt a permanent or chronic timeline for their condition, an ongoing medication regimen may not make sense to them. These findings suggest a need for health care professional to assess the timeline trajectories of patients and implement interventions that facilitate a chronic timeline trajectory.

Specific Aim 5: Controllability Western oral hypoglycemic medicines were believed to be necessary and effective by most of the participants. However, some faulty knowledge structures existed such as people who take these medicines can develop tolerance and dependence and that these medications are “too strong” for the body system. Additionally, the participants expressed fear of adverse side effects of Western medicines. As a result of this fear, some participants adjusted the medication dosage without consulting with their physicians. Glucose monitoring is an important aspect of diabetes management. However, the utility of glucose monitoring was perceived as minimal among the participants. Many participants were confident they could serve as their own internal monitor and they can “sense” the glucose level if it becomes abnormal. This data indicated the participants’ regimen was constructed and perceived as efficacy to their logic of self-management. Another perceived method of self-management is through food consumption. Because participants attributed excess consumption of white rice and sugary food to the development and worsening of diabetes, most participants thought that avoiding sugary foods and consuming less white rice would suffice. Last, a majority of the participants reported they used home remedies that included various sources of natural plants to normalize their blood glucose. The home remedies most frequently used were bitter melon, Pandan leaves, ginger roots, and Reishi mushrooms. Many participants continued to use these products concurrently with Western medicines as prescribed by their physicians. The participants’ self-management strategies included the integration of both Eastern and Western treatment belief systems, which were on a continuum. This continuum is illustrated in Figure 1, which is bidirectional rather than unidirectional. This behavior suggested that many Vietnamese believed in the principle of yin and yang to achieve harmony with nature. The principle of yin and yang explained the reason for the use of bitter melon to balance the high glucose in the blood. The implications for this belief suggested that health care services need to be patient-centered and holistic.

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Nguyen

EASTERN…..

WESTERN

Figure 1.  The Eastern–Western diabetes treatment perspectives continuum.

Specific Aim 6: Adaptive and Coping Decisions Family members and spirituality influenced participants’ adaptive and coping behaviors. For many participants, psychological coping with diabetes as well as with other chronic illnesses was largely a private and family affair. The participants valued explicit and practical advice from health care professionals to help them cope with their immediate physical problems rather than emotional problems. They demonstrated pragmatism as their predominant mode of managing diabetes. Participants perceived that expression of emotions such as sadness was futile; they felt expressing emotional support does not benefit their health outcomes. Rather than seeking psychological help from health care professionals, the majority of the participants saw spirituality as a means to help them cope with diabetes and to help them deal with the complications. Some participants used the term “Heaven” and “Mary” to describe their health satisfaction; they thanked God for the health they have, for taking care of their diabetes, and for the availability of medical treatments. Praying was a strategy more commonly used for emotional coping and psychological support. The participants mentioned asking God to help them control their diabetes and to keep them from developing diabetes complications.

Limitations of the Study There are three limitations in this study. The first limitation was the location, which was a medium-size metropolitan area in the Midwest. The second limitation was the use of a convenience sample, and a small sample size for this study. This sampling methodology also might not include participants of various socioeconomic statuses. Also, a younger age group was not included in this sample. The third limitation was that all data were based on self-report. There was a lack of objective information about the participants’ level of diabetes control, such as the glycosylated hemoglobin (HbA1c) level. The HbA1c would be valuable for the interpretation of the effectiveness of their self-management behaviors.

Discussion and Conclusions As a result of the limitations in this study, the conclusions cannot be generalized and are limited to the population

studied. This study found that a majority of participants labeled diabetes by the symptoms they experienced with hypoglycemia and hyperglycemia and focused on the relief of symptoms. They were confident in their ability to use their symptoms as a guide for managing their diabetes. As a result, they rarely tested their blood glucose. Equally important was the findings that the participants’ symptoms were inconsistent with the diagnostic symptoms of the biomedical health care system. This inappropriate symptomatology undermined their diabetes management as a majority of the participants reported having diabetes complications. The participants constructed implicit theories of the causes of their diabetes. This research study sought insights into the reality of living with diabetes from the shared perspectives of a group of Vietnamese adults. The findings of this study supported the use of Leventhal’s illness representation model (Diefenbach & Leventhal, 1996; Leventhal, Nerenz, & Steele, 1984) as a framework to determine personal representation of the symptoms, causes, consequences, timeline of diabetes, and controllability of diabetes. These attributes of Leventhal’s model can be extended to explain how Vietnamese adults structured and managed diabetes. The results provided evidence of how cultural factors and beliefs affected their representation of diabetes as a health threat and how these factors influenced their self-management behaviors. People living with diabetes can hold very different views of their illnesses, and inadequate views of illness representation can hinder diabetes self-management. Findings from this study lead to several implications for research and practice.

Implications for Research Future research studies are warranted to explore illness representation among Vietnamese who are able to effectively control their diabetes as evidenced by their HbA1c level. Actual biomarkers such as HbA1c would strengthen the methodology in future studies. More research is needed to identify interventions that successfully modify inadequate diabetes representation structures within this population. Self-reported data alone may be susceptible to overestimation or underestimation of diabetes control. Data from such study will provide additional information on the effectiveness of the strategies

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adopted by Vietnamese with diabetes as well as valuable information on cultural acceptability and appropriateness. Another implication for future research is the need to design and test Leventhal’s model with culturally tailored behavioral educational interventions to prevent or delay diabetes-related complications among Vietnamese adults with diabetes. Furthermore, future research should incorporate a larger and more representative sample and explore differences within groups or use a comparison group. Examination of the underlying factors that enhance or inhibit the effectiveness of diabetes self-management may benefit from study of individuals that are more homogeneous with respect to the level of acculturation, socioeconomic status, health care coverage, and English-speaking proficiency.

about diabetes and related regimens may enhance the development of interventions that address faulty illness representation, thus decreasing diabetes-related complications. Acknowledgment This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

Implications for Practice One of the major findings in this study was the low diabetes literacy among the participants. According to Tang, Pang, Chan, Yeung, and Yeung (2007), low health literacy was common among racial and ethnic minorities, older people, and people with chronic diseases. People with low diabetes literacy may have lower awareness of their disease condition, which may have a negative impact on their self-management behaviors. Because of the lack of knowledge of HbA1c among the participants, HbA1c level should also be emphasized in diabetes education. This indicated a wide gap existing in the communication of vital information between the health care providers and the people living with diabetes. To overcome the barriers of limited English proficiency and low diabetes literacy, a set of educational DVDs could be produced with Vietnamese individuals’ involvement. The method of education through films may be useful because they allow for visual display of Vietnamese who are managing diabetes. Vietnamese with diabetes would benefit from education that focused on Leventhal’s model to overcome the problem of faulty diabetes representations. Implications and recommendations for practice must focus on assisting Vietnamese with diabetes to gain knowledge about diabetes and transfer that knowledge into their daily routines of self-management.

Summary This qualitative research methodology expands the understanding of the context in which diabetes self-management occurred and the organized knowledge structures the participants used to manage their diabetes. The major contributions of this research are that it enhances the understanding of the illness representation and diabetes self-management among Vietnamese adults with diabetes. The results of this study revealed the complexities of how Vietnamese with diabetes in a medium-sized city in Midwestern United States perceive, interpret, and internalize diabetes information and how their interpretations affect their self-management. The understanding of the participants’ illness representation

References American Association of Clinical Endocrinologists and the American College of Endocrinology. (2003). The American Association of Clinical Endocrinologists medical guidelines for the management of diabetes mellitus: The AACE system of intensive diabetes self-management. Endocrine Practice, 8(1), 41-65. American Diabetes Association. (2007). Clinical practice recommendations. Diabetes Care, 30(Suppl. 1), S1-S103. American Diabetes Association. (2008). Standards of medical care in diabetes. Diabetes Care, 31(1), S12-S54. Centers for Disease Control and Prevention. (2004). Health status of Cambodians and Vietnamese: Selected communities, United States, 2001-2002. MMWR. Morbidity and Mortality Weekly Report, 53(33), 760-765. Diefenbach, M. A., & Leventhal, H. (1996). The common sense model of illness representation: Theoretical and practical considerations. Journal of Social Distress and the Homeless, 5(1), 11-38. Hughes, D. L. (2002). Quality of health care for Asian Americans: Findings from the commonwealth fund 2001 health care quality survey. Retrieved from http://www.commonwealthfund. org/~/media/Files/Publications/Other/2002/Mar/Quality%20 of%20Health%20Care%20for%20Asian%20Americans%20 %20A%20Fact%20Sheet/Hughes_factsheetasam%20pdf.pdf Jayne, R. L., & Rankin, S. H. (2001). Application of Leventhal’s self-regulation model to Chinese immigrants with type 2 diabetes. Journal of Nursing Scholarship, 33(1), 53-59. Leventhal, H., Diefenbach, M., & Leventhal, E. (1992). Illness cognition: Using common sense to understand treatment adherence and effect cognition interaction. Cognition Therapy Research, 16, 143-163. Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common-sense representations of illness danger. Medical Psychology, 2, 7-30. Leventhal, H., Nerenz, D., & Steele, D. (1984). Illness representation and coping with health threats. In A. Baum, S. Taylor, & J. Singer (Eds.), Handbook of psychology and health: Social psychological aspects of health (pp. 219-252). Hillsdale, NJ: Lawrence Erlbaum. McBean, A., Gilbertson, D., Li, S., & Collins, A. (2004). Differences in diabetes prevalence, incidence, and mortality among the

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Pham, T. (2003, November). Impact of immigrant patterns on the prevalence, prevention, management and treatment of diabetes within the Vietnamese community of San Diego County: Finding from a case study. Paper presented at the 131st Annual Meeting of APHA, Washington, DC. Povell, M. (2005). The American Immigration Law Foundation. The history of Vietnamese immigration. Retrieved from http:// www.ailf.org/awards/benefit2005/vietnamese_essay.shtml Tang, Y., Pang, S., Chan, M., Yeung, G., & Yeung, V. (2007). Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus. Journal of Advanced Nursing, 62, 74-83. U.S. Census Bureau. (2010). The Vietnamese population in the United States. Washington, DC: U.S. Department of Commerce.

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Self-management of type 2 diabetes: perspectives of Vietnamese Americans.

523470 research-article2014 TCNXXX10.1177/1043659614523470Journal of Transcultural NursingNguyen Research Department Self-Management of Type 2 Dia...

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