“Patchworking” Social Support Among Vietnamese Americans for Chronic Disease Management

Abstract

Vietnamese Americans commonly experience a variety of chronic medical conditions. Social support can play a salient role in chronic disease management, but little is known about these dynamics among Vietnamese Americans. A mixed-methods study aimed to understand medication adherence, health literacy, and cultural beliefs among Vietnamese American patients at a Massachusetts federally qualified health center. One hundred participants completed self-report surveys and pill counts, for which frequencies and descriptive analyses were conducted. A linear regression analysis was performed between social support and medication adherence. A sub-sample of participants completed in-depth interviews, chronic disease diaries, and home observations. All qualitative data underwent thematic analysis. No statistically significant association was found between social support and medication adherence. Qualitative findings highlighted substantial social support related to chronic disease management. Participants received instrumental support from their adult children, home health aides, and community organizations. Friends were a key source of affective and confidant support. Community organizations addressed instrumental needs, while also facilitating affective and confidant support among participants and their friends. While the quantitative data concluded that participants had low satisfaction with social support and that social support had no significant impact on medication adherence, the qualitative data revealed an extensive relationship between social support and the broader scope of chronic disease management. When possible, providers should engage patients’ adult children, home health aides, and community organizations as important members of their social support networks.

Background

Vietnamese Americans are one of the largest Asian American groups and fastest-growing immigrant populations in the United States (US) [1, 2]. Disproportionately impacted by structural inequity, they commonly experience low levels of income, education, health literacy, quality of life, and English proficiency [3]. Despite this, as well as their high rates of chronic conditions [4–7], Vietnamese Americans remain underrepresented in chronic disease research.

Social support, which refers to psychological and material resources provided through relationships with other persons, groups, and the larger community [8], can play an important role in managing chronic medical conditions and generating resilience and self-efficacy [9, 10]. Many immigrant communities comprise close-knit social networks and intergenerational households, potentially influencing health behavior and outcomes [11]. For different groups, including older adults and late-life immigrants, family, neighbors, community services, and religious organizations are significant sources of social support [12].

Kibria’s ethnography on Vietnamese refugees’ economic adaptation in the US points to “patchworking”, or the piecing together of resources and support systems [13], which may build social capital within communities. Previous literature indicates that social capital predicts better health outcomes [14] and augments resilience at the individual and community levels [15, 16]. Particularly for immigrants, social capital may play a salient role in combating barriers related to the social determinants of health (SDOH) [17], such as healthcare access and navigation [18, 19]. Other SDOH that critically impact immigrants include socioeconomic status, food insecurity, housing deprivation, and transportation barriers [20]. Because SDOH affect essentially every aspect of health, robust social support is critical. However, older Asian Americans reportedly experience lower social support than non-Asian Americans [21]. Furthermore, Vietnamese Americans have been shown to have a heightened risk of social isolation compared to other Asian American groups [22], which contributes to chronic illness [23].

Although growing evidence links social support with medication adherence [24, 25], a distinct marker of chronic disease control, little is known about the dynamics between social support and the broader scope of chronic disease management among Vietnamese Americans. This research explored Vietnamese American participant data from a cross-sectional, convergent [26] mixed-methods study that aimed to understand medication adherence, health literacy, and cultural beliefs at a federally qualified health center (FQHC) in western Massachusetts [27]. This study hypothesized that Vietnamese Americans with social support would have adequate medication adherence. Understanding the networks and resources that underpin chronic disease management among Vietnamese Americans may advance knowledge about the role of the social drivers of health in immigrant and refugee populations more broadly in the US.

Methods

Participants

The study included 100 Vietnamese American participants who were (1) diagnosed with depression, diabetes, dyslipidemia, and/or hypertension; (2) prescribed at least one oral medication taken at least daily for the aforementioned condition(s); (3) patients at the same FQHC and (4) at least 18 years old. Participants were recruited through daily clinic schedule reviews, disease registries, outreach in waiting rooms, clinical staff referrals, self-referrals from recruitment flyers, and snowball sampling. Consent forms were explained orally in the participant’s preferred language (Vietnamese), and individuals provided written consent and received a copy of the consent form in Vietnamese for their records. This study was approved by the University of Arizona Institutional Review Board.

Quantitative Data Collection

An initial sample size of 100 for the quantitative component of the proposed project provided sufficient power to conduct the proposed analyses based on previous research completed by this team. Self-report surveys were orally administered in person by a bilingual bicultural interviewer in the participant’s preferred language (Vietnamese), and data collection was conducted in private spaces at the FQHC or the participant’s home, according to the participant’s preference. Satisfaction with social support was assessed in the surveys using the LONGSCAN version of the Duke-UNC Functional Social Support Questionnaire (DUFSSQ) [28–30], which was professionally translated into Vietnamese for this study. Seven questionnaire items assess affective and confidant support, and three items assess instrumental support [30]. Affective support refers to love and affection, while confidant support refers to communicating important life matters, and instrumental support reflects help with tangible needs. A 5-point Likert scale, ranging from 1 being “much less than I would like” to 5 being “as much as I would like”, was used to score each response [30].

To measure medication adherence, pill counts were conducted manually during the baseline survey visit and the 3-month follow-up [27].

Quantitative Analysis

Frequencies and descriptive analyses identified patterns, trends, and mean scores for sociodemographic data, social support, and medication adherence. A linear regression analysis assessed the statistical significance of the association between social support and adherence. All data were analyzed in SPSS.

Qualitative Data Collection

Those who completed the self-report surveys were invited to participate in qualitative data collection and were welcome to participate in more than one qualitative activity. A subsample (n = 18) participated in in-depth interviews (n = 10), home observations (n = 10), and chronic disease diaries (n = 6) for a deeper contextual exploration of social support (Table 1), health literacy, cultural health beliefs, and medication adherence. Home observations allowed the ethnographer to directly observe participants’ medication storage and management practices, while also engaging with them about these behaviors. For chronic disease diaries, participants recorded daily medication practices over the course of 5–7 days, responding to provided prompts before each activity. The ethnographer met with participants every 2–3 days to review diary entries and ask clarifying questions. To achieve maximum variation by age, gender, and diagnosis among participants, we tracked completion of qualitative activities by gender and age and actively recruited additional participants to fill any gaps. A bilingual bicultural interviewer assisted the monolingual English-speaking ethnographer with all data collection, providing on-the-spot translation. Interview and consent materials were available in Vietnamese and English, and all data were collected in private spaces at the FQHC or the participant’s home, based on their preference [27].

Table 1.

Social support interview questions

Social Support Interview Questions:

What helps you stick to your doctor’s instructions for taking your pills?

What gets in the way of taking your pills as prescribed?

Tell me about your medication regimen.

What helps you to take your medicine as prescribed? What keeps you from taking it?

Is there someone that helps you take care of yourself? If yes, how does that “help” look like?

Qualitative Analysis

All data were audio-recorded, translated from Vietnamese to English, transcribed into English, and analyzed in Atlas. ti. Deductive codes were predefined from the DUFSSQ to organize data into broad themes (e.g., affective, confidant, instrumental). This approach allowed the qualitative and quantitative data to be analyzed within the same framework, facilitating stronger integration between the two [31]. Inductive coding was performed to develop emergent codes (e.g., family, transportation). Similar codes were clustered to identify connections and broad patterns. Themes were then refined to hold distinct definitions and meanings. We conducted within- and cross-case analysis, so that individual participants who completed multiple activities were compared with others.

Results

Quantitative Results

A total of one hundred patients participated in this study. The mean age was 67 years (range 32–86), and 65% were female. The mean household income was $861 per month. Over half of participants (56%) reported fair health, while 28% felt their health was poor. For 54.5% of participants, the highest educational attainment was between grades 1 and 8. Most participants (91.8%) did not consider themselves fluent in English (Table 2).

Table 2.

Participant demographics

Participant Demographics
N = 100
	Mean (± SD.)
Age	66.84 (10.02)
Monthly Income	860.75 (292.78)
Gender	N	%
Female	65	65
Male	35	35
Perceived Health Status
Poor	28	28
Fair	56	56
Good	15	15
Very Good	1	1
Education
Never attended/only attended kindergarten	7	7.1
Grades 1–8	54	54.5
Grades 9–11	12	12.1
Grade 12 or GED	20	20.2
Some college	5	5.1
College graduate	1	1
Missing/unsure/don’t know	1
English Fluency
Yes	8	8.2
No	89	91.8
Missing/unsure/don’t know	3
Marital Status
Married and living with spouse	47	47
Married but living apart from spouse	4	4
Single	34	34
Divorced	1	1
Separated	4	4
Widowed	10	10
Living Situation
Your own house, flat, or apartment	97	97
Relative’s place	3	3

Affective support had the highest mean score (2.86), followed by instrumental (2.74) and confidant support (2.60). Overall, participants were unsatisfied with their social support, as mean scores below 3 indicate low satisfaction [28].¹

Of the 90 participants with pill count data, 57.8% were considered to have high medication adherence. On average, medication adherence was 80.22% (range from 31.25% to 100%). A linear regression analysis determined no statistical significance of the association between social support and medication adherence (Table 3).

Table 3.

Social support and medication adherence

Duke-UNC Functional Social Support Questionnaire
N = 100
Dimensions of Social Support		Mean (± SD.)
Affective		2.86 (1.13)
Instrumental		2.74 (1.11)
Confidant		2.60 (0.98)
Overall		2.77 (0.95)
Medication Adherence		N	%
N = 90
Less than 80% adherent		38	42.2
80% adherent or higher		52	57.8
Missing		10
		Mean (± SD.)
Medication Adherence		80.22 (14.83)
Social Support and Medication Adherence
Dimensions of Social Support	Unstan-dardized Beta	Coefficients SE	Sig.
Affective	0.851	3.108	0.785
Confidant	0.345	4.075	0.933
Instrumental	−1.71	2.942	0.564

Qualitative Results

All but one of the 18 participants described at least one source of social support. Most participants (n = 16) described more than one source of social support, with adult children, home health aides, and friends as the top three. Though some described receiving affective and confidant support, most support was interpreted as instrumental. Community organizations played a critical role in all social support dimensions.

Instrumental Support

Participants commonly relied on their adult children for various needs, including medication cost and delivery. One participant shared, “My son paid every time he picked up my medication. He paid all of the copayments. I didn’t have to pay from my pocket.” Another described her daughter facilitating her medication adherence, especially when she was without insurance: “Any time my medications run out, my daughter buys my medications from Walmart, and she pays out of her pocket. I never skipped any medications for the two years that I didn’t have insurance.”

Transportation was another significant need often met by adult children. One participant described her son providing transportation and support for medical appointments: “My son will take me [to the doctor]. Sometimes he would go into the exam room with me, but most of the time he just drops me off. When I’m done, I call him to pick me up. Sometimes he goes into the exam room to ask the doctor a question about my health.” Others also recounted receiving support from their children with transportation to grocery stores, churches, and temples.

Many participants received Supplemental Nutritional Assistance Program benefits, an indication of food insecurity. Several recounted support for food-related needs from their adult children. One participant explained, “If I run out of food stamps or I run out of food for the month, I will ask my son and daughter. Let’s say they buy a whole chicken. I will ask for a quarter of it, or if they buy some meat, I will ask for some meat.” Another shared that her daughter delivers home-cooked meals nearly every night. Likewise, one participant described different ways his children provide food: “Sometimes they cook. Sometimes they bring food to our home. Sometimes my son goes to Boston, and he buys food for me.”

Other family members were also noted for instrumental support. One participant shared, “For dinner today, I had rice with fish that was cooked in a pot and vegetable soup. The special fish was from my younger sister, who brought it here for me this evening. Actually, my youngest sister frequently brings Vietnamese food over here for me when they cook special food.” Another participant described her son-in-law setting up her pillbox: “I don’t know English, so my son-in-law printed the medication labels in Vietnamese for me. The reason my son-in-law got the pillbox for me is because I forget easily. Sometimes my daughter asks me, ‘Did you take your medicine?’ and I said, ‘I don’t know.’ My son-in-law heard that. He got me a pillbox, and he did all of the labeling for me.”

Vietnamese-speaking home health aides were also integral to participants’ social support networks, filling in gaps for many instrumental needs. One participant described the ways her home health aide, paid for by the Commonwealth Care Alliance² [32], supported her: “She has only one hour with me, so she helps me with whatever I need inside my apartment. She knows all about medication, so she helps me if I need any help. She also helps me clean my apartment, and if I receive a letter in English, which I can’t understand.” Similarly, another participant expressed how much she relied on her home health aide, noting, “She comes every day for at least one hour, but Vietnamese people work more than the hours that they get. She’s very helpful. Anything I need, I call her, and she helps me. She reads the mail for me. She does a little bit of everything – personal care, cooking, cleaning, translating notice letters.” Participants shared their appreciation for having home health aides who are Vietnamese. One expressed gratitude by saying, “I am fortunate to have a home health aide that can speak Vietnamese. I just had my cataract done. At that time, I needed help with transportation, and she helped me.”

Additionally, community organizations offered instrumental support, including hot meals and groceries. One participant mentioned, “Today was the day that the center sent hot lunches, not for people who live in this housing complex, but for elderly people who live nearby. They could come and pay $2 for a hot lunch, and I paid $2 for my hot lunch as well. I was very happy with what they served today. Very good lunch, and I was happy chatting with my peers over there.” A few participants also mentioned receiving groceries from a local Vietnamese parent support group.

Some community organizations provided health education, medical screenings, and medication management support. One participant shared, “I did some exercise to stretch my muscle. They brought somebody to the center to teach us how to do exercises in the morning.” A few participants described nursing students visiting community centers for medical screenings, and one mentioned receiving a pillbox: “I got this pillbox from the community center, and I organize this myself. Piece of cake. If I don’t, I will not remember to take my medications. If I finish the whole thing, I will start from the beginning… The nursing students taught us how to do this. Before that, I was forgetting my medications all of the time.”

Affective and Confidant Support

Participants most often turned to friends for emotional support and to discuss important life matters. One individual expressed, “I was feeling very happy today because I had a friend come over and visit me. They heard I was homesick before, so they stopped by my house to visit me.” Another shared how her friend helped her cope with stress. “I go to my friend and talk because I don’t feel well. I don’t feel happy. I want to talk, and over there, there is no stress. It relieves my stress.”

Chronic disease management, medication management, and health care services were sometimes discussed with friends. One participant said, “My friends and I do talk about our conditions and the medications we take. I know my friend takes a different medication, but we do talk about it.” Another participant described a friend teaching her how to use pillboxes. She also mentioned, “My friend told me that Commonwealth Care Alliance is really good. No co-payment for medications, and they have a lot of other good services, so I made the switch suggested by my friends.”

Along with instrumental support, community organizations facilitated affective and confidant support. Several participants referenced religious institutions and community centers as hubs for socialization. One participant shared, “I felt happy today because I had a chance to go to [name of community center] to have a hot lunch and to socialize with my friends over there… A lot of other Vietnamese elderly are going to be there, so I want to go and talk with them.” Another described her temple as a place to interact with others and find enjoyment: “Especially at the temple, I see a lot of my friends. It is kind of fun and peaceful when I go to the temple. I have a good time.” Community centers and religious institutions also provided opportunities to volunteer, further facilitating social engagement.

Discussion

Social support is a dynamic factor that can facilitate chronic disease management. By exploring their experiences, this study sought to understand social support and chronic disease management among Vietnamese Americans. Prior evidence indicates that older Asian Americans have lower perceived social support than non-Asian American populations [21]. Another study using a modified DUFSSQ determined that Vietnamese Americans had low social support satisfaction [33]. Similarly, our survey findings indicated low satisfaction across all social support dimensions. Because the scale assesses the amount of social support a person feels they receive compared to how much they would like, it may be used as a measure of satisfaction with social support [29, 30]. Considering responses through a satisfaction lens can support understanding of how social support may be interpreted and valued in different cultures.

There was no significant statistical association found between social support and medication adherence. However, the qualitative data revealed an extensive relationship between social support and chronic disease management, as participants frequently described tapping into various supports for their health-related needs. For example, medication cost is a well-known barrier to adherence [34]. Familial support to pay for medications can increase or maintain medication adherence [35, 36], which is consistent with our findings. Inability to meet basic needs, including food and transportation [37], is also linked to low medication adherence [38–41]. Adult children and home health aides routinely helped participants with cooking, grocery shopping, and transportation, while community organizations provided hot meals or groceries. Such supports mitigated food shortage for participants, as Vietnamese Americans have been commonly impacted by food insecurity [42]. Adult children and home health aides facilitated medication management, while home health aides also filled other gaps, including cleaning and translation. Community organizations further enabled chronic disease management by offering medication management support.

Qualitative findings also indicate instrumental support as the main dimension of social support provided. Although social support dimensions were predefined by the DUFSSQ, sociocultural contexts shape how instrumental support is interpreted. For instance, caregiving is customarily expressed through food in Vietnamese culture, as comfort can be found in preparing and consuming meals [43]. Thus, in the Vietnamese cultural context, some forms of instrumental support, e.g., providing food, may serve as affective support. Though the DUFSSQ only inquired about one’s ideal amount of social support, qualitative data collection allowed for exploration of actual social support experiences.

Besides practical assistance, social support may decrease feelings of loneliness and isolation and promote resilience and self-efficacy, mitigating the psychological repercussions of chronic illness [44–46]. Many participants expressed positive feelings when describing their friends with whom they confided and discussed important life matters. Similar to Shahin and colleagues’ systematic review on social support and medication adherence [25], our qualitative findings highlighted family and peer support as important drivers of medication adherence and chronic disease management. Lastly, community organizations brought together participants with their friends and community, providing opportunities to receive affective and confidant support. Therefore, community organizations played a unique and important role by intersecting with all three social support dimensions.

Per Kibria’s ethnography on “patchworking,” social supports can help alleviate the burden of inaccessible resources [14]. Because Vietnamese Americans face numerous social inequities, including discrimination in healthcare systems and language barriers [47], these supports may buffer the effects of such inequities. This work expanded the definition of “patchworking” to go beyond support networks for economic adaptation to also consider the gathering of social supports for chronic disease management. Additionally, our qualitative findings reflect Sudha and Morrison’s depiction of family connectedness, community self-support, and nonprofit organizations as strengths within Asian refugee communities [48]. For many immigrants, social capital has the capacity to advance the dissemination and exchange of health information, form cultural norms, and improve health behaviors [19].

As indicated by the depth of context and experience of support via the qualitative data, adapted quantitative social support scales for Vietnamese Americans that account for sociocultural factors are needed to yield a more comprehensive and accurate assessment. Further qualitative inquiry, including ethnographic research, is also needed to more explicitly understand the experiences of and satisfaction with different types of support related to chronic disease management and to identify embedded community strengths and assets that are responsive to these drivers of social support. After all, social supports are community strengths that provide a practical framework for understanding health-related social capital.

Limitations

Broad quantitative measures may not comprehensively capture social support nor its unique aspects in diverse groups [49]. The DUFSSQ was developed in 1988 after being validated in a population of young adult white women with strong socioeconomic standing in the US [28]. Thus, certain scale items may not be valid for use with other populations, including Vietnamese Americans. Qualitative methods, on the other hand, allow for more nuanced understandings of distinctive sociocultural contexts surrounding social support experiences. The patterns of social support described here may reflect unique strengths, resources, and challenges among Vietnamese Americans, but we cannot generalize these findings to all refugee and immigrant populations, let alone all Vietnamese Americans.

Conclusion

This study’s quantitative data underscored a narrative of low satisfaction with social support, while the qualitative data drew attention to the importance of “patchworking” supports to mitigate social stressors and facilitate chronic disease management. Healthcare providers should consider patients’ social support circumstances and integrate them into targeted chronic disease management interventions. More specifically, when possible, they should engage adult children, home health aides, and community organizations as important members of their patients’ social support networks.

Our team hopes to extend this research to include a larger population of Vietnamese Americans and to develop a validated and tailored DUFSSQ in the Vietnamese language. Examining social support and chronic disease management using an intersectional approach in future iterations of this work will also help us to (1) understand how overlapping identities (e.g., gender, age) influence chronic disease management; (2) dissect structural inequities that create barriers to chronic disease management; and (3) inform the development of more equitable care for Vietnamese Americans.

Data Availability

No datasets were generated or analysed during the current study.