CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 15 • Number 3 • Fall 2002

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Diversity in Asian American and Pacific Islander Communities Poses Challenge for Health Care Providers

Overcoming health disparities in Asian American and Pacific Islander communities often means delivering information and services in innovative ways—using non-English languages, for example—and recognizing the integral role that culture and tradition play in daily life. But how do you achieve these goals when the populations that you are trying to reach boast nearly 50 national or ethnic origins, more than 100 languages and dialects, and people of vastly different backgrounds?

The need to serve these communities in culturally sensitive and linguistically appropriate ways will only increase in the future. Although Asian Americans and Pacific Islanders make up only 4% of the U.S. population (10.9 million people), they are the fastest growing ethnic group in the United States— increasing 95% in the 1980s and another 43% in the 1990s. By 2050, these groups are expected to make up 9% of the U.S. population (37.6 million people).

Asian Americans are often stereotyped as a “model minority” of overachievers with few problems or needs, but Asian American and Pacific Islander families are about twice as likely as whites to live in poverty. Some subgroups speak little or no English, which restricts their ability to access many services, including health care. 

High rates of cancer, diabetes, and heart disease have been reported in both populations, as well as high rates of infectious diseases like tuberculosis and hepatitis among many new immigrants, particularly refugees from Southeast Asia. Health care professionals who serve these populations say the key to reducing disease rates is to clearly define target communities and their needs. 

“I think it’s important always to look at the data available and target those populations that are most at risk and try to design programs that are going to be most effective with them,” said Ignatius Bau, JD, of the Asian and Pacific Islander American Health Forum (APIAHF). “That’s not anything new, but I think we often try to either generalize or find a one-size-fits-all solution for this very, very diverse population.” 

The Kalihi-Palama Health Center in Honolulu, Hawai’i, is one of six community health centers partnered with the Association of Asian Pacific Community Health Organizations (AAPCHO) to help reduce breast and cervical cancer mortality rates among Asian American and Pacific Islander women. This center currently focuses on outreach to Filipino women.
Photo courtesy of AAPCHO

APIAHF is a national advocacy organization dedicated to promoting policy, program, and research efforts to improve the health and well-being of Asian Americans and Pacific Islanders. Researchers and health department officials frequently contact APIAHF and expect quick, easy advice on how to serve these communities, such as which language to use for their materials. 

“People are often frustrated with our answers of ‘it depends’ and ‘you need to do more homework,’ ” Mr. Bau explained. “The language needs of a particular community may not be obvious. If the population is predominantly Filipino or Asian Indian, many of them speak English because it is common in their home country. So you have to dig a little deeper. Just because the dominant population in your area is Asian Indian, you wouldn’t automatically translate something into Hindi. Maybe there is a smaller Vietnamese population that doesn’t speak English as well as the Asian Indians do, so the language barriers are greater for them.” 

 
New OMB Category to Help Define Populations 
Understanding the characteristics of minority populations depends on having firm data, but data are not always available for Asian Americans and Pacific Islanders. Because 80% of people in these groups live in 10 states (California, Florida, Hawai’i, Illinois, Massachusetts, New Jersey, New York, Texas, Virginia, and Washington), most states don’t collect or report separate data. Instead, states lump these populations under “other.” Thus, the true picture of these groups and their needs is largely invisible, particularly at the national level. To solve this problem, data need to be disaggregated, or broken down into more detail.

In 1977, the U.S. Office of Management and Budget (OMB) sought to improve the collection and comparability of federal data by establishing five minimum categories for reporting race and ethnicity. Prompted by criticism that the categories did not reflect the country’s increasing diversity, OMB reviewed the standards and in 1997 issued new ones, which all federal agencies must begin using in 2003. 

One of the biggest changes is separating Asians and Pacific Islanders into their own categories and recognizing Native Hawaiians as a distinct group. How the changes will affect these communities will depend on how organizations use and interpret the data, according to Jeffrey B. Caballero, MPH, executive director of the Association of Asian Pacific Community Health Organizations (AAPCHO). 

“When you create smaller subgroups, in some ways, it diffuses the numbers in the community,” Mr. Caballero said. 

AAPCHO represents 14 community health centers dedicated to serving Asian Americans or Pacific Islanders. These centers are part of a network of 700 community health centers that provide primary and preventive health care services in medically underserved areas throughout the United States and its territories. The centers are funded by the Public Health Service Act and administered by the Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health and Human Services (HHS).

	The Family Health Center in Worcester, Massachusetts, works with Cambodian women to reduce their risk of dying from breast and cervical cancer. The center is part of the Association of Asian Pacific Community Health Organization (AAPCHO). Photo courtesy of AAPCHO

Now that the 2000 U.S. census and Healthy People 2010 have used the new racial and ethnic categories, Mr. Bau hopes more researchers will follow suit. However, these changes will not necessarily solve an ongoing conflict between state and federal program needs. Although more detailed or disaggregated data are needed for state and local planning, federal agencies like CDC typically use aggregated data to make national policy and program decisions. So if data on small subpopulations are always being collapsed into broader categories at the national level—or not analyzed at all—the new categories will not improve identification of health disparities among these populations. 

“We’re very happy that Healthy People 2010 is using the OMB categories,” Mr. Bau said. “This is the first time that we’ve gotten a detailed level of knowledge about data gaps. And there’s a long way to go to try to fill those gaps. But if the only place the data are collected are in national surveys, we’re never going to get the information we need because the sample sizes at the national level simply aren’t large enough.” 

Although Asians and Pacific Islanders will now be in different categories, groups like AAPCHO and APIAHF plan to continue serving both populations. One reason is that Native Hawaiians and other Pacific Islanders often can’t afford to travel to the continental United States to advocate for national policies and funding for their communities. 

Health Disparities Must Be Addressed 
Predictably, when people do not have adequate access to primary or preventive care services, their health suffers. Since 1980, cancer has been the leading cause of death for Asian Americans. Liver cancer rates are 12 times higher among Vietnamese men than among white men, and cervical cancer rates are five times higher among Vietnamese women than among white women. Breast and cervical cancer screening rates for Asian American and Pacific Islander women are the lowest in the country, and Cambodian, Laotian, and Samoan American women have low rates of early prenatal care. 

Smoking rates are particularly high among Southeast Asian men—for example, 70% of Laotian and Cambodian American men smoke. Rates of heart disease, obesity, and diabetes are high among many Asian American and Pacific Islander groups, and mental health problems are common among Southeast Asian refugees who came to the United States after the Vietnam War. 

These disparities can be linked to many factors, including low socioeconomic status, language barriers, lack of access to care, and racism. In some communities, a large proportion of immigrants—sometimes as high as 40%—have little economic or political power. Although Asian Americans have the highest median household income of all racial/ethnic groups, they also have the highest number of wage earners per household. Nearly 70% of Laotian Americans live below the poverty level, and most Korean and Vietnamese Americans are self-employed (earning an average of $14,000 a year) or work for small businesses that do not provide health insurance. 

Approximately 70%–80% of the people who visit AAPCHO facilities are uninsured or underinsured, and nearly 90% are not proficient in English. Such barriers can create a complex and confusing environment for new immigrants and prevent them from seeking health care at all.

Discrimination also creates barriers to care. A. Sam Gerber, MS, RD, a public health analyst in CDC’s Office of the Associate Director of Minority Health, said she has experienced racism when seeking health care for herself and when working as an advocate for other immigrants. 

“I took a Buddhist monk for help in getting medication because he had no income or insurance,” said Ms. Gerber, a U.S. citizen who emigrated from Thailand more than 30 years ago. “The person who was interviewing us said, ‘What right do you have to come to my country and try to siphon off of us?’ So I told him that his ancestors once came from another country and faced the same issues.” 

Even when people are not directly discriminated against, they may fear rejection or reprisal through immigration laws or because of past events like the internment of thousands of people of Japanese ancestry during World War II. Many people still view Asian Americans and Pacific Islanders as perpetual foreigners who are not “real” Americans. 

Culture Is a Two-Way Street 
Even when health care planners recognize the need to address language barriers in Asian American and Pacific Islander communities, they often neglect to ensure that their programs are culturally appropriate. Successful programs value the cultural diversity of the populations they serve and understand that cultural differences can affect health and the effectiveness of health care delivery. 

For example, some Cambodians believe that if you do not talk about a disease, you will not get it. The Hmong, a tribal group from Laos, use a term for epilepsy that translates literally as “the spirit catches you and you fall down” because they believe epilepsy occurs when an evil spirit steals your soul from your body. Many Asian Americans and Pacific Islanders, particularly women, will not talk openly about personal subjects with people outside their communities. In addition, some immigrants are accustomed to taking directions only from community or tribal leaders. 

Another difference between many Asian American and Pacific Islander cultures and Western culture is the use of alternative medical practices such as herbal remedies and acupuncture. 

“Culture is a two-way street,” Mr. Bau said. “Western medicine itself is a culture. Western medical providers should understand that many people will turn to traditional remedies first rather than thinking of making an appointment with the doctor. And instead of trying to force a change in that, providers should integrate other healing practices into the system of care.” 

The U.S. approach to prevention, which emphasizes disease screening and national health recommendations, is uncommon in Asian and Pacific Islander cultures. That’s why education programs that target these groups must be culturally and linguistically appropriate. 

“Some cultures believe immunization is bad for your immune system,” said Ms. Gerber. “How do we get the message across that they need immunization to protect them from harmful diseases?” 

Although cultural and language barriers can make eliminating health disparities in minority populations a challenge, Mr. Bau believes these factors often just add to the existing barriers created by the complexity of the U.S. health care system. 

Building trust in target communities is critical. A good example of this is AAPCHO’s Community Approach to Responding Early (CARE) program, a CDC-funded program that seeks to lower breast and cervical cancer rates among Asian American and Pacific Islander women. To account for the diversity of these populations, AAPCHO partnered with six project sites to implement culturally tailored strategies to encourage women to get screened for breast and cervical cancer. Community health center workers at these sites worked with community volunteers and translators, made multiple home visits, offered help with transportation, and used visual aids for women who did not speak English.

Barriers Are Not Insurmountable 
To eliminate health disparities in any population, health officials have learned that affected communities must be included when interventions are planned and implemented. One way to involve communities is to form partnerships among community leaders and organizations, businesses, and government agencies. Together, these partners can build new infrastructures or draw on existing ones. 

“If people are struggling, for example, with how to overcome language barriers, we often suggest using community-based organizations that have that language capacity,” Mr. Bau said. “Use ethnic media that are obviously printing and broadcasting in those languages. You don’t have to reinvent the wheel.”

AAPCHO’s community health centers are governed and operated by members of the communities they serve. At the national level, AAPCHO advocates for policies and services that are community-driven, financially affordable, linguistically accessible, and culturally appropriate. These goals are achieved through national and regional projects that build community resources and infrastructures; provide technical assistance and training; and conduct media campaigns, research projects, and community and provider education programs. 

For example, the CDC-funded BALANCE (Building Awareness Locally and Nationally through Community Empowerment) Program for Diabetes works collaboratively with CDC and the National Institutes of Health’s National Diabetes Education Program (NDEP) to increase awareness about diabetes among Asian Americans and Pacific Islanders. AAPCHO assessed the health care needs of Asian Americans and Pacific Islanders with diabetes in California, Hawai’i, Massachusetts, New York, and Washington. The results were used to develop strategies for disseminating culturally and linguistically appropriate diabetes information to these populations. 

AAPCHO partnered with the NDEP to (1) develop and implement a national media campaign targeting Asian Americans and Pacific Islanders, (2) review and develop diabetes educational materials published in Asian and Pacific Islander languages, and (3) recruit multiple partners for community activities and projects. In addition, the organization established a recommended list of materials that are culturally and linguistically appropriate and scientifically current (available at http://www.aapcho.org/*). 

“Culturally and linguistically appropriate strategies are extremely important when serving Asian American and Pacific Islander communities,” said Nina L. Agbayani, RN, AAPCHO’s Director of Programs. “Because we’re trying to reach numerous ethnic communities, one universal model of health education and prevention simply won’t work.” 

BALANCE is a good model for other projects because it is well coordinated at the national level, said Mr. Caballero. When several federal agencies get involved in one community, efforts can be duplicated and resources wasted. 

Looking to the Future 
Providing necessary health care services to Asian Americans and Pacific Islanders is not always easy. Many communities lack the basic resources and infrastructure to share information and improve access to services, so even when groups like AAPCHO develop effective interventions, they do not always reach the intended audiences. 

“Some people say there are more American Samoans in California than there are in Samoa, but the current community infrastructure is inadequate to effectively serve this community,” Mr. Caballero explained. “More effort needs to be made to provide technical assistance and capacity-building opportunities in some of these communities because their numbers are growing very rapidly.” 

The challenges will be particularly acute in states where Asian and Pacific Islander populations have been small in the past but are now growing rapidly. In Georgia and North Carolina, for example, several counties reported 200% increases in their Asian populations during the 1990s. Although existing community health centers are a valuable resource for underserved populations, many have limited expertise in serving Asian Americans and Pacific Islanders. Fortunately, the federal government supports doubling the number of community health centers in the near future, and AAPCHO intends to take full advantage of this political climate to increase access to services for their populations. 

In addition, HHS is spearheading other national efforts to improve the quality of life for these populations, including support of the White House Initiative on Asian Americans and Pacific Islanders (WHIAAPI). This initiative aims to improve research and data collection, promote greater access to government services (including language programs), and increase outreach and partnerships with community groups. 

In May 2002, the WHIAAPI President’s Advisory Commission conducted a public meeting to hear testimony from community organizations, individuals, and federal agencies. The commission also updated its 2001 Interim Report (available at www.aapi.gov). 

Again and again, the same key point emerges: improved data collection is critical to eliminating health disparities among Asian Americans and Pacific Islanders. As the President’s Advisory Commission Interim Report notes, the lack of specific and timely data make it difficult to identify problems, track trends, pinpoint solutions, or enforce civil rights laws. 

“The first step is to disaggregate the data to show the needs of the Asian American community and the Native Hawaiian and other Pacific Islander communities,” Ms. Gerber said. “Until we can do that, we won’t have adequate programs or dollars going to the people who need them.

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This page last reviewed August 10, 2004

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