Asian American Culture and Health Status

MPHP 439

Online Chapter

Yen Luong

 

Introduction and Objectives

This document is meant to serve as a resource for researchers and health care professionals working with Asian and Pacific Islander communities.  This guide is meant to give the basic introduction how different communities are organized and defined by the U.S. Census and where these communities are located within the US.  This chapter will discuss different traditional Asian attitudes towards medicine and health maintenance, common health concerns among Asian American and Pacific Islander groups and protective effects of Asian ancestry.  Finally, a brief discussion on an approach to providing culturally competent are to this very diverse group will be discussed. 

Definitions of “Asian,” status and origin of major Asian populations in the U.S.

            The terms “Asian” refers to people having origins in parts of the Far East, Southeast Asian, or Indian subcontinent.  Asian groups are not limited to a single nationality culture or language or religion but include a variety of ethnic dimensions as different from each other as from Western culture.  Far East Asians include those with origins from China, Japan, North Korea, South Korea Mongolia, Taiwan and the easternmost, portion of Russia.  Southeast Asians countries are bounded by China in the north and the Pacific Ocean on the east.  The region is comprised of 10 countries including Brunei, Cambodia, Indonesia, Laos, Malaysia, Mayanmar, the Philippine, Singapore, Thailand and Vietnam. Finally, the Indian subcontinent includes those with origins from Pakistan, India Bangladesh and the Himalayan states of Nepal, Bhutan, and Sri Lanka (1).  

The US Census in 2000 showed that the US population was 281.4 million.  Of those 11.9 million or 4.2 percent reported Asian.  This number includes 10.2 million people or 3.6 percent, who reported only Asian and 1.7 million who reported Asian as well as one or more other races. The other major race categories included white, black or African American, American Indian and Alaska Native, Native Hawaiian and other Pacific Islander and other race.  Those that reported either Asian alone or in combination with one or more races are included in the numbers for Asians.  The Census bureau is projecting that the Asian-American population will grow to 37.6 million individuals by the 2050 (1). 

            Most Asians living in the US are populating urban areas concentrated equally on the West Coast and the East Coast.  Half of all Asians living in the U.S. are living in Hawaii and California.  On the East the Asian populations are more disperse, with large numbers in Washington, New Jersey and New York.  Additionally, steady increases have been observed in metropolitan cities like Boston, Chicago and Philadelphia (2).

Languages and Religion

            Through all of the Far East, Southeast Asia and the Indian subcontinent there is not a country that is homogenous in language or religion.  It is impossible to identify exactly how many languages are spoken in those collective regions due to the number of dialects and ancient indigenous tongues spoken.  It is estimated that 2,197 languages are spoken in the collective regions of Asia.  Southeast Asia contains languages termed Austro-Asiatic.  That is, languages spoken between China and Indonesia, as well as pats of India and Malaysia.  There are over 100 Austro-Asiatic languages.  The Indian subcontinent languages are termed Indo-Iranian.  In this very dense part of the world over 500 million people, there are over 500 languages spoken including Hindi, Urdu and Bengali.  Finally, the largest language family in Asia is the Sino-Tibetan which includes Chinese.  Chinese is spoken by over 1 billion Asians.  There are at least eight main dialects of Chinese alone.  Here in the U.S.,  it is estimated that Asian and Asian American speak more than 100 different languages.  

            The practice of religion is similarly very diverse.  Though most Asians are Theravada or Mahayana Buddhists, there are also significant populations practicing Islam, Hinduism, Christianity, Animism, Taoism and Confucianism.  Most Asians and Asian American continue to practice the religion of their homeland by establishing neighborhood temple or places of worship.  While, language and religion are two major challenges to assimilation in the U.S., they are also how traditions are maintained through generations. 

Waves of Asian Immigration:

During the 19th century, the two largest groups of Asians in the U.S. were the Chinese and the Japanese.  During this time large amounts of Chinese and Japanese began immigrating to the U.S. as skilled laborers on the transcontinental railroad.  Ninety percent (90%) of the workforce that was credited with completion of the railroad were Chinese.  Similarly, in Hawaii, the Chinese, Japanese and later Filipino laborers, were brought in during the 19th century to work on sugar plantations.  Up until 1965 the Naturalization Act of 1790 effectively banned nearly all immigration from Asia to the U.S..  Asian immigration increased significantly after the 1965 Immigration Act altered the quota system formerly set by the Naturalization Act.

              War, the other major influence on Asian immigration to the U.S., created two major waves.  Prior to the start of the war, Filipinos were not yet citizens of the U.S.  Because of this status, they were not drafted into the armed forces.  Before the conclusion of the war Filipinos were granted citizenship; many men were recruited into the army and navy.  After World War II immigration preferences favored family reunification, almost doubling the number of Filipinos in the U.S..  Since then, Filipino immigration to the U.S. has remained steady making this the 2nd largest Asian group. 

The U.S.’s involvement in the Korean War and Vietnam War brought similar waves of immigration. Families from Korea, Vietnam, Laos, and Cambodia further diversified the U.S.’s Asian population.  Prior to 1965, only a few thousand Koreans entered the U.S. annually.  After 1965’s immigration reform the number of Koreans increased to 30,000 by 1970.  Korean immigration continued to flourish through the 1980s, but has seen a sharp decline as the economy of South Korea has improved. 

There were two major waves of immigration from Vietname.  The first wave followed collapse of the Thieu regime in 1975.  Many fled by boat to neighboring countries in Southeast Asia, eventually arriving in the U.S..  By 1980 nearly 175,000 Vietnamese were living in the U.S. The second wave flowed into the 1990’s, where the total number of Vietnamese grew 142% in a decade. 

Japanese-Americans are a widely recognized sub-group of Asians.  Though many perceive their numbers to be high, they are in fact only the 6th largest group of Asians in the U.S..   In 1970, with 600,000 Japanese Americans in the U.S., they were the largest sub-group.  However, due to relatively low birth rates and low immigration, their numbers have increased only slightly. A dramatic increase in immigrants from Asian Indian and across all of Asia has caused the Asian and Asian American population in the U.S. to be more representative of the entire continent.  

Today, regardless of location, the largest Asian sub-group is Chinese.  In the 2000 census, 2.7 million people reported being Chinese. The next largest groups were the Filipinos (2.4 million), Asian Indians (1.9 million), Vietnamese (1.2 million), Koreans (1.2 million) and Japanese (1.1 million).  Asian Americans continue to be the fastest growing population in the U.S..

 

The Model Minority and Access to Care

            The reference to Asians as the “model minority” stems stereotypes that Asians and Asian Americans are hardworking, respectful, and place a high value on education, family and elders.  Asians Americans are seen as passive, compliant, and without problems or needs.  Asians are often times overlooked due to this “Myth of the Model Minority”.  The myth has lead to neglect of the very real concerns of the population.  Furthermore, the needs of the communities, particularly of newer refugee communities, can be nearly invisible.   

            Asian Americans represent a wide variety of languages, dialects, and cultures here in the U.S.  Overall about 21 percent of Asians lack health insurance compared to about 16 percent of the general population.  Asians do represent both extremes of socioeconomic and health indices:  while more than a million Asian American live at or below the federal poverty level, Asian American women have the highest life expectancy of any other group(4).  Factors that contribute to poor health outcomes include language and cultural barriers, stigma associated with particular medical conditions, lack of health insurance and lack of data.  The lack of data on Asian populations is just recently being addressed as studies begin to stratify within Asian populations and over sample.  Data and statistics for prevalence of disease, therefore, are often sparse and dated, if present at all.    

Asians and the Traditional View of Medicine:

            The vast differences in traditions and culture make it difficult to comment on all traditional view of medicine.  Many views for smaller isolated communities can be undocumented altogether.  The Chinese however, have practiced a worldview on health for more than 3,000 years.  Chinese medicine views the mind, body, and spirit as a holistically; each component influences the function of the others.  A balance, therefore, is extremely important to good health. 

Many Asian Americans believe that opposing elements must be held in balance.  The Vietnamese call the balance am and duong.  Most are more familiar with the Chinese terms yin and yang.  In health these are translated as “hot” and “cold”.  Each illness is caused from a force that is too hot or too cold.  The cure, therefore, must be the opposing force, bringing balance to the body.  When ailment present, the traditional cures rely on herbal medicines. 

Herbal medicines were typically prescribed to bring the body back to equilibrium.  Medications as a whole are thought of as bodily maintenance and repair, and not as longtterm answers.  This concept can be a barrier for treatment of chronic diseases, particularly hypertension.  For this reason, adherence can be a challenge for Asian populations.  They believe that medication can be interrupted when one simply “feels better.” 

Asian and Disease in the U.S.

Diabetes – Persons of Asian backgrounds may share a common genetic factor that may affects their insulin secretion and insulin resistance. Asian Americans and Pacific Islanders may share a "thrifty gene" left over from their ancestors, which enabled them to survive during "feast and famine" cycles. However, with those cycles phasing out, that same gene may make a person more susceptible to developing type 2 diabetes.  A study showed that Native Hawaiians were 2.5 times more likely to develop diabetes than non-Hispanic white Hawaiians.  (4) Additional resources can be found at http://www.diabetes.org/communityprograms-and-localevents/asianamericans.jsp   Diabetes management workbooks in Chinese, Korean, Hmong, Cambodian, Tagalog are available at the following site.  http://www.ndep.nih.gov/diabetes/pubs/Tworeasons_tips_eng.pdf

 

Cancer - While the leading killer of Asians in the U.S. mirrors the nation’s mortality rates, with cardiovascular disease being among the greatest killer followed by cancer, certain Asian subgroups are more prone to developing certain types of cancers.  During 1988-1992 the highest age-adjusted incidence rate of cervical cancer occurred among Vietnamese American women (43 per 100,000), almost five times higher than the rate among non-Hispanic white women (7.5 per 1000,000). (3)

Hepatitis B – While the rates of acute hepatitis B have been steadily decreasing, the reported rate in 2001 was more than twice as high among Asians American and Pacific Islander (2.95 cases per 100,000).  Non-Hispanic whites had infection rates of 1.31 per 100,000 individuals.  Chronic Hepatitis B in Asian population often goes un-noticed until the development of liver disease.  It is known as a silent killer due to low screening rates.  The Stanford Liver Foundation reports that among foreign born Asian immigrants 1 in 10 can is a chronic Hepatitis B carrier.  Hepatitis B is also more prevalent in the Asian population, as mothers pass on the disease to their children.  If the children are not immunized within 2 hours, they too will be infected.  Though as many at two-thirds (2/3) of all cases will recover, one-third (1/3) will become chronic carriers of the Hepatitis B virus and could develop liver disease.  For more information on Hepatitis B contact the Asian Liver Center at Stanford University or go to http://liver.stanford.edu.

Tuberculosis (TB) – Asians have the highest TB case rates among all racial/ethnic groups.  In 2003 Asian accounted for 23 percent of all new TB cases.  U.S.-born persons accounted for 2 percent, while 41 percent of the cases were among foreign-born persons.  The TB case rate was 21 times greater in Asians than in non-Hispanic whites (29.7 vs. 1.4 per 100,000). 

AIDS -  Although Asians have the lowest diagnosis rates (4.0 per 100,000), the percent of AIDS incidences had increased by 38 percent between 1998 and 2002, compared to a 2.4 percent increase among African Americans and 12 percent decrease among whites.  Asians represent approximately 2 percent of all AIDS cases in the U.S.   The increased percentage during the late 1990s through the 2002 have been attributed to HIV-positive immigrants moving to the U.S. (3). For more information on the treatment and management of HIV and AIDS, visit the Asian Community Aids Service at http://www.acas.org/treatment/vietmap.html

Osteoporosis and Asian American Women – According to the National Institutes of Health Osteoporosis and Related Bone Diseases’ National Resource Center, thin, smaller framed women with diets low in calcium and Asian ancestry are at significantly greater risk.  Compared to Caucasian women, Asian women have been found to consume less calcium.  Diary is not a common component in the traditional diets of Asian cultures.  In fact, soy milk is a popular substitute for cow’s milk because of lactose intolerance.  Some studies report as many as 90% of Asian Americans are lactose intolerant with symptoms varying in severity (9).  For more information on osteoporosis in Asian populations and fact sheets in Cambodian, Vietnamese, Laotian, Chinese, Korean, English and Spanish go to http://www.osteo.org/osteolinks.asp

When being Asian American is protective:

Family is a concept of utmost importance to Asians.  In almost any traditional Asian cultures, the individual puts the family’s needs above his or her own.  Included in this concept of family is respect for parents and respect for elders.  It is not uncommon for extended families to live together in homes or villages.  These extended families may include uncles, aunts, cousins, grandparents, etc.  Children are expected to obey elders without exception.  This cohesive family structure in times of stress and illness creates becomes a natural source of social support.  For chronic diseases, social support is a strong indicator of successful management. 

Cardiovascular disease in Asians and Americans are the number one killer, generally Asians and Asian Americans do have lower body mass index (BMI), particularly Asian women.   It is hypothesized that as diets become westernized BMI could also increase.  In addition to cardiovascular disease BMI is a risk factor other chronic diseases like diabetes and hypertension to name a few. 

First Steps to Culturally Competent Care:

             The first and most basic step of providing culturally competent care is providing linguistically and culturally appropriate services.  The lack of health care access for Asian-American groups is most commonly the result of language barriers (7).  While developing and understanding of cultural norms takes time, seeking a translator or intermediary agency to assist, particularly with a language barrier, can often be the most beneficial step in bridging a gap in the short term.  Families will often use younger children or friends who speak better English as interpreters.  The caveat is that information can be lost or not understood at all without a proper interpreter.  

            Sensitivity to culturally appropriate behaviors is of the utmost important so as to not offend the patient.  In many Asian cultures physical contact such as a handshake or a hug between a man and a woman may be interpreted as a sexual advance.  Signs of disrespect may include a limp handshake.  Even looking straight into the eyes of an elderly person can be seen as a challenge to authority.  When in the presence of a group addressing the oldest male is often a safe practice (7). 

Additional Resources:

The National Network of Libraries of Medicine’s website provides a complete list of links to language specific health information by organization and condition.  References are for practitioners, clinicians, educators and trainers.

http://nnlm.gov/train/chi/multi.html

Selected Patient Information Resources in Asian Languages or SPIRAL is a collection of various health information assembled by the New England Region of National Network of Libraries of Medicine.  Languages include Cambodian/Khmer, Chinese, Hmong, Korean, Vietnamese, Laotian and Thai with a pull down menu of health topics.

http://spiral.tufts.edu/abou

http://ecu3.msh.org/mainpage.cfm?file=5.4.3.htm&module=provider&language=English

 

References:

(1) Census Bureau, Census 2000 Brief:  Overview fof Race and Hispanic Origin , 2000.

(2) Census Bureau, Census 2000 Brief.  The Asian Population 2000.  Issued February 2002

(3) Centers for Disease Control. HIV/AIDS Surveillance Report, Vol 14, 2003. 

(4) Centers for Disease Control. Trends in Tuberculosis – U.S. 1998 – 2003.  Morbidity and Mortality Weekly Report. 2004 ; 53 (10).

(5) http://en.wikipedia.org/wiki/Asian_Americans -Asian Americans

 

 

(6)http://www.cdc.gov/od/oc/media/pressrel/fs040402.htm  CDC Racial/Ethnic Health Disparities

(7) http://www.erc.msh.org/quality&culture  The Providers Guide to Quality and Culture

(8) http://asianamericanhealth.nlm.nih.gov/intro.html  National Library of Medicine- Asian American Health

(9) http://www.nlm.nih.gov/medlineplus/osteoporosis.html Special Issue for Asian Women Regarding Bone Health