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OCA - GREATER SEATTLE CHAPTER

EMBRACING THE HOPES AND ASPIRATIONS OF CHINESE AND ASIAN PACIFIC AMERICANS IN THE UNITED STATES

Excerpted from:

Women of Color Health Data Book
Office of Research on Women's Health
Office of the Director
United States' National Institutes of Health
3rd Edition, 2002 updated 2006

The health problems of Asian Americans are worsened by a complex set of cultural, linguistic, structural, and financial barriers to care. In 2000, a language other than English was spoken at home by 79 percent of Asian Americans, compared to 18 percent among the total U.S. population.227 More than two-thirds (69 percent) of Asian Americans are foreign-born, and, in 2002, only 17 percent of all Asian and Pacific Islander mothers who gave birth in the United States had themselves been born in the United States.110,227 If residing illegally in the United States, Asian Americans may not seek medical care for fear that this would expose their illegal status and result in deportation. Fifty-nine percent of all Asian and Pacific Islander women were in the labor force in 2002, with 37 percent in managerial or professional occupations. More than 33 percent of Asian and Pacific Islander females had technical, sales, or administrative support occupations, while an additional 17 percent had service occupations.252

In 2002, poverty rates were generally low for Asians and Pacific Islanders. Only 10 percent of all individuals who identify themselves as Asians and Pacific Islanders, 7 percent of households headed by Asian and Pacific Islander married couples, and 15 percent of households headed by Asian and Pacific Islander females (with no husband present) reported incomes below the poverty level.252 These averages, however, mask considerable variation among subpopulations.

For example, the percent of the population below the poverty level ranged from a low of 6 percent among Filipino Americans to a high of 38 percent among Hmong in 1999 (compared to about 12 percent for the entire U.S. population). A relatively high proportion of Cambodian Americans also reported poverty-level incomes (29 percent).227 The proportion of Vietnamese Americans reporting incomes below the poverty level in 1999 (16 percent) had decreased from 1990, when 24 percent of Vietnamese Americans lived in poverty. The poverty rate among Laotian Americans decreased significantly, from 66 percent in 1990 to 19 percent in 1999, while the poverty rate among Asian Indians increased from 7 percent to 10 percent during that same period of time.227,253,254

Both household and individual incomes for Asian Americans support the finding of disparate poverty rates among the subpopulations. In 1979, Asian Americans had average household income of $6,900, less than the U.S. average of $7,400. At that time, only Indonesian, Chinese, and Japanese Americans had average per capita incomes above the U.S. average. 249 In 1989, the median family income for Asians and Pacific Islanders was $35,900 (higher than the $35,000 median family income for non-Hispanic white Americans), and 37 percent of all Asian and Pacific Islander American households had annual incomes of at least $50,000. At that same time, more than 5 percent of Asian and Pacific Islander households had incomes of less than $5,000, and nearly 12 percent had incomes of less than $10,000.255

In 1999, the median family income for Asian Americans was $59,324.227 By 2002, the estimated median family income for Asians had increased to $63,883, considerably higher than $55,938, the median family income for whites that same year.172 Forty percent of Asian and Pacific Islander families had incomes of at least $75,000 in 2001.252

The employment status of Southeast Asian immigrants improved dramatically between 1980 and 2000. In 2000, although the unemployment rates among the Hmong (5.4 percent), Cambodians (4.8 percent), and Laotians (4.7 percent) exceeded the U.S. average (3.7 percent), these rates were considerably lower than in 1980. In 1980, unemployment rates for these groups were 20 percent (Hmong), 11 percent (Cambodians), and 15 percent (Laotians). 17,249

[Health Insurance]

Health insurance coverage varies among Asian American women, as do employment and income levels. Eighty-one percent of all Asian women and 97 percent of Asian women ages 65 years and older reported having some type of health insurance coverage in 2003.256 More than 10 percent of Asian women reported Medicaid coverage and nearly 10 percent reported Medicare coverage. Nearly two-thirds (66 percent) of Asian and Pacific Islander women had private health insurance. Despite high rates of coverage in general, selected populations lack health insurance, and this lack of health insurance causes some Asian American women to become frequent users of hospital emergency rooms. Among all U.S. Asian populations, almost 19 percent were without health insurance in 2003.35 When examining the lack of health insurance coverage by ethnic subgroup, however, the proportions uninsured range from a low of 8 percent among third generation and higher Asian and Pacific Islander Americans, to a high of 34 percent among Koreans, and 27 percent among Southeast Asians. Koreans and Southeast Asians were also the least likely to have health insurance coverage through their employers (48 and 49 percent, respectively). However, Koreans also were the subpopulation most likely to have privately purchased insurance coverage (14 percent). Southeast Asians were the group most likely to have Medicaid coverage (18 percent) during 1997, a marked decline from the more than two-fifths (41 percent) reporting this coverage in 1994. This decline is doubtless associated with the severing of the link between welfare recipiency and Medicaid eligibility when the AFDC (Aid to Families with Dependent Children) welfare program was reformed into the TANF (Temporary Assistance for Needy Families) welfare program in 1996. Medicaid enrollment dropped during this period for all populations.257 However, although all Asian and other racial/ethnic subgroups witnessed a decline in Medicaid coverage between 1994 and 1997, Southeast Asiansexperienced the most precipitous decline.24

One study of Korean American residents in Los Angeles County in 1999 found that 49 percent of those under 65 years of age and 24 percent of those 65 years of age and older had no health insurance.258 Among Asian ethnic groups in California, Koreans are most likely to be uninsured (45 percent). This is higher than the uninsured rate among Hispanics or Latinos (36 percent), the ethnic group most likely to be uninsured in California. Vietnamese and Chinese residents of California also have high rates of uninsurance (29 percent and 28 percent, respectively). Overall, 23 percent of Asian and Pacific Islanders in California are uninsured. However, the uninsured rate among Asian and Pacific Islanders in California who have lived in the United States for three or more generations (and are therefore more acculturated) is 15 percent.259 Thus, acculturation seems to be associated with greater likelihood of health insurance coverage for Asian Americans.

[Life Style Healh Factors]

Although Asian American women overall exhibit healthful lifestyle behaviors, such as a lower smoking prevalence (10 percent) than all American women (16 percent), there is variation by subpopulation in both healthful behaviors and the prevalence of illness.37 For example, in one California study, 8 percent of all Asian women were found to be current smokers, including 6 percent of Chinese women and nearly 11 percent of Filipino women.260 Even though Asian women smoke less than their female counterparts of other races, Asian men of some subgroups (for example, Cambodians and Vietnamese) have high smoking prevalences, exposing the females in their homes to noxious levels of second-hand smoke.261 A survey of Asians in Pennsylvania and New Jersey found that 38 percent of those surveyed had been exposed to second-hand smoke in their homes during the last week, including 30 percent of Chinese, 42 percent of Korean, 44 percent of Cambodian, and 45 percent of Vietnamese respondents.262

The risk of hypertension also varies by subpopulation. In the 2001 California Health Interview Survey, 18 percent of all Asians reported having ever been diagnosed with hypertension. Hypertension was more of a problem for Japanese (28 percent) than for Filipinos (22 percent), Koreans (18 percent), Vietnamese (17 percent), Chinese (16 percent), or South Asians (11 percent). In the same survey, 22 percent of all Californians reported having ever been diagnosed with hypertension.263 Other conditions, such as tuberculosis, are more common among Asian populations than among other racial/ethnic groups. The prevalence of tuberculosis among Asian Americans, the highest among all groups, was nearly 21 times that for white non-Hispanic Americans in 2004. This higher prevalence is due primarily to the facts that a larger percentage of Asian Americans than other racial/ethnic groups is foreign-born and that foreign-born Americans have much higher tuberculosis rates than nativeborn Americans-nearly 9 times as much.264,265

The lack of knowledge of risk factors or preventive behaviors for various diseases also is a problem for Asian Americans. One study of Vietnamese women in San Francisco revealed that although 96 percent of the women had heard of cancer, they did not know risk factors, common symptoms, or signs of breast or cervical cancer.266 In another survey of Vietnamese women in San Francisco, 73 percent of women reported that they had never heard of a Pap test, 49 percent had never heard of a clinical breast exam, and 32 percent had never heard of a mammogram. The lack of knowledge about cancer risk factors can result in the failure to conduct breast self-examinations or to get screening such as mammography or Pap smears to foster early detection of breast or cervical cancer.266

[Cancer Screening]

The failure of Asian women to get regular screenings relates not only to a lack of knowledge of risk factors but also to knowledge and beliefs about cancer. A study conducted in Philadelphia found that 71 percent of Cambodian American and Vietnamese American women did not know what cancer is.267 One survey of Vietnamese women in Seattle found that nearly two-fifths (39 percent) did not believe that cervical cancer is curable, even if detected early.268 More than one-third (35 percent) believed illness was “a matter of karma or fate.” Cervical cancer, which is associated with infection by the human papillomavirus (HPV), disproportionately affects certain Asian women. Fewer than one-fourth (23 percent) thought Vietnamese women were more likely to get cervical cancer than white women, although Vietnamese women have one of the highest incidences of invasive cervical cancer of racial/ethnic subgroups in the United States (43 per 100,000).268,269 The incidence of invasive cervical cancer among Korean American women exceeds 15 per 100,000.270 Cervical cancer is the most frequently occurring type of cancer among Laotian women in California, and it is the second most common cancer among Cambodian women in California.267

Despite these high incidence rates, Asian women often do not avail themselves of screening with a Pap smear, which can detect cervical cancer at an early treatable stage. In a survey of Vietnamese women in Seattle, only 62 percent believed that regular Pap smear tests could reduce the risk of cervical cancer, and only 61 percent believed cervical cancer was curable if caught early.268 Combined with concerns about modesty, as well as concerns about pain and discomfort associated with this test, this lack of confidence in the importance of cervical cancer screening no doubt contributes to low testing rates. Only 62 percent of the women in the survey reported having had a Pap test in the past two years. Married Vietnamese women are much more likely than single, divorced, or widowed women to have had recent Pap smears. This may be related to the existing stigma in the Vietnamese culture against unmarried women who are sexually active.268 Fewer Cambodian American women in Seattle-less than half (47 percent)-reported recently receiving a Pap test.267

Women belonging to other Asian subgroups and living in California report comparable Pap testing rates. Although 78 percent of Filipino American women reported receiving a Pap test in the preceding two years, smaller proportions of Chinese American (56 percent) and Korean women (65 percent) reported having had the procedure.271

Hmong women also have high cervical cancer incidence rates and, once diagnosed, are less likely to accept standard Western medical treatment for cervical cancer. For example, the rate among Hmong women in California during the period 1996-2000 was 33.7 per 100,000, a decrease from their rate of 50.5 per 100,000 during the period 1992-1995. However, the rate of 33.7 per 100,000 was still more than three times the rate among all Asian/Pacific Islander women and more than four times the rate among white non-Hispanic women during that time period. Most striking, though, was the difference in rates of first course treatment for cervical cancer. Whereas fewer than 6 percent of all Asian/Pacific Islander women and fewer than 5 percent of white non-Hispanic women declined first course treatment, 51 percent of Hmong women declined treatment. This difference is attributed to lower literacy and education rates, less access to health care, more linguistic and cultural isolation, and differences in beliefs surrounding treatments-namely, a greater focus among the Hmong on traditional healing rituals than on Western medicine.272

The reluctance of Cambodian and other Southeast Asian women to access health screening such as the Pap smear often relates to the traumas that resulted in their resettlement in the United States. Although experiences such as torture, starvation, rape, forced labor, and witnessing murder are shared by many refugees who have come to the United States, among recent waves of immigrants, Cambodians are thought to be the most traumatized by the turmoil in their homeland during the Khmer Rouge regime. “Ghosts of things over and done with” often assume a “seething presence” (of a lost child, a lost village, or a war remembered in detail) that presents itself and must be addressed during a clinical exam.273 Ironically, in the case of Pap testing, the technology (applied via the use of a speculum) that is intended to relieve suffering instead very often invokes it.274 Thus, the disparity in rates of cervical cancer between Cambodian (and other Southeast Asian) women and white non-Hispanic women is not only about the prevalence of a preventable disease within this population of women but also about colonial history, education, communist ideology, U.S. retaliation, and then relocation to the United States.

Mammography, another form of screening for early disease detection, is underused by Asian women. As with the Pap smear and cervical cancer, the failure to get mammograms is of particular concern because of the increase in breast cancer rates among Asian women (especially Chinese, Japanese, and Filipino) over time after their migration to the United States. Breast cancer rates among Asian women in their native countries are only 25 to 50 percent as high as those among Asian women in the United States. Within 10 years of immigration, however, breast cancer rates among Asian women increase to mirror the higher overall rates in the United States.275 Breast cancer is the most common cancer among Chinese, Filipino, Japanese, and Korean women, and the second most common cancer for Vietnamese women.276

[Prenatal Care]

Prenatal care is yet another form of preventive care that many Asian American women do not receive. This is due to a variety of cultural and socioeconomic factors, including lack of knowledge about its importance. Hmong women, for example, may not seek prenatal care because they do not consider pregnancy an illness that necessitates the use of Western medicine and care. However, studies suggest that when they are educated about prenatal care, Hmong women are likely to comply and seek out the recommended care. Even among Southeast Asian women who seek out care, further barriers arise. As suggested by their reluctance to get a Pap smear, the pelvic exam is often one such barrier. For some Hmong women, in particular, the pelvic exam may cause flashbacks to sexual assault and rapes they experienced in Laos or Thailand before immigrating to the United States. Traditional Hmong beliefs also hold that pelvic exams can expose infants to cold wind, which can then cause miscarriage or illness to the baby. Thus, education and cultural awareness are necessary to encourage Hmong women, and many other Asian American women, to receive prenatal care.277

[Mental Illness]

Fear of difficulties in communicating-compounded by shame, guilt, anger, depression, and other responses to certain stigmatized conditions such as mental illnesses and substance abuse-often deter Asian Americans from seeking care promptly.233 For example, many Chinese Americans will seek treatment for the physical symptoms resulting from depression or other mental health disorders but will not directly attribute those symptoms to their mental health origins, a phenomenon known as somatization. However, if properly prompted or asked directly, they will also report psychological factors and symptoms. This pattern of reporting symptoms could be due to a lack of awareness of mental disorders and of the possibility that symptoms have psychological rather than physical origins, or to a belief that health care providers are more interested in physical symptoms.278 Some Cambodians perceive mental health problems as the result of evil spirits that must be warded off. Because of their religiosity, Korean Americans are likely to confuse hallucinations with spiritual voices and not seek care. They also are likely to self-medicate for conditions that may not respond to medication. Japanese Americans, however, are most concerned about who knows that they are in treatment and have canceled appointments for fear of running into someone who knows them when leaving a mental health care facility.279

The traumas due to war, leaving one's homeland, and resettling in another land often result in unique medical conditions, such as the psychosomatic or non-organic blindness reported among Cambodian women 40 years of age and older.273 Cambodians have the highest levels of psychological stress of all Southeast Asian groups.280 Depression and posttraumatic stress disorder are widely prevalent among Cambodians and other Southeast Asians, even after years of living in the United States.233,281 Some immigrants, such as the Hmong, have been found to be particularly susceptible to developing substance abuse problems in the wake of their resettlement. Some use alcohol to alleviate insomnia, pain, and emotional stress. Opium use to cure physiological and psychological problems also has been reported. The use of alcohol and opium among the Hmong to cure medical problems may stem from their distrust of Western medicine. However, it also may be a result of cultural factors; it is apparently common for some Southeast Asian populations to attempt to cure medical problems through drug and alcohol use.280 Although most of the Hmong treated for substance abuse are male, these problems of Hmong males affect the households in which the men live with their wives and other family members.

To compound their stresses and trauma, some poor Southeast Asian immigrants resettle in violent, inner-city environments in the United States.246 A study of Cambodian refugees who resettled in California found that, post-migration, 34 percent had seen a dead body in their neighborhood, 28 percent had been robbed, 17 percent had been seriously threatened with a weapon, and 14 percent had experienced a serious accident in which someone was hurt or died.282 Although psychological problems are often found among such resettled immigrants, depression is also found among Korean Americans, most of whom are recent immigrants but who migrated to the United States without war-related trauma. Depression, in fact, is more common among Korean Americans than it is among either Chinese, Japanese, or Filipino Americans. Paradoxically, depression levels among Korean Americans decrease among those with higher levels of acculturation (measured by language use) but also increase among those whose greater assimilation into U.S. culture has resulted in some loss of a connection with traditional Korean culture and identity.283

[Language Barriers]

Even if Asian American patients seek care, language barriers (lack of English proficiency and a shortage of health care providers who possess the necessary cultural and language skills) limit nearly half of the Asian/Pacific Islander population's ability to access the mental health care system.233 Although Asian American patients prefer trained interpreters, sometimes patients' children or grandchildren are used to translate at medical appointments due to a lack of trained interpreters. However, family members may not be familiar enough with medical terminology to adequately translate, or may be reluctant to fully translate out of embarrassment or discomfort. This can compromise the quality of the patient's care.284

In addition, not all English medical/health terminology can be readily translated into the various Southeast Asian languages, nor can many Southeast Asian expressions describing physical and mental conditions be directly translated for U.S. health care providers. For example, there are no words in the Khmer language for medical terms such as “Pap testing,” a fact that creates a barrier to increasing cervical cancer screening rates among Cambodian women.285 Not only do many Hmong (especially those born in Laos) have no knowledge of the human body organs or how they work, but most English medical and anatomical terms also have no equivalents in the Hmong language. Translators may need to use several sentences to translate a term that would require one word in English. In addition, Hmong from Laos are not familiar with chronic illnesses that can be “controlled but not cured.” In Laos, “you got sick and you either got better or you died.” Thus, it is difficult for many Hmong to understand diagnoses and treatments.286 Vietnamese women, due to cultural norms and modesty, generally do not distinguish between anatomical parts when discussing their genital area. Whereas “Americans distinguish every part,” Vietnamese “talk generally about the bottom area of a woman,” often referring to the cervix and uterus interchangeably. This can create difficulties for patientphysician communication, especially for a physician who is unaware of such cultural norms.287

[Cultural Barriers]

Differences in cultural patterns, even among highly acculturated Asian Americans, suggest different interpretations of etiology, personal control, and responsibility with respect to health. For example, many Chinese follow the Confucian principle of behavior that discourages individuals from sharing upsetting information with other people. Thus, Chinese Americans may delay sharing health concerns with family or friends for fear of causing pain or discomfort. Likewise, they may be reluctant to consult physicians about health problems, believing that the problem is a personal issue best kept to themselves or among close family members.288 Japanese Americans, on the other hand, see health as a matter of will, with a strong emphasis on the mind-body connection. They are likely to believe that thinking about getting sick can make one sick. Filipino Americans, however, are more likely to emphasize the relationship between body and soul for health maintenance and illness prevention. For them, health is a moral statement about the correct fulfillment of social (particularly kin) obligations.234

If Asian Americans get to health care providers and if translators are available, communication still is not guaranteed, and appropriate care still may not be received.289 For example, differences between the medical systems in the United States and China constitute a further deterrent to Chinese Americans born in China but in need of health care in the United States. In China, physicians generally prescribe and dispense medication, charging only a nominal fee for their services; the major cost for the visit is the medications.290 Because the idea of a visit to a medical professional for a checkup without getting prescriptions for medications does not live up to the expectations of many Chinese Americans, they are reluctant to make visits for routine or preventive care.290

Some Korean Americans (especially the elderly), many of whom have extreme difficulty with English, report using the traditional Korean medicine hanbang, and other over-the-counter Korean home remedies rather than going to physicians in the United States. They avoid going to physicians because of communication and cultural difficulties. However, Korean Americans are more likely to use traditional medicine as a supplement to Western medicine than traditional medicine alone.291

Other cultural characteristics that influence the health of Asian Americans are collectivism, familism, respect for authority, and a desire to preserve harmony within groups. Asian cultures-like Hispanic cultures- often emphasize family decisionmaking. All family members are typically involved in learning all the details of a patient's condition, and decisions regarding care are made (often by the eldest son in the family) with the good of the overall group in mind.292 In Korea, doctors are given absolute authority regarding treatment and Koreans generally trust doctors to make treatment choices. Thus, Koreans in the United States are often uncertain when faced with the practice of informed consent (which is required before surgical procedures in the United States) and must adjust to the idea of having the ultimate choice in the course of medical treatment they undergo.293

[Drug and Substance Abuse]

Although little research has been done on either alcohol or substance abuse among Asian American women, available research suggests that Asians use and abuse alcohol and other substances less frequently than members of other racial/ethnic groups.294 This has been attributed, in part, to the fact that Asians (especially Chinese, Japanese, and Koreans) are sensitive to ethanol, and drinking alcohol can result in facial flushing, or “flushing syndrome.” Although this sensitivity to alcohol is rare among whites, 40 to 50 percent of Japanese possess it.294 Low drinking rates among all Asian American groups seem to be due to high percentages of abstainers.37

One study of Asian populations found that Japanese Americans were the most likely to report having consumed any alcohol in the past year (38 percent), followed by Filipinos (32 percent), Koreans (29 percent), Chinese Americans (20 percent), and Vietnamese Americans (18 percent).294 High rates of alcohol consumption also have been noted among persons with one Asian and one Caucasian parent. The rate of substance use among Chinese and Vietnamese American adolescents of mixed heritage (primarily mixed with whites) has been found to be up to four times that of unmixed-heritage adolescents from those same groups.294 Alcohol use among Asian Americans tends to increase with acculturation, although other factors, such as socioeconomic status and religious affiliation, also play a large role in determining alcohol use.295

Although risk factors for and patterns of substance use and abuse have been identified among selected Asian youth populations, prevalence is generally lower than among youth of other racial/ethnic groups.296 The vast differences between Asian societies and the United States mean that the most basic economic and socioemotional needs of new immigrants may not be met by existing institutions. False expectations about the “Gold Mountain” to be found in the United States may exacerbate adaptational stress in the years following migration and may produce a high prevalence of mental illness among Asian Americans.246

[Social Condition Factors]

Some of this mental illness results from prolonged and intense stress encountered in social situations and the occupational environment, especially among those of higher socioeconomic status.297 In addition, when Southeast Asian women, in particular, achieve greater upward mobility (relative to Southeast Asian men) as a result of paid employment in the United States, marital tensions sometimes result that may lead to marital conflict or spousal abuse.298

Among the major mental health problems for Asian Americans, though, are racism and racial discrimination-which adversely affect their psychoeconomic status, as they do for other people of color. From Japanese Americans who lived on the West Coast and were interned during World War II to contemporary Chinese Americans living in Los Angeles, racism both blatant and subdued has been and continues to be part of the life of Asian Americans.246 One recent study of both individual (self perceived) and institutional (segregation and redlining, for example) racial discrimination found that both were associated with poor health among Chinese Americans living in Los Angeles.299 This study found that both individual and institutional measures of discrimination were associated with health status, after controlling for acculturation, sex, age, social support, income, health insurance, employment status, education, neighborhood poverty, and housing value.

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