Asian American Health Research: What Community Agencies on the Front Line Need to Know
To be most effective, community agencies working to improve the health of Asian Americans require a deep knowledge of their target community and have evidence-based programs and policies at their disposal. Unfortunately, Asian American health research is still emerging. For some health promotion curricula that have proven effective among general populations, there is no evidence that these curricula will be as effective among Asian American populations, particularly those with limited English proficiency. In addition, the effect of acculturation on health-seeking behaviors among Asian Americans is still poorly understood, but has a large bearing on looming health problems such as obesity and diabetes. Last, given that 30% of Asian Americans are of limited English proficiency, how does the cultural competency of the American health care system impact access to care among Asian Americans? These and other questions are key considerations in developing effective community health approaches for Asian Americans.
Community health partnerships, community-based participatory research, health disparities, health promotion, hepatitis, Asia, health services, accessibility, delivery of health care, health care quality, access, evaluation
A couple of years ago, I was asked to serve as a “community respondent” to the keynote presentation at a local health disparities research conference. The out-of-state keynote speaker provided an excellent review of her research within the Hispanic community. In addition to acknowledging her fine efforts in this community-based participatory work, I offered a well-known saying from the world of golf: “It’s a long way from the driving range to the first tee.” In other words, it is one thing to produce results in a controlled research environment; however, it is another to do it consistently in the real world. In the passages below, I provide some context regarding Asian American health, our agency and efforts to improve community health, and how I believe researchers and communities can work together to produce the information and capacity to positively transform the health of Asian Americans.
Asian American Health
Asian Americans continue to be a fast-growing racial/ethnic group in the United States. Although still laboring under the monolithic label of the “model minority,” the Asian American population is in fact highly diverse in terms of socioeconomic status, educational attainment, and other social determinants of health. For instance, poverty rates approach 30% for some Asian American subgroups.
It is estimated that Asian Americans constitute close to 50% of the 1.4 million Americans chronically infected with hepatitis B (HBV), even though they constitute only 4% of the nation’s population.1 Asian Americans also have the highest race-specific rate of tuberculosis incidence2 and underutilize preventive services such as colorectal, breast, and cervical cancer screenings when compared with non-Hispanic Whites.3–5 [End Page 59] Furthermore, selected subgroups of Asian Americans have high rates of tobacco use.6–8
Those of us working at a community level to address these and other health disparities among Asian Americans face the longstanding challenges of population-based health improvement work: Lack of sufficient and sustained funding, overworked and often undertrained staff, and a health care system that rewards acute and end-of-life care in lieu of primary and secondary prevention.
In addition, we are working with a dearth of descriptive Asian American health data disaggregated by ethnic subgroup and a paucity of evidence-based interventions specifically adapted for and tested among Asian American subgroups. A review of MEDLINE found that only 0.01% of studies referenced Asian Americans and Pacific Islanders (AAPI) as a studied group.9
Fortunately, there exists some exemplary and foundational health research among Asian Americans. For instance, Nguyen,10–13 Gor,14–16 Ma,17–20 Chen,21–23 and Kagawa-Singer24–28 have been relatively prolific in the area of cancer prevention research. Takeuchi29–31 and Gee32–35 have been active in mental health research, and Ngo-Metzger36–39 and Ponce40–42 have elucidated issues related to health care access among Asian Americans. In particular, Kagawa-Singer and colleagues have conducted commendable community-based participatory research relating to cancer-related patient navigation.43,44 Additional research of this type can benefit agencies working at the community level.
This is not an exhaustive list of important researchers in the area of Asian American health, but it is meant to suggest that there is a growing body of health research among Asian Americans. Having said that, these and other researchers would roundly agree that Asian Americans are disproportionately understudied in terms of health, and many unanswered and critical questions remain.
Asian Pacific Community in Action
Established in 2002, the Asian Pacific Community in Action (APCA) is a nonprofit agency headquartered in Phoenix, Arizona. Its mission is “to improve the health and well-being of the Asian Pacific community in Maricopa County through empowerment, health promotion and disease prevention.” Our agency has a relatively small staff—11 full- and part-time workers—and an annual budget of $600,000. APCA is one of eight health agencies participating in the groundbreaking community capacity building initiative known as “Health Through Action,” funded by the W. K. Kellogg Foundation and managed by the Asian & Pacific Islander American Health Forum.
The agency’s target population is the 146,000 AAPIs residing in the greater Phoenix metropolitan area.45 They constitute just 3% of the total Maricopa County population and are diverse unto themselves. From larger to smaller in population size, Asian American communities include the Asian Indian, Chinese, Filipino, Vietnamese, and Korean groups.
In its 9 years of existence, APCA has built a relatively broad base of work, including programming in the areas of HBV awareness and screening, breast and cervical cancer education and referral, tobacco prevention and cessation, and chronic disease prevention. We have enjoyed relative success, having screened more than 2,500 AAPI individuals for HBV infection and referred more than 300 women for mammograms and cervical cancer screening. We have more than twenty trained lay health advisors who conduct educational outreach into local immigrant and refugee communities. The majority of individuals served by the agency are Korean, Vietnamese, or Chinese American. Most of these individuals are of limited English proficiency and lack health insurance coverage.
The agency has worked hard to better understand its target communities, having conducted three separate randomized telephone surveys, many focus groups, and several key informant surveys. However, there remains a strong sense that our work can be significantly improved through enhanced AAPI-related health research, particularly community-based participatory research. So, what are our research needs? I can divide our needs into three sections: Programs, policies, and systems.
As stated, chronic HBV infection disproportionately impacts Asian Americans, and APCA has an active HBV screening and education program. Although we have been successful in screening a sizable number of individuals for HBV, we have unanswered questions related to the outcomes of this screening that are not addressed in the current literature. For instance, do newly identified, chronically infected individuals remain in medical care after initial screening and referral? This is an important question, given that HBV infection is [End Page 60] not curable (although viral replication can be suppressed with medication), often causes severe liver disease, and therefore requires lifelong medical monitoring. If infected individuals are not continuously being medically monitored, what can be done to ameliorate this situation? Identified barriers may call for changes in medical referral and case management services, patient education, provider training, and/or systems-level changes. APCA, having identified more than 125 chronically HBV-infected individuals, would be interested in partnering with academic colleagues in this inquiry.
Improving breast and cervical cancer screening rates among Asian Americans is another area of health disparity and an agency priority. Whereas existing research provides important insights to screening-related beliefs (e.g., Asian American women think screening is in response to symptoms rather than to detect cancer before symptoms occur5), translating this and related researching findings is challenging at best. Collaboration with researchers in translating this research into effective practice would be welcomed and may hold the key to bringing Asian American cancer screening rates in line with other racial/ethnic groups.
The impact of acculturation on health behaviors is an area of common interest among researchers and community health practitioners. For Asian Americans, it seems clear that acculturation is a mediating factor related to tobacco use46 and overweight/obesity.47,48 The largely descriptive, cross-sectional research conducted to date has set the stage for detailed behavioral studies and interventions. Related to obesity, specific areas for examination include, but are not limited to, dietary habits (including native food intake and access to native food ingredients) and physical activity, including culturally derived activities (e.g., tai chi). Again, this is potentially a fruitful area for community–academic partnerships, and, more important, may hold the key to preventing Asian Americans obesity rates from rising to the rates seen among the general U.S. population.
Last, community-level practitioners are in need of culturally adapted health curricula. For instance, APCA recently conducted an evidence-based program known as “Living Well with a Disability.”49 The program was conducted in Mandarin for Chinese American participants; however, the curriculum itself was not culturally adapted for this audience. Such an adaptation is beyond the resources and expertise of our small community-based organization. Adaptation of this curriculum for multiple Asian American subgroups would be of great value and seems an ideal project for community–academic partnership.
We see a growing role for our agency in advocating for policies meant to improve the collective health of our target population. For this reason, relevant health policy research is of interest.
For instance, although the immigration policy furor has largely surrounded Latino individuals and communities, what has been the impact on the Asian American community? Have individuals and/or families returned to their native lands? Are they now less likely to access government health and social services? Has this resulted in poorer health outcomes? For us, this is a particularly acute area of interest, given that Arizona has enacted some of the strictest immigration laws in the nation. A partnership with our academic colleagues could help to illuminate this matter, which is particularly important given the rapid growth of Asian Americans in this country and anticipated efforts to seek immigration reform.
As an agency, we have a strong interest in improving access to health care services for Asian Americans of limited English proficiency. I met with an executive for a major hospital system in Arizona several months ago about the use of trained medical interpreters. She advised me that there is a system-wide policy prohibiting the use of family members or untrained staff to interpret for limited English proficient individuals during medical visits. Many questions arise. What is the level of compliance with this policy? Have medical outcomes improved since the implementation of this policy? What is the feedback from Asian American patients of these facilities? Do other local hospital systems have similar policies? Little is available in the literature with regard to compliance to federal requirements around culturally and linguistically appropriate health services50 and the relative impact of such policies. This presents an opportunity for community agencies representing affected parties and academic researchers to collaborate on a potentially far-reaching policy evaluation.
We hear anecdotally that many Asian Americans return to their native countries to receive non-urgent medical care. Reasons cited include affordability and cultural preference. [End Page 61] How widespread is this phenomena? What would it take for these individuals to seek care locally? In other words, how can the current health care system be reengineered to adequately meet the needs of this subpopulation? In a state such as Arizona, with a relatively low percentage of Asian Americans, is the establishment of a clinic specifically designed for Asian Americans a productive effort? Does this enable individuals who would be better served seeking ongoing and comprehensive care in the mainstream health care system to remain in cultural silos? Answers to these questions can potentially guide efforts to improve the acceptability of local health care services to Asian Americans, which could result in improved care and health outcomes.
Although cultural competency has been an issue in the health care system for many years, seemingly very little research attention has been paid to the cultural competency of the public health system. This would seem to me to be a critical area of inquiry. The public health system’s ability to intervene in tobacco use, ensure broad infant immunization coverage, provide nutrition education (e.g., WIC) and protect entire communities during emergencies demands cultural proficiency to meet the needs of growing populations such as Asians Americans. However, little research exists to determine whether public health agencies are effectively serving the needs of Asian Americans. This would seem an interesting opportunity for collaborative research involving community agencies, governmental agencies, and academic institutions.
In developing this commentary, it has become clear to me that there is a growing body of Asian American health research that provides critical pieces of a jigsaw puzzle representing the optimal knowledge base necessary to transform Asian American health. However, from my perch in the community, there are significant missing puzzle pieces—culturally adapted curricula and interventions, more information about impact of acculturation on immigrant health, research into health care policies that affect Asian American health outcomes, and more research into health-seeking behaviors.
I offer two recommendations. The first is the development of a national Asian American health research agenda. We can finish the jigsaw puzzle most quickly if everyone works together. The Asian & Pacific Islander American Health Forum and the Center for the Study of Asian American Health of New York University has put together an advisory group that is working in this area. I think it will be of great benefit. My second suggestion is to ask some of the previously mentioned Asian American health researchers to host national webinars, allowing them to share their latest research findings, comment on translating their research into practice, and, most important, allowing participants a chance for some discourse with these individuals. For their part, community-based agencies working in the area of Asian American health are in a good position to test and evaluate innovative, culturally responsive health improvement strategies. In partnership with academic colleagues, this work can inform the current evidence base.
In the final analysis, the body of Asian American health research is not growing as quickly as many of us would like. In the meantime, grass roots community-based agencies like APCA do the best they can with what they have. Active collaboration between community-based organizations and academic researchers can fill many of these gaps and facilitate the translation of research into effective community health practice. However, the lines of communication between communities and researchers needs to be strengthened and synergy found in pursuing mutually beneficial work. The result will be findings that empower Asian American communities to effectively address their most pressing health concerns. [End Page 62]
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