› Ask Asian immigrants open-ended questions and encourage them to share their use of alternative remedies. C
› Consider providing an interpretation service for patients not proficient in English, as opposed to asking family members to help. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Though often considered a “model minority,” Asian immigrants pose significant challenges for Western health care providers, including radically different ideas of disease causation, differing communication styles, and somatic presentations of mental illness. Asian diversity is tremendous, but several cultural trends are held in common: strong family structures, respect, adaptability, and, for first generation immigrants, widespread use of traditional therapies.1
While Asians and Pacific Islanders (APIs) represent only 5.6% of the US population, or 17.3 million people, that figure represents a 46% increase between 2000 and 2010, the most rapid for any ethnic group.2 A 79% increase is anticipated by 2050, bringing Asians to 9.3% of the US population. In order of population, API subpopulations include Chinese, Filipinos, Asian Indians, Vietnamese, Koreans, and Japanese.2 More than half of Asian Americans reside in the states of California, New York, and Hawaii, although enclaves exist in most major cities.3
Addressing the health needs of Asian immigrants in an increasingly diverse society mandates that US physicians develop the necessary skills to communicate, even when expectations for care may be very different. Fortunately, excellent resources are available (TABLE 1).
Barriers to good healthcare
The most formidable obstacle is limited English proficiency of patients, making them significantly less likely to seek care.4 They often struggle to arrange an appointment, although they arrive on time.5
Inadequate interpretation services. Frequently family members must interpret for patients, despite a federal mandate (Title VI of the 1964 Civil Rights Act) requiring professional services be provided at no charge if there is a federal payer (Medicare or Medicaid) involved.6 Unfortunately, these services are not currently reimbursable. Use of family or friends as interpreters, while convenient, results in far less accurate interpretation, frequent embarrassment, and loss of patient confidentiality. Trained medical interpreters or even telephone services are preferable, as they are much more accurate. Interviews involve a triad comprised of provider, patient, and interpreter, with the provider speaking directly to the patient using first-person address at all times. The interpreter should sit to the side or slightly behind the patient. All communication should be interpreted sentence by sentence so everyone is able to understand the entire conversation. It is well documented that proper interpretive services vastly improve the quality of care.7
Patient illiteracy. Health care illiteracy leads to medication errors due to the inability to understand instructions.8 Some immigrants have the added disadvantage of being illiterate both in English and in their native tongue.4 If not remedied, these situations easily lead to drug overdoses or missed allergies.9 Older immigrants neither understand the intricacies of the US health care system nor possess the language skills to master it.4
Stereotyping by caregivers must be surmounted if patients are to receive quality care. Many Asian patients report that physicians fail to understand them as unique individuals apart from their ethnic identity. Others feel excluded from the decision-making process or find culturally sensitive treatment options lacking.10
Subtleties of relational interaction. Asian culture has been defined as possessing a high Power Distance Index (PDI).11 The PDI refers to the distance or level of respect which an individual must afford to a superior, and this ideal is reflected in Asian conformance to a strict social hierarchy. Thus, physicians are viewed as authority figures and it is proper to nod or smile to indicate polite deference.12 However, showing respect and “buying in” to treatment recommendations are entirely different matters. Cultural factors make it difficult for patients to openly disagree with physician recommendations without feeling as though they have been disrespectful.12 Asian cultures are also “high context” cultures, having far more unwritten rules for conduct and communication that often prove baffling to westerners from “lower context” cultures.
Financial limitations. Socioeconomic influences also play a role. Although Asians have a higher income than other minority groups, 12.5% of Asians still live in poverty and 17.2% lack health insurance.2 Lack of coverage makes many Asians reluctant to seek regular medical care.13
Special medical concerns
Asian-Americans face a variety of challenging medical issues, including disproportionately high rates of tuberculosis (TB) and hepatitis B.
TB. Although rates of TB infection in the United States are low, rates in Asian immigrants are up to 100 times greater than that of the general population, more than any other immigrant group.14 Screening with interferon gamma release assays (IGRAs), such as T-SPOT TB, should be routine for Asian immigrants, since IGRAs do not cross-react with the bacillus Calmette-Guérin (BCG) vaccine. The Centers for Disease Control and Prevention now recommends IGRA blood testing in lieu of tuberculin skin testing (TST) for immigrants who received BCG in infancy, with the exception of children <5 years, for whom the TST is still preferable.15 Patients with positive IGRA tests are also more likely to be amenable to treatment.