One Name, Many Faces

Kem Louie, RN, PhD, FAANKem Louie, RN, PhD, FAAN

The next time you read a statistic such as “there are 2 million Asian Americans and Pacific Islanders in the U.S. with no health insurance” or “visits to the emergency room represent 18.8% of total visits to health care facilities by Asian Americans and Pacific Islanders, compared with 11.7% for whites,” stop and think for a moment. What exactly does the term “Asian Americans and Pacific Islanders” really mean?

Did you know, for example, that this simple-sounding classification actually encompasses more than 30 different countries and 100 languages? Are you aware that there are very few links connecting these different ethnicities other than the government-assigned label? How much do you really know about the people, their cultures and their health?

“The majority of Asian American and Pacific Islander subgroups each have their own distinct language, history, culture and migration pattern [to the U.S.],” explains Kem Louie, RN, PhD, FAAN, associate professor in the Department of Nursing at William Paterson University, Wayne, N.J., and president of the Asian American/Pacific Islander Nurses Association (APINA). “Even though there seems to be a clustering of Asian immigrant groups in larger cities, especially on the East and West Coasts, there is no common thread among them.”

That said, it should come as no surprise to learn that health beliefs, behaviors and risks can vary substantially between the different Asian American and Pacific Islander (API) populations in this country–including Chinese, Japanese, Filipinos, Koreans, Vietnamese, Native Hawaiians, Samoans and many more. Unfortunately, medical researchers traditionally have classified Asian Americans and Pacific Islanders as one broad umbrella group with similar, if not identical, health care concerns. Few, if any, research studies have bothered to make distinctions between Native Hawaiians and Hmong, for example, despite the fact that the people are dramatically different in their diets, languages and traditional beliefs.

But today, in response to federal mandates for increasing cultural competence in health care and eliminating racial and ethnic disparities in health outcomes, this oversimplified view of the nation’s API populations is finally changing. Recent culturally sensitive research studies have begun to uncover groundbreaking information about how the multiple subgroups differ from one another. Here’s an in-depth look at some of the initial findings that are helping to paint a more definitive picture of the health needs of Asian Americans and Pacific Islanders–and the implications of those findings for the nurses who provide them with care.

The Past

According to Census 2000 figures, there are approximately 11.2 million people of Asian and Pacific Islander descent living in the U.S.–up from 9 million in 1990. This increase reveals a significant immigration movement. In fact, 24% of foreign-born U.S. residents in 1997 were Asians or Pacific Islanders. In other words, six out of 10 API persons living in the United States at the time were born elsewhere. That diversity–and varying degrees of acculturation–creates an interesting and complex situation for health care providers.

“There is a changing of demographics for the Asian-American population in general and there are so many nuances and variations from one [API] culture to another,” says Daisy Rodriguez, RN, MN, MPA, an administrative nursing supervisor at San Ramon Regional Medical Center in San Ramon, Calif., and coauthor of a recent study on the health status of Filipino immigrants in the San Francisco Bay area.

Each API subgroup possesses its own cultural characteristics that are just now being examined in terms of how they impact the overall health of the people. The lack of focus on such differences in the past, say some practitioners, may have resulted from a long-held stereotype of Asians as the healthy “model minority.”<

Two Members of the Samoan National Nurses AssociationTwo Members of the Samoan National Nurses Association

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“Asians are often seen as a self-sufficient minority group, but that might simply mean that the issues are hidden,” asserts Rodriguez.

Adds Louie, “Many Asian Americans, like those of Chinese and Japanese descent, have been here for generations and have done very well through the acculturation process. But perhaps because they have done so well, the government hasn’t taken seriously the thought of examining [population-specific] health care issues.”

To fill these information gaps, API health care professionals like Rodriguez are initiating their own research to gain insight into the specific health issues affecting their communities. In addition, several federal agencies, such as the Office of Minority Health, have begun investigating health differences between API populations. The 1999 White House Initiative on Asian Americans and Pacific Islanders and the more recent Initiative to Eliminate Racial and Ethnic Disparities in Health are two such endeavors that have dispelled the misconception that Asian Americans have few major health care worries compared to other racial and ethnic groups.

 

The Present

Although much of the current research data on minority health disparities suggests that Asian Americans and Pacific Islanders generally fare better than African Americans and Hispanics when it comes to health outcomes, this does not mean that API communities don’t suffer from their share of disproportionately high health risks and mortality rates. In fact, recent reports have raised a number of red flags indicating serious API health concerns that physicians, nurses and other health professionals urgently need to address. Some of the most critical areas of concern include:

Cancer
This deadly disease appears to be a prevalent health problem for Asian Americans and Pacific Islanders in general, regardless of differences between specific subgroups. There is overwhelming evidence that many types of cancer are more common among Asians and Pacific Islanders than even heart disease, which still ranks as the leading cause of death for the U.S. population as a whole. “This is the first time that cancer is the leading cause of death among any [racial or ethnic] group,” Louie points out.

More Asian Americans and Pacific Islanders suffer from liver, stomach and nasopharyngeal cancer than Caucasians, according to the Asian/Pacific Islander National Cancer Survivors Network. More specifically, Vietnamese Americans are 11 times more likely to develop liver cancer than whites, and Chinese Americans report the highest rate of nasopharyngeal cancer among all racial or ethnic groups, according to The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination and Ensuring Equality, a 1999 report ordered by the U.S. Commission on Civil Rights.

But what has many caregivers particularly worried is the growing numbers of API women diagnosed with breast and cervical cancer. Again, incidence rates vary among subpopulations, but Native Hawaiians top the list of breast cancer sufferers, with 106 cases occurring per 100,000 people. Vietnamese women are 2.5 times more likely to develop cervical cancer than women in any other racial or ethnic population. Both anecdotal and qualitative research suggests that these disparities are linked to cultural issues that may be creating barriers to early diagnosis and preventive care.

For example, says Rodriguez, “Some Filipino women who feel lumps in their breasts may not be reporting them to their physicians because it involves a sensitive part of their bodies and they don’t want to be examined.”

Dorothy E. Schmidt-Vaivao, coordinator of the Samoan National Nurses Association (SNNA)’s cervical cancer program, based in Carson, Calif., has encountered similar resistance to cancer screening among Samoan women. “We have had women comment that they don’t want anyone other than their husbands touching them.”

Statistics from the API Cancer Survivor Network further confirm the prevalence of these attitudes. A study of Vietnamese women living in California revealed that 34% had never had a mammogram and 54% had never had a Pap test. The Network also notes that Asian American and Pacific Islander women, as a whole, have the lowest screening rates for breast and cervical cancer among all ethnic groups.

Recognizing the immediate need for interventions in their community, SNNA has initiated two outreach programs in Southern California: the Pacific Islander Women’s Breast Health and Breast Cancer Early Detection Program, and Breast Cancer Awareness–The Fa’a Samoa Way Project. “We go to community churches where we talk to the women members,” explains Schmidt-Vaivao. “Afterwards, the women tell us that they now know why they have to follow up [and get breast exams].”

Although these programs are relatively young, Schmidt-Vaivao believes the grassroots effort is making an impact. “Our goal is to create a prevention awareness in the Samoan community,” she emphasizes.

Tuberculosis and Hepatitis
More than a decade ago, researchers discovered a worldwide resurgence of tuberculosis (TB). This time, however, the airborne, infectious disease had mutated into a new, drug-resistant strain. Even though health experts in various countries had hoped to curtail its spread by developing more aggressive medications and treatment programs, TB remains a serious public health issue, especially in API communities.

The World Health Organization (WHO) estimates that, under current conditions, nearly 1 billion people will become newly infected with TB by 2020, and 35 million will die from it. Many of these victims will be from Southeast Asia, which is already recording 3 million new TB cases per year. These predictions worry U.S. public health officials because of the increased immigration from that part of the world. According to WHO, nearly half of all TB cases in industrialized countries occur in foreign-born people. In the United States, 40% of TB patients are immigrants, many of them from Southeast Asia.

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In fact, the American Lung Association reports that Asian Americans and Pacific Islanders are 15 times more likely to contract an active case of TB than Caucasian Americans. As with cancer, this disparity is often exacerbated by cultural taboos that can prevent Southeast Asian immigrants from seeking treatment.

“In some Asian cultures, TB is a stigma,” notes Louie. “And if patients perceive they are being chastised by health care providers, they may not come back for follow-up care or take the treatment at all.” Such behaviors can result in a significant public health risk, experts warn, because untreated or half-treated TB can evolve into a drug-resistant form of the disease.

Similarly, hepatitis B seems to be hitting the API population harder than other racial or ethnic groups. Again, the concern in the public health arena is the effects that can develop if the disease isn’t identified and treated early enough. While not an airborne contaminant like TB, hepatitis B is the leading cause of liver cancer–and as noted earlier, Asian Americans and Pacific Islanders, especially those of Vietnamese descent, have a higher incidence of this cancer than whites.

“The rate of hepatitis B [among Asian Americans] is on the rise, and we weren’t looking in that direction,” says Louie. “Children who contract it are especially at risk for developing cancer later in life.”

 

Obesity, Diabetes and Kidney Disease
Interestingly, many Asian Americans, and especially Pacific Islanders, are following in the footsteps of other minority groups when it comes to problems with obesity and sedentary lifestyles–unhealthy behaviors that can increase the risk of developing diabetes. In fact, type 2 diabetes has become so prevalent among Americans of all races that health experts have virtually declared it a national epidemic.

Diet, of course, plays a huge role in the both the cause and the treatment of diabetes. While Pacific Islanders have traditionally been known for their healthy eating habits, Schmidt-Vaivao is concerned that this pattern is changing as the people become more acculturated to the American “burgers and fries” lifestyle.

“We [Samoans] have the highest incidence of obesity among the Pacific Islander community,” she says, adding that it’s a problem both in the U.S. and on the island of American Samoa. “There are a lot of fast food places over there now. The people on the island are turning to that eating habit versus the fresh fish and fruit that’s been traditional. It’s scary to see that happening, because it can create problems with diabetes and hypertension.”

Diet is also a leading suspect behind the unprecedented number of renal problems among API subgroups. “I’ve noticed a lot of Samoan people on the island, young and old, on dialysis,” Schmidt-Vaivao reports. “We need to find out why. Is it because of our diet? Is it hereditary? Has this always been going on but we weren’t testing for it before?”

Southeast Asians in the U.S. are also on dialysis in record numbers, says Ana Schaper, RN, MSN, PhD, an epidemiologist at Gundersen Lutheran Medical Center in La Crosse, Wisconsin. Currently there is no conclusive research available to shed light on why so many Asians and Pacific Islander are requiring this complicated treatment.

HIV/AIDS
Generally speaking, America’s API population has some of the lowest numbers of HIV and AIDS cases compared to other minority groups. The Civil Rights Commission report states that Asian Americans accounted for eight AIDS cases per 100,000 people in 1996, which is extremely low compared with the 111 and 52 cases for African Americans and Hispanics, respectively. But within the Asian community, Filipinos lead the subgroups in known AIDS cases, with 45 cases per 100,000.

Furthermore, both Louie and Rodriguez suggest that these statistics may be misleading. “We believe there are more API people who are infected but are not reporting it because of the cultural barriers in their communities,” explains Rodriguez.

In addition to cultural mores, factors such as language barriers and lack of education about the disease may also be clouding statistical findings and preventing people from seeking care. Some research suggests that awareness and understanding of AIDS and its risk factors among the more recently immigrated Asians lags behind that of their counterparts who have lived in America for some time. For example, a 1992-94 National Health Interview Survey found that 21.2% of Vietnamese adults in the U.S. admitted knowing nothing about AIDS and its transmission, compared to only 5.1% of Japanese-American adults.

As more research among API subgroups is conducted, and as community education efforts broaden, the number of reported HIV/AIDS cases among Asian Americans and Pacific Islanders could start to inch upward as more people come forward for testing and treatment.

The Future

Because there has historically been so little definitive research into differences between API subgroups, the current body of knowledge about their health care needs is all relatively recent and preliminary. But now, nurse researchers who are concerned about providing better care to Asian American communities are hoping to make up for lost time–and Asian American/Pacific Islander nurses are leading the way.

“There has been more printed about Asians in the medical literature in the past five years compared with the previous 25 years,” Louie comments. “Still, we need to do a better job in specific data collection if we are really to get a handle on health care concerns among Asian Americans and Pacific Islanders. Currently, we’re dependent on government-gathered data. So much depends on how well the Health Department and other agencies define their categories.”

Adds Rodriguez, “There may be many differences between the various API groups, but the only way to know is to do the research.” That’s exactly why she, along with colleagues from the Philippine Nurses Association of Northern California, initiated their in-depth study of Filipino Americans’ health status, risk behaviors and health promotion practices.

What started as a local survey of older Filipino adults in the Bay Area has expanded into a comprehensive national project, Rodriguez reports. “We realized our focus needed to extend beyond just the elderly because there were so many health care issues in the Filipino community that needed to be addressed.” The study’s initial findings will be presented this summer at the 2002 Philippine Nurses Association of America national conference in Philadelphia.

Schaper recently concluded a project examining the existence of postpartum depression in Hmong women. Wisconsin is home to a large Hmong population and state officials had done some initial research on this issue. Their report concluded that this condition was not prevalent in the Hmong community. However, translators working with Hmong maternity patients at Gundersen Lutheran told Schaper and her colleagues they believed this conclusion was incorrect.

“Because of those initial research results, we weren’t screening Hmong women for postpartum depression like we did with other patients,” she says. As a result, Schaper and several local midwives embarked on a two-year project to clarify the issue. Her findings proved that there was indeed a growing presence of postpartum depression in young Hmong mothers, but because of cultural and linguistic misunderstandings, it had been overlooked by the previous research.

“We didn’t realize how difficult it was to become trusted within the Hmong community,” Schaper adds. “Confidentiality is a big part of their lives. Issues surrounding childbirth are not usually talked about with people outside the family for fear of starting rumors.”

Through her research, Schaper determined that a more symptomatic-oriented screening tool was able to better identify postpartum depression in Hmong women. “Now we screen all our patients for postpartum depression,” she says. “We’ve also developed [educational] materials for Hmong families to help them prepare for the birth of their babies.”

Schaper also discovered some interesting generational and acculturation issues impacting the women in her focus groups. Generally speaking, the younger women who were either born in the U.S. or had lived here since childhood had more “Americanized” expectations about motherhood. It was often the clash between these views and the traditional Hmong philosophies that caused much of the anxiety and depression.

“There was a difference in how the young women saw their world compared with their mothers who had given birth in Laos,” Schaper explains.

The Providers

Other recent studies have confirmed that the degree of acculturation in Asians and Pacific Islanders who have migrated to the U.S. has both direct and indirect connections with their health and their use of health care providers. For example, the Civil Right Commission’s research found that the longer Korean women had lived in the United States, the greater their risk was for developing breast cancer. Furthermore, it’s often the newly immigrated who lack access to health care services the most, in part because of such factors as poverty, language barriers, lack of insurance and unfamiliarity with the American health system.

But that’s also why it’s important for nurses and other health care professionals to approach Asian and Pacific Islanders with cultural sensitivity and an open mind. “While we may not know all the specifics about health care issues in API communities, we do know what makes for good health. Now we have to look at these factors within the framework of their culture,” Schaper advises.

For nurses, that process must begin with taking the time to listen as well as learning to ask the “right” questions. “Samoans don’t believe in saying much,” comments Schmidt-Vaivao. “As health care providers, you have to dig because they won’t volunteer information.”

Such cultural barriers to communication are common among many API subgroups, Louie agrees. For instance, there’s often an attitude of “automatic” respect assigned to health care professionals that can actually be counterproductive. “Asians don’t want to offend a care provider, even if they don’t agree with him or her,” she explains. “Nevertheless, nurses have to find a way to get an accurate assessment. You have to take the time to listen and ask many questions. It seems like a simple philosophy, but when you do it, they’ll respond.”

Nurse researchers who have studied health issues affecting Asians and Pacific Islanders advise nurses in clinical practice who care for API patients to seek out as much information about Asian cultures as possible, whether it’s from published research or simply talking with colleagues who have firsthand knowledge in this area. After all, most hospital staffs are a microcosm of the communities they serve. Don’t hesitate to ask for translation assistance, or for information on traditional diet, religious beliefs or anything else that can help you provide more culturally competent care.

Above all, cautions Louie, avoid the stereotype that all Asians and Pacific Islanders are alike. “The API population is a diverse group,” she says, “and I can’t stress enough the importance of not generalizing.”