Culture, risk, and vulnerability to blood-borne viruses among ethnic Vietnamese injecting drug users in Australia: a focus on a case study on overdose management practice

Culture, risk, and vulnerability to blood-borne viruses among ethnic Vietnamese injecting drug users in Australia: a focus on a case study on overdose management practice

Dr. Ho Thi Hien

BackgroundBackground

• Increase in HIV notifications among Vietnamese IDUs (VIDU) in NSW and Victoria

• High rates of incident and prevalent HCV infection

• High rates of exposure to HBV among IDUs in SWS (28%) - HBV core antibody positivity associated with Asian COB

• Low rates of BBV testing, high levels of risk behaviours and under-utilization of services by Asian IDUs

Aim and ObjectivesAim and Objectives

AIM:

• Investigate cultural influences on risk-taking behaviors & the prevalence of HIV & HCV

OBJECTIVES:

• Identify cultural beliefs & practices (Explanatory Model) & influences on risk behaviors

• Determine the prevalence of risk behaviours & barriers to health behaviours

• Document HIV & HCV prevalence

Research DesignResearch Design

Seroprevalence Survey

Seroprevalence Survey

Behavioral Survey

Behavioral SurveyEthnographyEthnography

Behavioral Questionnaire

Link with National NSP

data

In-depth interviews & ethnographic observation

HIV & HCV testing

N= 56 N= 109 N= 109

Ethnographic StudyEthnographic Study• Ethnography is “a family of methods

involving direct and sustained social contact with agents” (Willis & Trondman, 2000) involving a systematic approach to witnessing and describing the social organisation, culture, geography and political economy of human groups. It entails intensive observation and extended fieldwork in order to provide a “thick description” of groups or cultures (Geertz, 1973).

Ethnographic StudyEthnographic Study• Ethnographic approaches refer to a range

of research techniques, including fieldwork, observation, in-depth interviews, social survey methods and the use of visual images in order to encourage discussion and elicit information (Maher et al., 1998).

FieldworkFieldwork

South Western SydneyBankstown

Liverpool

Cabramatta

Main ThemesMain Themes

HealthBeliefs

CulturalCharacteristics

AccessingServices

Sexual RisksInjecting Risks

Blood Beliefs

Barriers to

Main Themes Main Themes

Cultural Characteristics Risks

Trust and Obligation

Stoicism

Maintaining the ‘face’

Belief in fate

Blood BeliefsHealth BeliefsBarriers to Accessing

Services

Bodily Balance

Natural Process

Self Medication

Western Medicine for symptomatic reliefs

Importance of Blood

Effects of Drugs on Blood

Withdraw blood in overdose

Injecting Risks: “Jump in”

Sexual Risks

Stigma

Confidentiality

Resistance treatment

Late presentation

Language

Case Study: Blood BeliefsCase Study: Blood BeliefsBlood as the essence of life, “keeping life”. Blood keeps internal organs functioning by balancing the body & helping fight sickness.

Blood balances our body. For instance, if blood balances well, we don’t have diseases. If it balances badly, we are sick, not healthy. [Blood] is very important thing. When it [sickness] goes in your blood, it might kill your system, the whole system.

Blood was seen as a vector, for BBVs & common illnesses

It is very easy to contract diseases through blood. We inject the unclean needles, we easily get diseases. For example, if they got flu, we got flu too. We got what they have, all by sharing needles. All diseases can be transmitted through blood.

Good blood is red and thin. Bad or “dirty blood” is dark and thick.If people are healthy, the blood is average red, not too dark and not too thick.

Blood - Traditional MedicineBlood - Traditional Medicine

• These beliefs are consistent with traditional Vietnamese medicine where blood (huyÕt) is analogous to Qi (life force) which contains nutrients and flows through meridians (pathways) to all parts of the body, “keeping life” (Oriental Medicine, Hanoi Medical University 1994).

• The flow of Qi through the meridians roughly corresponds to the flow of blood in veins and arteries.

Effects of Drugs on BloodEffects of Drugs on Blood

Like other forms of western medicine, drugs were “hot” & heated the blood.

Heroin makes your blood hot … It’s like taking western medicine. It makes your blood hot because it has a lot of chemical in it. Because most of the medicine, after you take it, your body feels hot.

Drugs, particularly heroin, were widely believed to be

responsible for “bad blood” & made blood thick, dark & dirty. For instance, we play heroin too much, blood will be blacker and darker. Blood seems to changes into black and purple.

Causes of OverdoseCauses of Overdose

Overdose

Over the

dose

Poly-drug use

Greed Illegality

Mechanisms of OverdoseMechanisms of Overdose

The circulatory system, rather than the central nervous system (biomedical explanatory model) was the major system implicated in heroin overdose.

Overdose is overcirculating drug in the blood. Make your heart pump blood too fast and make your vein explode and you gone

Blood becomes hot and thick and the heart is placed under increased strain as it works to circulate the thick blood in order to overcome or “balance” the effects of drugs.

Heroin “hits” the blood, making it so “bad” or “thick” that it can no longer circulate.

Withdrawing Blood Withdrawing Blood

Withdrawing blood reduces the amount of drugs in the body.

After you have a shot, the white [heroin] still in your blood system so you suck the blood out, take the drugs out and reduce the amount of drug in the blood.

Withdrawing blood is a well-established folk practice

I thought it came from one of my friends. She the first I know I have used that. Told me and then done it, yeah, then like got from one person and spread around, yeah, that’s who I found out from.

Obligation and responsibility to friends

We are friends, we play together, if something happens, we have to help him. Of course we withdraw blood.

Withdrawing Blood Withdrawing Blood

• Practice confirmed by survey with 38% of participants.

• Withdrawing blood is widely believed by VIDUs to be an effective antidote to overdose.

• The practice is informed by the belief that drugs primarily affect the cardiovascular system.

Withdrawing BloodWithdrawing Blood

Risk Associated with Withdrawing BloodRisk Associated with Withdrawing Blood

For overdose victims, medical assistance is not sought or sought too late.

We only call the ambulance after taking out blood and the person not awake. I don’t call ambulance, they will think I am a dog [informer]. You know, because when ambulance come, police come too. It the person is awake, he will ask you why you called the police, because he doesn’t know what has happened to him.

Risk of criminal charges in the event of death or injury

When I finished taking the blood out, he’s sleeping. Yeah we leave him sleeping and he died. He breathing and he sleeping but he died! I don’t know how! You know. Yeah. But we came back and he’s died. We got blamed for murder. We got blame for the murder!

Risks Associated with Withdrawing BloodRisks Associated with Withdrawing Blood

Risk of BBV transmission through the use of contaminated N&S

And you know what? He still get you know, the white stuff, bubble coming out, you know like that…biting tongue, like that. So me, my friend get the fit, 2 ml and 1 ml, you know, we take it out? OK? … 21 fit, take it out, all his blood! Me and another four friends … Fuckin he still die.

Explanatory Model of Overdose Explanatory Model of Overdose

Blood Beliefs

Causes

Mechanism

Withdraw Blood

Withdraw Blood

Withdraw Blood

Drug Effects on

Blood

ConclusionConclusion

• Case study illustrates how different EMs of overdose mechanisms lead to differences in management and response. These differences result in preventable deaths.

• Health services and interventions are unlikely to be effective unless they explicitly take into account the beliefs and practices of diverse cultural groups.

• Need for interventions based on culturally specific meanings and contexts of health, illness and risk.

AcknowledgementsAcknowledgements• Parents and Family• AusAID scholarship• A/Prof Lisa Maher• A/Nicolas Crofts• ICON Network (Tram Nguyen, Steve Pham, Heidi

Coupland, Anna Bates, Khanh Duy Le, Jarlienne Enriquez)

• Study Participants• School of Public Health and Community Medicine

Publications on overdose Publications on overdose • Overdose beliefs and management

practices among ethnic Vietnamese heroin users in Sydney, Australia

• Co Vay Co Tra (What Goes Around Comes Around): Culture, Risk and Vulnerability to Blood-borne Viruses among ethnic Vietnamese Injecting drug users