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Download PDF Version SILENT TRAUMA:Diabetes, Health Status, and the Refugee
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The United States Citizenship and Immigration Service (USCIS) screening of new immigrants to the United States addresses existence of infectious disease, but not chronic diseases such as diabetes and cardiovascular disease. Data on chronic disease prevalence, complications, and the effectiveness of health care delivery approaches would help with community preparedness for meeting the healthcare needs of newly-arriving refugees. 
If you are Asian American: |
If you are not Asian American: |
||
|---|---|---|---|
Height |
Weight |
Height |
Weight |
5’6” |
142 |
5’6” |
155 |
5’7” |
146 |
5’7” |
159 |
5’8” |
151 |
5’8” |
164 |
Source: U.S. Department of Health and Human Services. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report.53
Table 4: Co-morbidities risk associated with different levels of BMI and suggested waist circumference in adult Asians
Classification |
BMI (kg/m2) |
Risk of Co-morbidities |
|
|---|---|---|---|
Waist Circumference |
|||
< 90 cm (men) ≥ 90 cm (men) |
< 80 cm (women) ≥ 80 cm (women) |
||
Underweight |
< 18.5 |
Low, but increased risk of other clinical problems |
Average |
Normal Range |
18.5-22.9 |
Average |
Increased |
Overweight At Risk Obese I Obese II |
≥23 23-24.9 25-29.9 ≥ 30 |
Increased Moderate Severe |
Moderate Severe Very Severe |
Source: The Asia -Pacific Perspective—Redefining Obesity Report, February 2000
Spotlight on the Clinic:
Cultural Differences in Perception of Mental Health
and Implications for Diabetes Care
Mental illness can negatively influence physical health. In addition, cross-cultural communication issues further complicate timely diagnosis and subsequent care. Because SEAs have a different model by which they conceive of physical and mental health,
misdiagnosis and inadequate treatment can occur easily if a patient’s somatic expression of mental illness is misinterpreted through Western medical models.
Depression is more common in people with diabetes,107 and in SEAs,14, 37 and presents with myriad signs and symptoms, often expressed in unique cultural constructs. As physician Arthur Kleinman writes in the New England Journal of Medicine, “Culture confounds diagnosis and management by influencing not only the experience of depression, but also the seeking of help, patient-practitioner communication, and professional practice.”108 He later illustrates his point by discussing the perspective of Chinese immigrants, many of whom find the diagnosis of depression “morally unacceptable and experientially meaningless.” Like SEA immigrants, their beliefs are vastly different from those of U.S. clinicians, who consider depression a significant mental disorder.
The difficulty of dealing with multicultural conceptions of mental health in the clinic was affirmed by another study in the New England Journal of Medicine. Using data from 14 countries, the study examined the relationship between somatic (physical) symptoms and depression, concluding that, “Somatic symptoms of depression are common in many countries, but their frequency varies, depending on how somatization is defined.”109 The complexity of their findings was amplified by the observation that patients often waited for the appearance of physical complaints before seeking medical help from their health care providers. Physical expressions of depression can be mistaken for vascular disease or gastroparesis, for example, leading to a medical “workup” without a culturally appropriate mental health intervention. Conversely, symptoms of neuropathy might be attributed to mental health disorders without appropriate evaluation and treatment.
Dealing with the multifaceted issues surrounding mental health is a key factor in reducing the impact of diabetes and other chronic diseases on SEAs. Since depression, anxiety, and other mental conditions have such a great impact on diabetes self-care,1,42 clinicians need to be aware of the fact that such conditions manifest different reported symptoms depending on the cultural beliefs of their patients. Given the traumatic history of many SEA refugees, the importance of addressing these mental health symptoms cannot be underestimated as a way to build trust and to improve compliance with diabetes treatment regimens.
Health Care Provider Counseling on Risk
Asian Americans, in general, are less likely to receive physician counseling about smoking cessation, healthy diet, weight control, exercise, and mental health than the U.S. general population.54 There is additional evidence that SEAs are even less likely than Asian Americans in general to practice healthy behaviors and receive preventive care counseling.
- A 2001 study of 669 Asian Americans in the United States found that Vietnamese Americans are less likely than other Asian Americans to report receiving preventive care services and counseling.54
- A 2001 survey of 1,026 Cambodians living in Lowell, Massachusetts and 2,658 Vietnamese living in California found that SEAs in the United States self-report less fruit and vegetable consumption than those who live in their native countries.7 Only 16% of Cambodians and 11% of Vietnamese in the United States reported eating at least five servings of fruits and vegetables a day.7
- In 2001, Vietnamese were less likely to meet physical activity recommendations than other Asians or the general U.S. population (14%, 28%, and 33%, respectively).7 Counseling by health care providers and dietitians regarding healthy diet and physical activity levels is an important intervention to reduce diabetes risk.
Photo Courtesy of Gary Jacobson
Tobacco Use
Tobacco use increases the risk of cardiovascular, kidney, foot, and eye complications in people with diabetes.55 Although the overall rate of smoking among AAPIs is lower than for whites (17% vs. 25%, respectively) in the United States,56 the smoking rate among subgroups of SEAs noted in regional surveys is higher.
- According to one regional survey conducted in Washington state in 1989, smoking prevalence among 253 SEA men was highest for Laotians (51%), followed by Vietnamese (42%) and Cambodians (33%) (data were not collected for Hmong in this study).57
- Other studies conducted in San Francisco, Los Angeles, and other regions of California during the 1990s showed that the smoking prevalence rate among SEA men ranged from 34% to 43%.58
- The 1997 National Health Interview Survey revealed the smoking rate among Vietnamese males to be as high as 55%.59
- No comparable data on tobacco use are available for SEA women living in the United States.
A closer examination of the high smoking rates among the Vietnamese provides insight to how cultural influences have affected tobacco use in SEAs.60 Smoking, which is a social norm widely accepted in Vietnam, has a prevalence among Vietnamese males living in their home country that is one of the highest in the world (72.8%).60,61
Many SEA tobacco users face cultural barriers in seeking assistance to quit. A study in Minnesota found that Vietnamese smokers feel ashamed of being identified.62 Youth smoking is becoming a sad reality among Vietnamese Americans, although tobacco use has traditionally been rare among Vietnamese youth in their home country. A study by the American Legacy Foundation in 2001 revealed a seven-fold increase in smoking prevalence among Asian youth—including Vietnamese—between grades 7 and 12.63 Interventions concerned with preventing diabetes complications must acknowledge the impact of high tobacco use prevalence as a comorbid condition and consider public health approaches that address multiple unhealthy behaviors.
High Blood Cholesterol
People with diabetes are at a higher risk for CVD than those who do not have diabetes. High low-density lipoprotein cholesterol, in particular, increases the risk for developing coronary heart disease. Focus group research has shown that many Asian Americans perceive themselves to be at low risk for elevated cholesterol and CVD.52 Few data exist on blood cholesterol levels in SEAs with or without diabetes, but regional studies have found low rates of self-reported cholesterol testing.7, 64
• In a 1992 CDC study of 154 SEA refugees with and without diabetes in Seattle, Washington, a majority of U.S. Vietnamese men (56%) and women (55%) had never had their cholesterol levels checked.64 Another study, conducted among 1,026 Cambodians living in Lowell, Massachusetts, with and without diabetes reported that a large number of Cambodians (52%) had never had their cholesterol checked.7
Cholesterol testing and management is a standard of care for diabetes management.65 No data exist on cholesterol testing among SEAs with diabetes, but suboptimal rates of screening and control have been found in general for SEAs, regardless of diabetes status.66 Health disparities in cholesterol testing and control have been noted for other ethnic minority populations.66
Stroke: A Major Diabetes Complication Affecting SEAs
Overall, among people with and without diabetes, the age-adjusted death rate from stroke is approximately 26 per 100,000 in AAPIs while the general U.S. age-adjusted rate is 27 per 100,000. Although this statistic refers to all AAPI populations as a whole, regional data suggest health disparities in SEAs with regard to stroke. According to the 1990 U.S. Census Bureau and California Department of Health Services data, Cambodians in California with and without diabetes had the second highest death rate from stroke compared with all other races in that state (125.3 vs. 63.6 per 100,000, respectively).67, 68 Understanding the determinants of a higher stroke rate among SEAs is relevant to diabetes care because this complication is a major cause of morbidity and mortality for people with diabetes.
Quantitative data on SEAs, diabetes prevalence, and complications are limited. However, data from death certificates reveal a need to examine the prevalence of diabetes complications in SEAs. According to a 2001 study in Lowell, Massachusetts, where the majority of Asians are Cambodian, “Asians aged ≥45 years die from diabetes at higher rates than the general MA population.”7 Qualitative data such as focus group reports and key informant interviews can provide insight to diabetes complications prevention among SEAs. The “Project Asian Diabetes: Access, Prevention, and Treatment” (Project ADAPT) report of a focus group was initiated in response to health care and social service provider perceptions in San Joaquin County, California that, “Patients from Southeast Asia are more likely to present with more advanced disease upon initial diagnosis of type 2 diabetes and more likely to progress quickly to complications than are other patients.”69 Although no quantitative data currently exist to support these perceptions, this ongoing project seeks better understanding of the challenges confronting SEAs with diabetes in San Joaquin County. The CD-ROM accompanying this monograph contains the full January 2006 Project ADAPT report findings and recommendations. Such qualitative reports provide information on cultural beliefs and practices that are at odds with the Western medical model, mental health issues, and other challenges to quality medical care delivery, as well as suggested solutions.
Access to and Quality of Health Care Services
Insurance Matters: The 2003 California Endowment Report
Results from a multilingual poll given to Californian immigrants showed that the lack of health insurance was the main barrier to seeking medical care.
SEAs face multiple challenges to accessing quality health care services, including underinsured or uninsured status, language barriers, lack of culturally appropriate care, mental health disorders related to previous physical and emotional trauma, and concurrent chronic disease. These challenges affect the ability of SEAs to access effective health care that could prevent, delay, or diagnose diabetes. Such barriers also prevent SEAs who have diabetes from receiving appropriate services to manage and control their disease.
Insurance Status
The lack of health insurance has been linked to decreased provision of preventive health care services and poorer outcomes for people with chronic disease.70,71
- As of 1997, 27% of SEAs in the United States were uninsured, compared with 14% of whites.72 Less than half (49%) of SEAs had job-related health insurance, compared with 73% of whites.73
- A national study reported in 2002 found that one in five Asian American adults aged 18–64 had been uninsured at some point in the past year, and the rate was especially high for Vietnamese Americans (37%) (data on other SEAs were not collected).54
A regional case in point regarding this lack of health coverage can be seen in California. According to the 2001 California Health Information Survey, the rate of non-elderly Asians who do not have health insurance is 1.4 times the rate of whites (13% vs. 9%, respectively).74
Studies have shown that the extensive lack of health insurance can seriously hamper the ability of patients to obtain care and treatment for diabetes—another factor that magnifies the existing burden of disease in SEAs.75 However, access to quality health care remains a problem even among those who have adequate insurance coverage.76 According to the 2003 California Endowment report, approximately a quarter of SEAs with private insurance, Medicare, or other medical coverage reported experiencing problems when seeking medical assistance.76
Language Barriers
Effective diabetes prevention and control rely on good communication between patients and health care providers. Because SEA populations speak several distinct languages, however, language barriers remain among the most difficult aspects of establishing effective public health and primary care interventions.
Language Proficiency
The U.S. Census defines a linguistically isolated household as one in which all adults (high school age and older) have some limitation in communicating in English. According to the 1999 U.S. Census, more than 60% of Hmong, 56% of Cambodian, 52% of Laotian and 44% of Vietnamese households were linguistically isolated, affecting those SEA populations’ access to health care and information.76, 77
Spotlight on Policy:
HIPAA’s Effect on Access to Care in Southeast Asian Communities
The Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress in 1996 to protect privacy of health information.110 Although HIPAA has fulfilled its purpose with regard to electronic transactions, it has also inadvertently erected barriers for health care providers who serve people in SEA immigrant communities.
“The act of patient privacy is a barrier for limited English-speaking people,” said Theanvy Kuoch, executive director of Khmer Health Advocates. “Though HIPAA’s objective is to protect the patient’s privacy, it also prevents those trying to assist from receiving information on behalf of their limited-speaking client.”79
In Kuoch’s experience, HIPAA regulations have led to increased time and effort spent by patient advocates working with SEA patients in communicating with health care providers. In some instances, incorrect interpretations of HIPAA have prevented access to care. For example, a local agency in Connecticut required clients to call for services on their own behalf, even if they do not speak or understand English. Recalling earlier experiences with this agency, Kuoch said, “Nine out of 10 times, when I have clients seek assistance on their own, they call directly after their appointment and say that they were not provided medical services.”
While many immigrants of other ethnicities (e.g., Hispanics/Latinos) have access to clinics in which their native language is spoken, this is less often the case for SEAs.76 The following points, taken from the California Endowment report, illustrate the scope and consequences of this situation:
- Approximately half of the Cambodians and Hmong surveyed in California regularly visited a clinic in which their native language was not spoken.
- Seventy percent of Cambodians, 57% of Hmong, and 42% of Vietnamese reported that they had a problem understanding a medical situation because it was not explained in their native language.
- Even if interpretive services are offered in the health care clinic, language difficulties may arise at the pharmacy. Fifty-nine percent of Hmong, 51% of Cambodians, and 25% of Vietnamese reported having trouble understanding the labels on prescription medicines.76
A health survey in Connecticut echoes the findings of the California report. According to the 2003 study of 366 randomly selected SEAs, more than 80% of Vietnamese, 33% of Laotians, and 70% of Cambodians living there reported that they needed an interpreter during medical visits.38 This study also noted that among those who do speak English, many do not understand the medical terminology often used in health care settings. In addition, according to the Cambodian Community Health 2010 Behavioral Risk Factor Surveillance Survey conducted in 2002 (CCH 2010 BRFSS), 96% always spoke Khmer at home.8 Within a clinical setting, more than three quarters of Cambodians preferred the Khmer language for health information, nearly 70% wanted an interpreter when talking to a non-Khmer-speaking doctor, and 18% reported a time when they needed an interpreter but did not have one.
Together, communication barriers such as the ones described above contribute to underrecognition of diabetes risk and inadequate counseling about risk reduction and ongoing care.
“Bridging Language Barriers in Health Care”
The California Endowment Report
With immigrants making up 25% of the state population,76 California is at the forefront of a demographic change that is sweeping the nation. Such is the context surrounding the California Endowment report,76 a multilingual poll of Californian immigrants designed to address the linguistic and cultural barriers to quality health care.
The report is particularly enlightening regarding the plight of SEAs. According to the polls, 70% of Cambodians, 45% of Hmong, and 35% of Vietnamese respondents said that they had had a problem understanding instructions when they were discharged from a hospital because the instructions were not given in their native language.69
Excerpts from the report:
“The chance of misunderstanding instructions either from a physician or upon being discharged from the hospital doubles among immigrants who do not speak English well.”
- “Substantial percentages of California immigrants, especially … Hmong, Cambodians … are often confused about how to use prescription medicines.”
- “Many immigrants also have trouble understanding the label on their prescription medicines.”
- “More than a quarter of these immigrants with a poor understanding of English have gotten sick as result of this handicap.”
For more information, visit: www.ncmonline.com/media/pdf/tce_summary.pdf.
"I still hear the Khmer Rouge slogans in my head.I don't know who this person on the phone is, so I am polite, but I don't tell them anything.
Interpreter Services
Lack of awareness with regard to interpreter services remains an obstacle to providing quality medical care to SEAs. Eighty-four percent of Hmong, 72% of Vietnamese, and 55% of Cambodians surveyed in the California Endowment report were unaware of their legal right to interpreter services at health care facilities.76 Of those poll respondents who did not speak the same language as their doctor, fewer than 10% used a trained interpreter. Most (56%) reported that they did “the best I can in English,” and some (19%) had asked a family member or friend to help them communicate with their doctor. Unequal Treatment, a report published by the Institute of Medicine on racial and ethnic disparities in health care, specifically advises against the use of family or untrained personnel as interpreters.78
Some health care facilities have begun to rely on telephone interpreter services to compensate for the absence of trained interpreters in their communities.79 However, these services can be problematic for SEAs who came to the United States as refugees, who are more likely to trust health care providers in a face-to-face interaction than a phone interaction, according to some advocates. According to Theanvy Kuoch, executive director of Khmer Health Advocates, telephone interpreter services have been, in her experience, particularly disturbing for Cambodians, who may associate the unknown voice on the other end of the line with brainwashing sessions performed by the Khmer Rouge. When Kuoch asked a Cambodian community health worker if her patients liked to use the telephone interpreter service, the woman said, “An old man told me, ‘Even though I know it’s not true, I still hear the Khmer Rouge slogans in my head. I think maybe I am safe if I just don’t talk. I don’t know who this person on the phone is, so I am polite, but I don’t tell them anything.’ I think my other patients are like that too.”80
Language and Patient-Physician Interactions
Differences in patient-physician interaction were notable between Asian Americans whose primary language was English and those whose primary language was not English.54 Asians with limited English proficiency preferred using professional interpreters, when available, rather than family members.81
The CCH 2010 BRFSS showed that among adult Cambodians over 25 who preferred an interpreter, 76% usually relied on hospital or health center interpreters. Among men aged 25 to 35, 93% of whom reported they speak English well enough to converse, 35% usually still wanted an interpreter in health care settings.8 Failure to address interpreter services ignores SEA patients’ limited language skills to interpret medical terminology, as well as cultural traditions and practices.
This failure also goes against recommendations given by the Department of Health and Human Services, as stated in a document titled, National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. These standards reflect legislation that ensures a patient’s right to an interpreter when seeking health care services at a clinic or hospital.82,83
Lack of Culturally Appropriate Care
The 2002 California Endowment Study reported that Asian Americans were less likely than the overall population to rate their medical care highly, less likely to be confident about their care, and more likely to indicate having a communication problem with their doctor.76 The issue is not only one of common language but of cultural health beliefs and the perceived need for preventive health care services.69, 84, 85
According to focus group research conducted by the National Diabetes Education Program (NDEP), many immigrants do not seek preventive health care services, indicating reasons such as the lack of these services in the country of origin, unfamiliarity with these services, and a cultural attitude of seeking health care for symptomatic complaints, not prevention.12 Indeed, results from the CCH 2010 BRFSS survey show that, few Cambodian adults older than 25, knew about CVD and diabetes, and very few knew the modifiable risk factors for CVD and diabetes, or even that diabetes and hypertension were chronic diseases.8
Thirty-six percent of immigrants (from all ethnic groups) interviewed in the California Endowment survey reported the main reason they did not have a regular doctor or clinic was because they “never get sick.”76 This response highlights a lack of belief in preventive health care. Indifference toward preventive care has major implications for diabetes prevention and control, as can be seen in the comments of one Cambodian participant in a NDEP focus group on diabetes: “When I feel bad, I check [my blood sugar]. When I feel good, I don’t check. What’s the point of hurting your finger with a needle if you aren’t sick?”86
Little information exists on the percentage of SEAs who access preventive health care services for diabetes, usually in the form of surveys conducted among only one group of SEAs. For example, according to the Year 3 REACH 2010 Risk Factor Survey conducted by the National Opinion Research Center in 2004, only 26% of adult Cambodians with diabetes reported having an A1C test in the past year.8 No comparable information is available for other SEA subgroups.
Since little is known about diabetes preventive care services among SEAs, we conducted a literature review of cancer screening practices among Asian Americans. Like diabetes, the early stages of cancer are mostly asymptomatic. Because of this similarity, understanding of attitudes and barriers to cancer screening can offer possible insights relevant to other chronic disease preventive services.
- Cervical cancer rates among Vietnamese women are five times higher than among white women.87 SEA women are more likely to have late diagnosis of cervical cancer that could have been prevented by routine Pap smear testing and appropriate treatment.88
- Compared with other ethnic groups, AAPI women in the United States have the lowest cancer screening rates. A national study conducted in 2000 found that less than 60% of adult AAPI women in the United States had obtained a Pap test within the past 2 years.89
- A 2002 report on the health status of 7,429 state residents by the Massachusetts Department of Health found that 37% of Asian women aged 18 and older living in Massachusetts had never had a Pap test (compared with 10% of white women and 15% of African American women).90
- A 1992 study of 1,011 Vietnamese living in California found that nearly 50% of Vietnamese women over 40 had never had a mammogram.91 In addition, a California survey of 201 Hmong women living in Fresno, Long Beach, Orange County, and San Diego found that only 52% of women over the age of 30 had ever had a clinical breast examination and only 30% had ever had a mammogram.92
- Another study conducted in 2001 of 566 SEAs residing in California found that white men are twice as likely to have been screened for prostate cancer than Asian men. The authors also said that in fact, “60% of Cambodian and Vietnamese men have never even heard of the test.”93
Opportunistic screening:
Screening carried out at a time when people are seen, by health care professionals, for a reason other than the disorder in question
- WHO, 200397
Current programs that rely on opportunistic screening94 for diabetes and counseling about chronic disease risk presuppose that AAPIs present to the health care system for preventive care services. However, these low rates of cancer screening indicate the need to educate the SEA population about the importance of seeking preventive care. Such educational measures are particularly relevant to risk counseling, early diagnosis, and optimal diabetes management.
Some studies offer evidence that many AAPIs do not receive recommended preventive care tests in part because of the lack of awareness campaigns in their native languages. Findings from a 2001 California Health Interview Survey found a direct correlation between level of English proficiency and cancer screening rates in immigrants.95 In addition, focus group research with non-physician health care providers revealed that physicians tend to provide SEA patients with less education and therapies than they provide to other patients mainly because of language barriers.69
Other cultural barriers play a role in addition to the above linguistic factors. For example, the extent to which provider behavior can affect patient relationships can be seen in the following quote from a Hmong patient, “I understand that the doctor is trying to help, but when the medication is not helping, the doctor won’t change the medication for me. Sometimes I feel like they’re just in it for the money.”69 In addition, the California Endowment report revealed that compared with 62% of the overall population, only 45% of Asian Americans were “very satisfied” with their health care.76 Important aspects of quality of health care services identified by study participants included the providers’ respect for traditional health beliefs and practices, access to professional interpreters, and assistance in obtaining social services.76
Vietnamese American patients with limited English proficiency want to discuss the use of non-Western medical practices with their providers, but encounter many barriers, according to a study examining cultural barriers to care.81 They viewed providers’ knowledge of, inquiry about, and nonjudgmental acceptance of traditional Asian medical beliefs and practices as part of quality of care, and they found this quality lacking. In addition, lack of communication about traditional medicine can lead to poorer health outcomes. Physician training has traditionally focused only on the use of prescription drugs, with little information on complementary and alternative treatments such as herbal remedies. Many traditional herbal remedies have pharmacologically active properties that can interact with prescription medication and worsen chronic conditions such as high blood pressure or unstable blood glucose levels. Ginseng, for example, is a popular herbal remedy that has been known to counteract hypertension medication and to cause hypoglycemia when taken in conjunction with diabetes agents.96, 97 It is important both for health care providers to ask about herbal remedies and for SEA patients to understand the reason for sharing this information with their providers.98, 99
CLAS Standards: Focus on Cultural Competence
and Health Care
In 2000, the U.S. Department of Health and Human Services convened a committee of health care providers, policy makers, and researchers to recommend cultural and linguistic guidelines for national health care delivery and policy making. This report, National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care, is the culmination of this committee’s efforts.83 Provision of clinical services consistent with these standards is federally mandated by law.
As defined by the report, cultural and linguistic competence suggests “an ability by health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounter.” Finding ways to develop this competence is a necessity for today’s health care providers, advocates, and policy makers, who face an increasingly diverse patient population in a variety of clinical settings. In the words of a recent commentary in the New England Journal of Medicine, “Cultural competence is not a panacea that will single-handedly improve health outcomes and eliminate disparities, but a necessary set of skills for physicians who wish to deliver high-quality care to all patients.”111
The CLAS report lists 14 standards that health care providers can use to define and implement linguistic and cultural competence. For a full list of these standards, please visit www.omhrc.gov/CLAS/cultural1a.htm#Summary.
“Pulling Out the Cold Air”: Snapshots of the Contrast Between Eastern and Western Medicine in the United States
To a physician trained in the American system, seeing a patient with a back full of swollen lesions would be cause for alarm. However, in the eyes of a Vietnamese healer, these lesions would not be considered signs of injury. They would instead be seen as part of a common Asian treatment for minor ailments that works by “pulling out the cold air” from a person’s body.
This treatment, known as cupping, uses heated cups to create a localized suction effect on the skin that in turn is believed to remove elements that cause disease. Unfortunately, as an article in the Journal of General Internal Medicine reports, the process leaves behind conspicuous welts that U.S. clinicians can mistake for signs of abuse or hematological disease.81 The article describes how Asian immigrants who encountered negative reactions from their Western doctors were “reluctant to tell their providers about their use of Asian medicine.”
The confusion of U.S. clinicians about treatments such as cupping has had serious ramifications for the care of SEA immigrants. In one instance, a comatose Hmong girl was under the care of a group of Californian doctors, who, with well-meaning intentions, had given permission to her parents to “take her home to die” with dignity. The remark so frightened the father that he snatched his daughter away from the doctors and attempted to run from the hospital without signing the required discharge forms. His flight, which triggered a security breach alarm throughout the hospital, was later explained through the insights of a Hmong translator: “In the Hmong moral code, foretelling a death is strongly taboo … it means you’re going to kill a person. Maybe poison him. Because how do you know for certain he’s going to die unless you’re going to kill him?”112
The inability of many Western-trained clinicians to discuss symptoms within their patients’ cultural concept of illness is particularly detrimental to those who already have difficulties trusting their providers. Khmer Health Advocates reports situations where this mistrust has led many Cambodians to rely solely on their own home remedies, thus “postpon[ing] treatment for serious conditions or threaten[ing] the compliance with Western medicines.”113
As the encounter between Eastern and Western medicine becomes more frequent, the need for culturally competent health care providers grows more urgent. This urgency was the subject of a Journal of the American Medical Association article, which states that, “In the clinical setting, effective communication is maximized when the patient and health care provider share beliefs about the sickness. Discrepancies in beliefs and behaviors are often greatest when the physician and patient have different cultural orientations.”105, 114, 115
Learning how to deal with these “differences in cultural orientations” is a big challenge facing U.S. clinicians today. Though it is not necessary for clinicians to agree with the logic or efficacy of Eastern medicine, being open, nonjudgmental, and appreciative of the cultural context surrounding Asian remedies is an important first step.
Other barriers to care as revealed by the CCH 2010 BRFSS survey include low education levels and lack of transportation. These issues are not unique to the SEA population, but there is a high prevalence of low educational levels, low literacy even in native languages, and transportation barriers among SEAs.69 In the CCH 2010 BRFSS study, many Cambodians reported transportation challenges when they wanted to see a doctor, especially women, 37% of whom relied on rides from others to medical appointments. Public transportation was seldom used.8 Sixty-one percent of Cambodians had no formal education in the United States—a statistic that has implications for the ability to navigate the U.S. health care system, and for health literacy.8
Physicians and other health care providers can play a key role in improving patient participation in preventive care by nonjudgmentally asking their patients about cultural practices, beliefs about disease causes and treatment, and traditional medicine use. Health care providers of SEA heritage can act as cultural brokers to help improve cultural competency and understanding of their non-SEA health care provider peers. However, according to the most recent Census data available on the U.S. labor force (2000),100 physician representation was lower for most SEA groups than for non-Hispanic whites. In terms of patient-to-physician ratio, the 2000 Census data show that there was 1 Cambodian physician per 2,473 Cambodian people, 1 Laotian physician per 3,570 Laotian people, and 1 Hmong physician per 4,148 Hmong people. In comparison, the ratio for non-Hispanic whites was 1 per 389 people.100
Public opinion surveys of SEAs provide evidence that health care is a high priority for those interviewed, despite low utilization of preventive services, and perhaps highlighting the issue of barriers to quality care. According to the 2003 California Endowment report, more than 90% of the Vietnamese, 80% of the Hmong, and 60% of the Cambodians interviewed stated that health care was very important to them. Medical care was rated the number one concern for Vietnamese Americans interviewed, in contrast to the general population Gallup poll of June 2002 in which unemployment and the economy were ranked far above health care as top-priority issues. Nevertheless, the report also stated that nearly 30% of both Hmong and Vietnamese and 23% of Cambodians experienced problems getting medical care when needed.
Successful Models Reaching SEAs
“Diabetes is simply beyond the capacity of any single physician, patient or caregiver to manage all alone.”
- Dr. Athena Tsimikas, regarding the importance of community health centers101
Local and regional interventions to improve access to, quality of, and communication in health care practices with SEAs are not well documented. However, refugee organizations such as mutual assistance associations (MAAs) can play an important role in improving outreach and education efforts directed toward underserved SEAs.83 MAAs comprise refugees who provide assistance to other refugees. Other refugee organizations, such as Khmer Health Advocates, are extending their service area through innovative use of technology. Telemedicine tools (e.g., videoconferencing) are user-friendly, can be created in the language of the targeted people, and can be programmed to collect and store patient data. These technologies are already widely used among health care providers in settings from Connecticut to Alaska and could serve to fulfill culturally and linguistically appropriate standards for geographically scattered populations who need interpreters.102
In many areas throughout the country, MAAs and other refugee agencies are the primary organizations helping underserved SEA communities. The Fresno County Human Services System Refugee Community Liaison provides services that include teaching refugee populations how to navigate the American health care system.103
The Vietnamese American Medical Research Foundation publishes a patient education newsletter in Vietnamese with discussion of cultural practices and foods relevant to diabetes and other chronic disease risks. Multiple organizations serving SEAs conduct local cultural competency training for health care providers. This training is in accordance with CLAS standards—which list the ongoing education of health care providers as the “single most important element of assuring the cultural competence of an organization—and one of the elements most directly related to clinical care and outcomes.”83
On March 23, 2005, New Jersey became the first state in the nation to mandate cultural competency training as part of medical education. The law stipulates that cultural competency—understanding cultural aspects of medical care and integrating these into the medical care plan—be included as part of continuing medical education requirements for practicing physicians as well.104 An increase in appreciation of the need for cultural competency training for health care providers and recognition of Western medicine itself as a culture with special language, models, values, and attitudes can be seen in recent articles in mainstream medical literature. Articles in the New England Journal of Medicine,1, 84, 85 Journal of the American Medical Association,105 and others have joined the public health literature in highlighting needs and directing the reader to successful models. Resources exist to help individual health care providers, clinics, and medical organizations access training, including case studies, role-playing exercises, and tools for successful interventions (see reference section at the end of this paper).
In addition to ongoing education, CLAS standards also encourage the use of community health workers as an important link in “bridging the gap between mainstream organizations and ethnic minority communities.” Project Dulce, a diabetes management and education program in San Diego, California, is one example of how community health workers can have a positive impact on diverse populations with diabetes. As part of its outreach to the Vietnamese community, the program uses trained Vietnamese peer educators to deliver health messages, nutritional counseling, and diabetes self-management support. Project Dulce staff also provide training to other community health workers on implementation of culturally appropriate diabetes management programs. This approach has led to successful outcomes, as measured through specific metabolic parameters such as cholesterol and triglyceride levels. In addition, patient compliance to American Diabetes Association standards also increased. A curriculum, flipcharts, and peer educator training curriculum are available online (www.whittier.org/pages/pp_dulce.html).
Spotlight Outreach Organization: Khmer Health Advocates
Khmer Health Advocates (KHA) in West Hartford, Connecticut, was founded with a mission to care for the health needs of survivors of the Mahandorai (the Cambodian holocaust), and their families. As the only Cambodian health organization in the United States, KHA provides care for Cambodian immigrants in Connecticut and Western Massachusetts, and advocates for Mahandorai survivors across the nation. KHA is meeting the challenges of outreach to this population through innovative technology tools that could be useful in other settings with marginalized populations.
Currently, KHA is in the final stages of developing a telemedicine Web site called the Cambodian Health Network (Cambodianhealth.org) which will provide spoken Khmer language assessment tools and health information and a patient case management system that collects and stores data on a sequel server.102, 114
In addition, KHA is evaluating a Connecticut initiative in which interpretive services for SEAs in the health care setting are provided via videoconferencing as part of a model program funded by the U.S. Department of Commerce Technical Opportunities Program, the Langeloth Foundation, and the Connecticut Health Foundation.
Telemedicine tools (e.g., videoconferencing and patient care peripherals such as glucose meters attached to a videoconferencing system) allow Mutual Assistance Associations to offer clinical supervision of in-home diabetes monitoring, and live face-to-face education.
For more information, visit: www.khmerhealthadvocates.org/about.asp.
Spotlight on Innovation: Lowell Community Health Center
Lowell Community Health
Center (LCHC) in Lowell, Massachusetts serves a culturally diverse city and its surrounding areas. Always an immigrant city, Lowell experienced its newest influx of immigrants in the 1980’s as a result of the Vietnam War and the Cambodian holocaust, with many SEA families settling in Lowell. Due to this influx, LCHC has responded with innovative approaches providing comprehensive, high-quality healthcare to this group of newcomers to its community.
In October of 2000, the LCHC added the “West Meets East Center” as a new site designated to improve access for Cambodians and Laotians to primary medical care and mental health services. As time passed, a Buddhist monk and a community advisory committee determined that a more culturally appropriate name for the center would be “Metta,” which is a Buddhist Pali word meaning loving kindness, or compassion. The LCHC Metta Health Center addresses the ethnocultural and institutional barriers to care for Lowell’s Southeast Asian population and builds on the strengths of culture that the Southeast Asians carried with them to Lowell. Located in a well-known Cambodian Mutual Assistance Association (CMAA) facility that houses an array of cultural programs and social services, the Metta Health Center integrates Western primary care and mental health services with traditional healing, meditation, and alternative medical approaches.
As a means to increase access to the health care system for Cambodians, CCH 2010 and LCHC’s Metta Health Center provide screenings at the Adult Education English as a Second Langauge (ESL) classes, faith-based facilities (the Glory and Trairatanaram Temples), and the Saint Julie Asian Center. Bilingual-bicultural health advocates are available to help people with transportation needs and assist those who are applying for free care and/or MassHealth. Screenings are linked to follow up health care services with advocates and health care providers available to arrange referral and care if indicated. Screenings also present opportunities for health education and health promotion about diabetes and high blood pressure.
For more information, please visit: www.lchealth.org/
The National Diabetes Education Program (NDEP):
Networking to Promote Awareness of Diabetes
in the SEA Population
The NDEP is a federally-sponsored initiative that unites public and private partners to improve the treatment and outcomes for people with diabetes, to promote early diagnosis, and to prevent the onset of diabetes.
A key to the success of these partnerships are work groups comprised of members from a variety of healthcare backgrounds. NDEP has work groups convened to address specific audiences and issues—for example, a work group concerned with diabetes in older adults and another involved with business and managed care—which help to tailor diabetes prevention and control messages to different audiences. The Asian American Pacific Islander (AAPI) Work Group, in particular, has been instrumental in promoting diabetes awareness in SEA communities.
Using a diverse network of representatives from national Asian health organizations, Asian community-based organizations, and other health professionals, the AAPI Work Group provides advice on the development and dissemination of culturally-sensitive NDEP materials and messages to Asian American and Pacific Islander communities. Initiatives pursued by the Work Group have included tailoring and making culturally-appropriate NDEP campaign materials (e.g., public service announcements, posters, brochures) into 15 Asian and Pacific Islander languages, as well as putting together a capacity-building toolkit for use by AAPI community-based organizations.
The following organizations from the AAPI Work Group have been directly involved in examining the impact of diabetes in SEA communities:
• Association of Asian Pacific Community Health Organizations (AAPCHO)
• Khmer Health Advocates, Inc.
• Charles B. Wang Community Health Center
• National Asian Women’s Health Organization
• National Vietnamese American Health Care Association
• Refugee Community Liaison, Fresno County Human Services System
• Office of Minority Health
For more information on NDEP, please visit:
Snapshots from the Field:
A Physician Reaches Out to SEAs with Diabetes115
Dr. Kwabena Adubofour, a Stockton, California, internist, was frustrated. His practice was seeing an increasing number of SEA patients with diabetes who, by the time they sought help, were already suffering from complications such as blindness or kidney disease. So Dr. Adubofour partnered with Lao Khmu Association (LKA) and Education, Training and Research Associates (ETR) to find solutions to the problem. The collaboration led to the creation of Project Asian Diabetes: Access, Prevention and Treatment (ADAPT), a two-phase project designed to obtain needs assessment data (phase one), then apply the findings toward the development of local programs (phase two) focused on preventing diabetes and treating patients with diabetes in the SEA communities of San Joaquin Valley. Funded primarily with internal funds from ETR and LKA, phase one of the project received a supplement of $10,000 from the Golden State Medical Association and completed its needs assessment report in November 2005.69
“We want[ed] to understand why the Lao, Cambodian, [Vietnamese] and Hmong [patients] who have diabetes come in so late to get health care,” explained Dr. Adubofour. “This initial [phase] is to look at the knowledge base, the practices, and the attitudes toward the disease and in doing so come up with some innovative ways for best treatments and prevention strategies [focusing on] Southeast Asians.”
Dr. Adubofour is a member of the Stockton chapter of the Golden State Medical Association, a group of black physicians aiming to reduce health disparities among minorities, including SEAs, a group that is largely underrepresented because of language and education barriers.
The Network of Ethnic Physician Organizations (NEPO, www.ethnicphysicians.org), to which the Golden State Medical Association belongs, consists of 53 ethnic physician organizations in California dedicated to reducing health disparities and improving health care access, health care workforce diversity, and cultural competency in communities of color through collaboration with community-based organizations. NEPO elected to focus on type 2 diabetes initially because it was having the greatest impact on their patients. In California, diabetes is currently the fifth leading cause of death and costs the state nearly $12 billion annually.
The next step for Project ADAPT is to meet with community stakeholders to identify one or more programs and services that would best meet patients’ substantial needs in culturally appropriate ways. Following that, Dr. Adubofour, ETR, and LKA will seek funding for implementing and evaluating the new program(s).
Patient Outreach/Education Efforts
Investment in patient outreach—particularly to communities that are the most linguistically and culturally isolated and traumatized by the refugee experience—is an important step in closing the gap in access to and quality of health care services. Specific interventions include, but are not limited to, the following:
- Increase availability and affordability of health insurance to small businesses and business owners through purchasing pools.
- Provide skilled medical interpreters and support staff, as legally mandated in the National Standards for Cultural and Linguistically Appropriate Care in Health Services.83
- Conduct outreach and educate communities about diabetes, stroke, and mental illness through community health workers or “patient navigators,” and provide support services such as facilitating access to appropriate diabetes prevention and management services.
- Provide linguistically and culturally appropriate tools to assess patients’ ability to read and understand diabetes prevention and management concepts in English or their own language.
- Train health care providers who work with SEA communities not only about culture and traditional beliefs of SEAs but also about the refugee experience.
- Provide nutritional counseling for refugees that includes information on the potential long-term consequences of malnutrition in earlier life.
- Provide training and funding for MAAs to increase their capacity to serve SEAs.
- Increase use of telemedicine tools for providing interpreter services, monitoring home care practices, and providing family conferencing in a culturally and linguistically appropriate manner.
- Provide patient education delivered in the patient’s native language on access to state-of-the-art glucose monitoring devices.
- Reduce pain associated with blood glucose testing through the use of improved monitoring supplies (e.g., lancets) and increase awareness of access to equipment covered by Medicaid, Medicare, and private insurance.
- Support grassroots advocacy efforts to educate policy makers on the impact of 1996 welfare reform laws,106 which stripped away Medicaid benefits from legal immigrants. These laws have added barriers to appropriate and timely preventive and disease management services in SEA populations.
Conclusions
Current evidence suggests that SEAs, a rapidly growing segment of the AAPI group in the United States, face unique mental health, sociodemographic, cultural, language, and health care access issues that complicate diabetes prevention and control. Unique health care needs generated by the refugee experience, cultural practices, and possible underrecognition of chronic disease risk by providers, policy makers, and individuals contribute to poor health outcomes.
Barriers such as poor health care access, low socioeconomic status, lack of interpretive services, coexistent mental health conditions, and cultural differences in understanding preventive care practices continue to exist despite the fact that many SEA immigrant populations have been in this country for decades. The barriers pose multiple immediate challenges to local, state, and national health professionals and decision makers. The far-reaching health implications of poorly controlled diabetes and its complications compel action to address these barriers while simultaneously seeking ways to gather more data on these populations.
Acknowledgements
The National Diabetes Education Program gratefully acknowledges the members of the Southeast Asian subcommittee of the Asian American/Pacific Islander Work Group, who conceived and developed or served as consultants on this paper:
Jeffrey Caballero, MPH, work group chair Association of Asian Pacific Community Health Organizations
Wilfred Fujimoto, MD, Professor Emeritus of Medicine, University of Washington
Theanvy Kuoch, MA, LPC, Khmer Health Advocates
Lan TH Nguyen, MD, FACP, FACE, FACN, Vietnamese American Medical Research Foundation
Tam Phan, consultant, formerly of National Vietnamese American Health Care Association
Peter Vang, Fresno County Human Services System
Compilation and formatting:
Mary Nishioka, MEd, American Institutes for Research—Health Program
Margret Chang, BA, Centers of Disease Control—Division of Diabetes Translation
References
1. Mollica RF. Surviving torture. New England Journal of Medicine 2004;351(1):5–7.
2. Burrows NR, Lojo J, Engelgau MM, Geiss LS. Using Survey Data for Diabetes Surveillance Among Minority Populations: A Report of the Centers for Disease Control and Prevention’s Expert Panel Meeting. 2004. Available at www.cdc.gov/pcd/issues/2004/apr/03_0018.htm. Ref Type: Electronic Citation
3. Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care 2002;25:464–470.
4. Fisher L, Chesla CA, Skaff MM, Mullan JT, Kanter RA. Depression and anxiety among partners of European-American and Latino patients with type 2 diabetes. Diabetes Care 2002;25:1564–1570.
5. Haas LB, Watts SA. Diabetes care in the Veterans Health Administration. Diabetes Spectr 2005;18:159–162.
6. U.S. Census Bureau. www.census.gov/hhes/poverty/histpov/hispov2.html. 2000. Ref Type: Electronic Citation
7. Centers for Disease Control and Prevention. Health Status of Cambodians and Vietnamese — Selected Communities, United States, 2001–2002. MMWR 2004;53:760–765.
8. Koch-Weser S, Grigg-Saito D, Toof R, Wall M. Cambodian community health 2010: Community Behavioral Risk Factor Surveillance System results 2002; 2005. Ref Type: Report
9. President’s Advisory Commission on Asian Americans and Pacific Islanders. A People Looking Forward: Action for Access and Partnerships in the 21st Century. Interim Report to the President and the Nation. 2001. Available at ftp://ftp.hrsa.gov/aapi/interimreport3.pdf. Ref Type: Electronic Citation
10. Fresno County Human Services System. Current Refugee Population in Fresno County, 2003. Available at www.fresnohumanservices.org/RefugeeServices/RefugeePopulation.htm. Ref Type: Electronic Citation
11. The Southeast Asian Health Program at the Family Health Center of Worcester, Massachusetts. Health and Well-Being of the Massachusetts Vietnamese Community, 2001. 2001. Ref Type: Report
12. National Diabetes Education Program. Focus Group Observations on Diabetes in Southeast Asians. 2003. Ref Type: Unpublished Work
13. Frank A, Pham L. University of California Irvine--Southeast Asian Archive. Available at www.lib.uci.edu/libraries/collections/sea/seaexhibit/credits.html. 1999. 8-15-0005. Ref Type: Electronic Citation
14. Hsu E, Davies CA, Hansen DJ. Understanding mental health needs of Southeast Asian refugees: historical, cultural, and contextual challenges. Clinical Psychology Review 2004;24:193–213.
15. Brave Heart MYH. The Return to the sacred path: Healing the historical trauma response among the Lakota. Smith College Studies in Social Work 2006;68:287–305.
16. VanEenwyk J, Sabel J. Self-reported concern about food security associated with obesity—Washington, 1995–1999. MMWR 2003;52:840–842. Available at www.cdc.gov/mmwr/PDF/wk/mm5235.pdf. Ref Type: Electronic Citation
17. Kuoch T, Scully M. Cambodians’ Voices and Perceptions: A Collection of Materials, Experiences, and Cross-Cultural Understandings; 1984. Ref Type: Unpublished Work
18. Kuoch T, Scully M, Miller R, Buoa C. Health Crisis in the Cambodian Community. West Hartford, CT: Khmer Health Advocates; 1996. Ref Type: Report
19. Ravelli AC, et al. Glucose tolerance in adults after prenatal exposure to famine. Lancet 1998;351:173–177.
20. Lumey LH. Reproductive outcomes in women prenatally exposed to undernutrition: a review of findings from the Dutch famine birth cohort. Proceedings of the Nutrition Society 1998;5:129–135.
21. Ravelli AC, van der Meulen JH, Osmond C, Barker DJ, Bleker OP. Obesity at the age of 50 in men and women exposed to famine prenatally. American Journal of Clinical Nutrition 1999;70:811–816.
22. Gonzalez-Barranco J, et al. Effect of malnutrition during the first year of life on adult plasma insulin and glucose tolerance. Metabolism 2003;52:1005–1011.
23. King H, et al. Diabetes and associated disorders in Cambodia: two epidemiological surveys. Lancet 2005;366:1633–1639.
24. Benyshek DC, Martin JF, Johnston CS. Reconsideration of the origins of the type 2 diabetes epidemic among Native Americans and the implications for intervention policy. Medical Anthropology Quarterly 2001;20:25–64.
25. Joffe B, Zimmet P. The thrifty genotype in type 2 diabetes: an unfinished symphony moving to its finale? Endocrine 1998;9:139–141.
26. Habtu E, Gill G, Tesfaye S. Characteristics of insulin requiring diabetes in rural northern Ethiopia--a possible link with malnutrition? Ethiopian Medical Journal 1999;37;263–267.
27. Dallman MF, et al. Chronic stress and obesity: a new view of “comfort food.” Proceedings of the National Academy of Science 2003;100:11696–11701.
28. Pine CJ. Anxiety and eating behavior in obese and nonobese American Indians and white Americans. Journal of Personality and Social Psychology 1985;49:774–780.
29. Townsend MS, Peerson J, Love B, Achterberg C, Murphy SP. Food insecurity is positively related to overweight in women. Journal of Nutrition 2001;131:1738–1745.
30. Anda R, et al. Adverse childhood experiences and smoking during adolescence and adulthood. Journal of the American Medical Association 1999;282:1652–1658.
31. Williamson DF, Thompson TJ, Anda RF, Dietz WH, Felitti VJ. Body weight and obesity in adults and self-reported abuse in childhood. International Journal of Obesity 2002;26:1075–1082.
32. Egede LE, Nietert PJ, Zheng D. Depression and all-cause and coronary heart disease mortality among adults with and without diabetes. Diabetes Care 2005;28:1339–1345.
33. Sapolsky R. Taming Stress. Scientific American 2003;289,87–95.
34. Kroll J. Posttraumatic Symptoms and the Complexity of Responses to Trauma. Journal of the American Medical Association 2003;290:667–670.
35. Philips N, Pearlman DN, Bradbury B, Boddie-Willis C, Vu THP. Vietnamese chronic disease health status: what do the data tell us? Scientific Session at the 130th Annual Meeting of the American Public Health Association; November 11, 2002; Philadelphia, PA. Ref Type: Generic
36. Kinzie JD, et al. The prevalence of posttraumatic stress disorder and its clinical significance among southeast asian refugees. American Journal of Psychiatry 1990;147:913–917.
37. Kroll J, et al. Depression and Posttraumatic Stress Disorder in Southeast Asian Refugees. American Journal of Psychiatry 1989;146:1592–1597.
38. Smith L, Phengsomphone H, Kuoch T. Assessing the aftermath of trauma in the Vietnamese, Cambodian, and Laotian communities. Presented at Karuna: Building a Community-Based Model of Health Care for Traumatized People Conference; 2003. Ref Type: Generic
39. Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental health of Cambodian refugees 2 decades after resettlement in the United States. JAMA 2005;294:571–579.
40. Weisberg RB, et al. Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder. Psychiatric Services 2002;53:848–854.
41. Ciechanowski PS, Katon WJ, Russo J, Hirsch IB. The relationship of Depressive Symptoms to Symptom Reporting, Self-Care and Glucose Control in Diabetes. General Hospital Psychiatry 2003;25:246–252.
42. Wong C, Yang K, Moua N, Srinivasan S, Gray K. Hmong Quality of Hypertension Care Project. Fresno, CA: Fresno County Human Services System; 2001. Ref Type: Report
43. Katon WJ, et al. Improving primary care treatment of depression among patients with diabetes mellitus: the design of the pathways study. General Hospital Psychiatry 2003;25:158–168.
44. Bjorntorp P, Holm G, Rosmond R. Hypothalamic arousal, insulin resistance, and type 2 diabetes mellitus. Diabetes Medicine 1999;16:373–383.
45. Chrousos GP, Gold PW. A healthy body in a healthy mind—and vice versa. the damaging power of “uncontrollable” stress. Journal of Clinical Endocrinology and Metabolism 1998;83:1842–1845.
46. Raison CL, Miller AH. When not enough is too much: the role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders. American Journal of Psychiatry 2003;160:1554–1565.
47. Heim C, et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000;284:592–597.
48. World Health Organization Expert Consultation. Appropriate body mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157–163.
49. Wang J, et al. Comparisons for body mass index and body fat among Puerto Ricans, blacks, Whites and Asians living in the New York City Area. Obesity Research 1996;4:377–384.
50. Mandavilli A, Cyranoski D. Asia’s big problem. Nature Medicine 2004;10:325–327.
51. U.S. Department of Health and Human Services. Small Steps. Big Rewards. Your GAME PLAN to Prevent Type 2 Diabetes. Health Care Provider’s Toolkit. Bethesda, MD: National Institutes of Health; 2003. NIH Publication No. 03-5334. Available at
www.ndep.nih.gov/resources/health.htm. Ref Type: Electronic Citation
52. Satterfield D, et al. Learning from listening: common concerns and perceptions about diabetes prevention among diverse American populations. Journal of Public Health Management Practices 2003;Supplement:S56-S63.
53. U.S. Department of Health and Human Services. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report.
www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf. Ref Type: Electronic Citation
54. Hughes DL. Quality of Health Care for Asian Americans: Findings from the Commonwealth Fund 2001 Health Care Quality Survey. New York: The Commonwealth Fund; 2002. Publication No. 525. Available at www.cmwf.org/programs/minority/hughes_asianamerican_fs_525.pdf. Ref Type: Electronic Citation
55. Haire JD, Glasgow RE, Tibbs TL. Smoking and diabetes. Diabetes Care 2003;26:S89–S90.
56. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 1997. MMWR 1999;48:993–996.
57. Frost FJ, et al. Cigarette smoking among Southeast Asian immigrants—Washington state, 1989. MMWR 1992;41:854–855.
58. U.S. Department of Health and Human Services. Addressing Cardiovascular Health in Asian Americans and Pacific Islanders: A Background Report. Bethesda, MD: National Heart, Lung and Blood Institute; 2000. NIH Publication No. 00-3647, 19-21. Available at www.nhlbi.nih.gov/health/prof/heart/other/aapibkgd/aapibkgd.pdf. Ref Type: Electronic Citation
59. National Center for Health Statistics. Healthy People 2000 Review, 1997. Hyattsville, MD: Public Health Service; 1997. Ref Type: Report
60. World Health Organization. Tobacco Use in Vietnam—A Major Health Hazard. Geneva: World Health Organization; 1999. Ref Type: Report
61. Jenkins C, et al. Vietnam: A Tobacco Epidemic in the Making. Suc Khoe La Vang, ed. University of San Francisco;1995. Ref Type: Report
62. Foldes S. Culture and Smoking Cessation Among Southeast Asians in Minnesota. The DREGAN Project; 2004. Ref Type: Unpublished Work
63. American Legacy Foundation. Cigarette Smoking Among Youth/Priority Populations. Washington, DC: American Legacy Foundation; 2001. Ref Type: Report
64. U.S. Department of Health and Human Services. Asian American and Pacific Islander Workshops: Summary Report on Cardiovascular Health. Bethesda, MD: National Heart, Lung and Blood Institute; 2000. NIH Publication No. 00-3793, 18. Available at www.nhlbi.nih.gov/health/prof/heart/other/aapi_sum.pdf. Ref Type: Electronic Citation
65. Standards of Medical Care in Diabetes. Diabetes Care 2004;27:15S–35.
66. Saaddine JB, et al. A diabetes report card for the united states: quality of care in the 1990s. Annals of Internal Medicine 2002;136:565–574 (2002).
67. Ng J. Silent survivors. Asian Week; August 3–9, 2001. Available at www.asianweek.com/2001_08_03/feature_cambodian.html. Ref Type: Electronic Citation
68. Wilson P, Smoley S, Belshe S. Analysis of Health Indicators for California’s Minority Populations. Sacramento, CA: Office of the Governor. Ref Type: Generic
69. ETR Associates, Lao Khmu Association. Project Asian Diabetes: Access, Prevention, and Treatment (ADAPT) Needs Assessment Report; 2005. Ref Type: Report
70. Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: National Academy Press; 2001. Ref Type: Report
71. American College of Physicians. No Health Insurance? It’s Enough to Make You Sick — Scientific Research Linking the Lack of Health Coverage to Poor Health; 1999. www.acponline.org/uninsured/lack-contents.htm. Ref Type: Electronic Citation
72. Pollitz K, et al. Health insurance and diabetes: the lack of available, affordable, and adequate coverage. Clinical Diabetes 2005;23:88–90.
73. Brown ER, Ojeda VD, Wyn R, Levan R. Racial and Ethnic Disparities in Access to Health Insurance and Health Care. Los Angeles, CA: UCLA Center for Health Policy Research; 2000. Available at www.healthpolicy.ucla.edu/pubs/files/racialandethnicdisparitiesreport.pdf. Ref Type: Electronic Citation
74. Brown ER, Ponce N, Rice T, Lavarreda SA. The State of Health Insurance in California: Findings from the 2001 California Health Information Survey. Los Angeles, CA: UCLA Center for Health Policy Research; 2002. Available at www.healthpolicy.ucla.edu/pubs/files/shic06002.pdf. Ref Type: Electronic Citation
75. Lee DL, Rose D, Bostock K. Asian and Pacific Islander Elders in the U.S.: A Demographic Report. Medicare Beneficiary Grassroots Rights and Protections Outreach Project for Vulnerable Populations: the Asian and Pacific Islander Population in the States of Washington, Idaho, and Alaska Study. Seattle, WA: The National Asian Pacific Center on Aging. 1999. Available at www.napca.org/API_DIST.pdf. Ref Type: Electronic Citation
76. California Endowment. Bridging Language Barriers in Health Care: Public Opinion Survey of California Immigrants from Latin America, Asia and the Middle East. 2003. Available at www.ncmoline.com/mecia/pdf/tce_summary.pdf. Ref Type: Electronic Citation
77. U.S. Census Bureau. Chinese largest Asian American group in the United States; 2002. Available at www.census.gov/Press-Release/www/2002/cb02cn59.html. Ref Type: Electronic Citation
78. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine; 2003. Ref Type: Report
79. Kuoch T. 2004. Ref Type: Personal Communication
80. Kuoch T. 2004. Ref Type: Personal Communication
81. Ngo-Metzger Q, et al. Linguistic and cultural barriers to care. Journal of General Internal Medicine 2003;18:44–52.
82. U.S. Department of Health and Human Services, Office of Minority Health. Call for comments on draft standards on culturally and linguistically appropriate health care and announcement of regional informational meetings on draft standards. Federal Register 1999;64(240). FR Doc. 99-32419. Availabe at www/omhrc.gov/CLAS/frclas.htm. Ref Type: Electronic Citation
83. U.S. Department of Health and Human Services, Office of Minority Health. National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care. 2000;65(247):80865–80879. Available at www.omhrc.gov/CLAS. Ref Type: Electronic Citation
84. Fox RC. Cultural competence and the culture of medicine. N Engl J Med 2005;353:1316–1319.
85. Malina D. Compliance, caricature, and culturally aware care. N Engl J Med 2005;353:1317–1318.
86. National Diabetes Education Program. Focus Group Observations on Diabetes in Cambodian Refugees. 2005. Ref Type: Unpublished Work
87. Asian and Pacific Islander American Health Forum. Cancer Survivor Capacity Building Project. 2004. Available at www.apiahf.org/programs/ncsn/facts.htm. 2004. Ref Type: Electronic Citation
88. U.S. Department of Health and Human Services. Steps to Healthier Women: Cancer. Washington, DC: Office on Women’s Health; 2004. Available at womenshealth.gov/pub/steps/Cancer.htm. Ref Type: Electronic Citation
89. Kagawa-Singer M, Pourat N. Asian American and Pacific Islander breast and cervical carcinoma screening rates and Healthy People 2000 Objectives. Cancer 2000;89:696–705.
90. Macaluso C, Borja N, Pan X, Keyes S, Zhang Z. A Profile of Health Among Massachusetts Adults, 2002: Results from the Behavioral Risk Factor Surveillance System. Boston, MA: Massachusetts Department of Public Health; 2004. Available at www.mass.gov/dph/bhsre/cdsp/brfss/rpt2002.pdf. Ref Type: Electronic Citation
91. Jenkins C, Kagawa-Singer M, Cancer. In Zane N, Takeuchi D, Young K, eds. Confronting Critical Health Issues of Asian and Pacific Islander Americans. Thousand Oaks, CA: Sage Publications; 1994.
92. Tanjasiri SP, et al. Breast cancer screening among Hmong women in California. Journal of Cancer Education 2001;16:50–54.
93. UCLA Center for Health Policy Research. California Health Interview Survey. 2001. Ref Type: Report
94. World Health Organization. Screening for Type 2 Diabetes. Report of a World Health Organization and International Diabetes Federation meeting. 2003. Ref Type: Report
95. Ponce N, Gatchell M, Brown ER. Cancer Screening Rates Among Asian Ethnic Groups. Los Angeles, CA: UCLA Center for Health Policy Research; 2003. Available at www.healthpolicy.ucla.edu/pubs/files/Asian_Cancer_FactSheet.pdf. Ref Type: Electronic Citation
96. Shane-McWhorter L. Biological complementary therapies: a focus on botanical products in diabetes. Diabetes Spectrum 2001;14:199–208.
97. Covington MB. Traditional Chinese medicine in the treatment of diabetes. Diabetes Spectrum 2001;14:154–159.
98. Richard CL, Jurgens TM. Effects of natural health products on blood pressure. Annals of Pharmacotherapy 2005;39:712–720.
99. Huang WF, Wen KC, Hsiao ML. Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan. Journal of Clinical Pharmacology 1997;37:344–350.
100. U.S. Census Bureau. 2000 Profiles of Asians and Pacific Islanders: Selected Characteristics. CPH-L-151. Washington DC: Government Printing Office; 2000. Ref Type: Report
101. Lott J. Project Dulce: Diabetes Care for Those at Risk. Available at www.scrippshealth.org/scrippsnews_1301.asp. 2002. 11-5-0004. Ref Type: Electronic Citation
102. Scully M, Chhun VM, Tan HK. Telemedicine: A Tool to Increase Access to Culturally and Linguistically Appropriate Care. Bristol, CT; 2003. Ref Type: Generic
103. Vang P. 2003. Ref Type: Personal Communication
104. Bryant WB. Cultural competency—it’s common sense. Advanced Studies in Medicine 2005;5:402.
105. Patcher LM. Culture and clinical care: folk illness beliefs and behaviors and their implications for health care delivery. Journal of the American Medical Association 1994;271:690–694.
106. Wang M, Holahan J. The Decline in Medicaid Use by Noncitizens since Welfare Reform. Washington, DC: Urban Institute; 2005. Available at www.urban.org/Template.cfm?
NavMenuID=24&template=/TaggedContent/ViewPublication.cfm&PublicationID=8406 . Ref Type: Electronic Citation
107. Depression and diabetes. Diabetes Spectrum 2004;17:167–168.\
108. Kleinman A. Culture and depression. New England Journal of Medicine 2004;351:951–953.
109. Simon G, et al. An international study of the relation between somatic symptoms and depression. New England Journal of Medicine 1999;341:1329–1335.
110. Department of Health and Human Services. Health Insurance Portability and Accountability Act of 1996. 1996. Ref Type: Report
111. Betancourt JR. Cultural Competence--Marginal or Mainstream Movement? New England Journal of Medicine 2004;351:953–954.
112. Fadiman A. The Spirit Catches You and You Fall Down. New York, NY: Noonday Press; 1997.
113. Khmer Health Advocates. The Roots of the Cambodian Health Crisis. 2004. Available at www.khmerhealthadvocates.org/healthcrisis.asp.
Selected Web sites for More Information
on Southeast Asian Populations
1) Hmong Studies Internet Resource Center. www.hmongstudies.org Includes Census data for Laotians, Hmong, and Vietnamese, along with the top metropolitan areas for each.
2) Hmong Health Education Network. Hmong Health. www.hmonghealth.org
3) Khmer Health Advocates. www.khmerhealthadvocates.org
4) Offi ce of Minority Health, Public Health Service, U.S. Department of Health and Human Services. A Practical Guide for Implementing the Recommended National Standards for Culturally and Linguistically Appropriate Services in Health Care. www.omhrc.gov/clas/guide2a.asp
5) Southeast Asian Resource Action Center. www.searac.org.
6) The White House Initiative on Asian Americans and Pacific Islanders. www.aapi.gov
7) UCLA Center for Health Policy Research. The State of Health Insurance in California: Findings from the 2001 California Health Interview Survey. www.healthpolicy.ucla.edu/pubs/files/shic062002.pdf
8) U.S. Census Bureau. www.census.gov
9) U.S. National Library of Medicine, National Institutes of Health, Department of Health and Human Services. Asian American Health. Asian American Health: Major Asian Populations-Southeast Asians. asianamericanhealth.nlm.nih.gov/majasian05.html
10) Vietnamese Studies Internet Resource Center. site.yahoo.com/vstudies/index.html
Selected Publications, Reports, and Studies
on Southeast Asian Populations
General
1) Caranzaro A, Moser RJ. Health status of refugees from Vietnam, Laos, and Cambodia. Journal of the American Medical Association 1982;247(9):1303-1308.
2) Friedman MJ, Schnurr PP. The relationship between trauma, post-traumatic stress disorder, and physical health. In: Friedman MJ, Charney DS, Deutch AY, eds. Neurobiological and clinical consequences of stress: from normal adaptation to PTSD. Philadelphia, PA: Lippincott-Raven; 1995.
3) Hennepin County Community Health Department and Bloomington Division of Public Health. SHAPE 2002: racial and ethnic data book, survey of the health of adults, the population and the environment. Minneapolis, MN: Author; 2003. Available at www.hennepin.mn.us/
vgn/images/portal/cit_100003616/4/7/10008817RaceDataBook20020122.pdf.
4) Hughes DL. Quality of health care for Asian Americans: fi ndings from the Commonwealth Fund 2001 Health Care Quality Survey (publ #525). 2002. Available at www.cmwf.org/programs/minority/hughes_asianamerican_fs_525.pdf.
5) Litz BT, Keane TM, Fisher L, Marx B, Monaco B. Physical health complaints in combatrelated post-traumatic stress disorder: a preliminary report. Journal of Traumatic Stress 1992;5:131-141.
6) Lewis JH, Le N. A profi le of the Cambodian, Hmong, Laotian, and Vietnamese people in the United States. Chicago, IL: National Association for the Education and Advancement of Cambodian, Laotian, and Vietnamese Americans; 1995.
7) U.S. Department of Health and Human Services. Addressing cardiovascular health in Asian Americans and Pacifi c Islanders: A Background Report. Bethesda, MD: National Heart, Lung and Blood Institute; 2000. NIH Publication No. 00-3793. Available at www.nhlbi.nih.gov/health/prof/heart/other/aapibkgd/aapibkgd.pdf.
8) President's Advisory Commission on Asian Americans and Pacifi c Islanders. A people looking forward: action for access and partnerships in the 21st century. Interim report to the president and the nation. 2001. Available at: ftp://ftp.hrsa.gov/aapi/interimreport3.pdf on www.aapi.gov.
9) Story M, Harris LJ. Food habits and dietary change of southeast Asian refugee families living in the United States. Journal of the American Dietetic Association 1989;89(6),800-803.
10) Surgeon General, U.S. Department of Health and Human Services. (2001). Mental health: culture, race, and ethnicity. A supplement to Mental health: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Available at www.surgeongeneral.gov/library/mentalhealth/cre/ or www.surgeongeneral.gov/library/mentalhealth/cre/sma-01-3613.pdf.
11) Office of Minority Health, U.S. Department of Health and Human Services. (2001, March). National standards for culturally and linguistically appropriate services in health care. Available at: www.omhrc.gov/clas/index.htm.
12) U.S. Census Bureau, (2000, September). The Asian American Pacifi c Islander population: population characteristics, March 1999. Available at: landview.census.gov/prod/2000pubs/p20-529.pdf.
13) International Diabetes Institute. (2000). The Asia-Pacifi c Perspective: Redefi ning Obesity and its Treatment. Available at www.diabetes.com.au/pdf/obesity_report.pdf.
Cambodians
1) Blair RG. Risk factors associated with PTSD and major depression among Cambodian refugees in Utah. Health and Social Work 2000;25(1),23-30.
2) Kuoch T, Scully MF, Miller RA, Miller D, Boua D. (1996). Health crisis in the Cambodian community. Khmer Health Advocates, Inc. (a working paper, Draft 7). [Internet version.] Available at www.hartnet.org/khmer/hlthcris.html.
3) Mollica RF, Donelan K, Tor S, Lavelle J, Elias C, Frankel M, et al. (1993). The effect of trauma and confi nement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. Journal of the American Medical Association 1993;270(5), 581-586.
4) Strumpf NE, Glicksman A, Goldberg-Glen RS, Fox RC, Logue EH. (2001). Caregiver and elder experiences of Cambodian, Vietnamese, Soviet Jewish, and Ukrainian refugees. International Journal of Aging and Human Development 2001;53(3),233-252.
5) Ton-That N. Post-traumatic stress disorder in Asian refugees. Psychiatry and Clinical Neurosciences 1998;52;377-379.
6) Toof R, Liang S. (2000). Community Conversations: Focus Groups with Cambodian Individuals Regarding Diabetes and Cardiovascular Disease. Report funded by the U.S. Centers for Disease Control and Prevention through Lowell Community Health Center.
7) Uehara ES. Understanding the dynamics of illness and help-seeking: event-structure analysis and a Cambodian-American narrative of "Spirit Invasion." Social Science and Medicine 2001;52(4),519-536.
8) U.S. Committee for Refugees. Refugee Reports, 12/18/87 and 12/31/94. Available at: www.refugees.org/index.cfm.
Hmong
1) Bates SR, Hill L, Barret CE. Cardiovascular disease risk factors in an Indochinese population. American Journal of Preventive Medicine 1989;5:15-20.
2) Gervais KG. Providing culturally competent health care to Hmong patients. Minnesota Medicine 1996;79(5):49-51.
3) Vang K, Vang HT, Simmons C, Tashima N, Ramirez DT. Hmong concepts of illness and healing, with a Hmong/English glossary (prepared for the Offi ce of Refugee Resettlement, U.S. Department of Health and Human Services, Washington, DC). Fresno, CA: Nationalities Service of Central California; 1985.
4) Westermeyer J. Mental health of Southeast Asian refugees: observations over two decades from Laos and the United States. In: T. C. Owan TC (Ed.), Southeast Asian mental health: treatment, prevention, services, training and research (pp. 65-89). Rockville, MD: National Institute of Mental Health; Washington, DC: Offi ce of Refugee Resettlement; 1985.
5) WWW Hmong Homepage. Available at www.hmongnet.org. Yang RC. The relationship between demographic variables and diabetes knowledge among the Hmong community Unpublished master's thesis. Fresno, CA: California State University-Fresno; 1998.
Laotian
1) Keohavaong S. Voices of the Laotian community. In: Voices of the communities: health care needs of Seattle's ethnic communities. Seattle, WA: Cross Cultural Health Care Program; 1996. Available at ethnomed.org/ethnomed/voices/lao.html.
Vietnamese
1) Anh NT, Do TT, Lien DT, Khoi HH, Chuyen NV, Yamamoto S. Food intake and lipid status of three Vietnamese populations with different incomes. Journal of Nutritional Science and Vitaminology 2001;476:64-68.
2) Mull DS, Nguyen N, Mull JD. Vietnamese diabetic patients and their physicians: what ethnography can teach us. Western Journal of Medicine 2001;175(5), 307-311.
3) National Heart, Lung, and Blood Institute. (undated) Cardiovascular risk in the Vietnamese community: Formative research from Houston, TX. Available at www.nhlbi.nih.gov/health/prof/heart/other/vietnamese.pdf.
4) Tomisaka K, Lako J, Maruyama C, Anh N, Lien D, Khoi HH, et al. (2002). Dietary patterns and risk factors for type 2 diabetes mellitus in Fijian, Japanese, and Vietnamese populations. Asia Pacifi c Journal of Clinical Nutrition 2002;11(1):8-1.
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