Advocating for Health Equity in the AAPI Community
Health-Care Disparities in AAPI Communities
Celebrate AAPI month by taking a moment to read valuable insights provided by Jean Chen-Vitulli, DPM, an AAPI-identifying podiatrist, on the health disparities and barriers that affect the AAPI community. It is important to raise awareness and learn about these crucial issues.
I am so proud to be an American and able to live in this great nation. We are one of the most generous and welcoming people. It is amazing to live in a nation of diverse cultures, languages, and beliefs. May is American Asian Pacific Islander (AAPI) month. AAPI have been touted as a "model minority" because of their achievements in the socioeconomic and educational spheres. However, generalizations such as these are very misleading, because they mask the glaring health disparities that are experienced by subgroups within the AAPI population.
AAPI account for at least 5.6 percent of the nation’s population and represent roots from at least 30 nations with diverse cultures, histories, and languages.1 The majority of AAPI in the US are citizens, adults, and many are parents or living in multigenerational households.2 However, according to the NIH, more than 70 percent of Asian Americans are foreign-born, and thus many have limited English proficiency. Other challenges include differing cultural beliefs and behaviors and unfamiliarity with the Western health system. In addition, Asian Americans have the most difficulty understanding instructions in a doctor’s office.3
The US Department of Health and Human Services Office of Minority Health reports that Asian Americans have a high prevalence of the following conditions and risk factors: chronic obstructive pulmonary disease, hepatitis B, HIV/AIDS, smoking, tuberculosis, and liver disease. Contributing factors include infrequent medical visits, language and cultural barriers, and lack of health insurance.1
AAPI communities face disparities in chronic diseases like cardiovascular disease, diabetes, osteoporosis, and mental health. Cancer remains the leading cause of death among Asian Americans. Unique risk factors for diabetes among Asian Americans include insulin resistance, differential body fat distribution, genetics, and emerging risks, such as metabolic syndrome, acculturation, and a traditional diet high in sodium and carbohydrates, and physical inactivity.3 According to Pfizer, “many Asian American ethnic groups have not been represented in existing research. And health data on Asian Americans and Pacific Islanders are often lumped into one category, masking the meaningful differences among the numerous AAPI subgroups. Available limited data on the AAPI population, however, point to substantial health disparities within the specific subgroups.”1
- US Filipinos had a higher prevalence of being obese or overweight, and having high blood pressure, diabetes, or asthma compared with non-Hispanic whites.1
- One of the highest risk groups for breast cancer is US-born Vietnamese women, who are four times more likely to die of breast cancer than any other AAPI groups.1
- Native Hawaiians are twice as likely to be obese as whites in their state and experience significantly higher rates of diabetes and obesity as compared to other communities.1
- US Korean children are four times more likely to have no health insurance as compared to others.1
A percentage of Asian American adults and Pacific Islander adults reported being in fair or good health, indicating a higher risk of preventive health issues. 19.4 percent of Asian adults, compared to 12.9 percent of whites, report being without a usual source of health care. Cambodians and Vietnamese are three times more likely to skip doctor visits due to cost compared to all Asians or US residents.1 Native Hawaiian and Other Pacific Islanders generally fare worse than their white counterparts across a range of social and economic measures.2
Language and cultural barriers can exacerbate health disparities, making it difficult for individuals to seek and receive appropriate health-care services. Some immigrants do not speak English well and sacrifice everything to see the next generation succeed economically and educationally. They depend on children who speak English well to go with them to medical appointments. Hence, they depend on their children’s work schedule and may not know about Family Medical Leave Act. As an example of the language barrier, my father was a person living with diabetes. Toward the end of his last few years, he told his primary doctor about his back pain. It was assumed it was lumbar stenosis as he had a history of L4-L5 fusion. For a few years, nothing was done. I recall being told medical staff ignored my father’s comments because of his thick accent. Eventually, an MRI was ordered. He denied he moved in the MRI machine. There was some “blurring” on the MRI, and his concern was not heard. No further workup was done. A few months later, we learned of his stage 4 pancreatic cancer. He passed away four months later.
Socioeconomic status, racial bias, and health literacy can contribute to health disparities. Data show variations in socioeconomic measures among non-elderly Asian and Native Hawaiian Other Pacific Islander subgroups, which may contribute to the differences in health coverage. For instance, among Asian subgroups, “there was an almost five-fold difference in the share of people who have received a bachelor’s degree or higher, with 18 percent of Laotian people having a bachelor’s degree or higher as compared to 87 percent of Taiwanese people. Overall educational attainment is lower among Native Hawaiian Other Pacific Islander Groups.”2 Higher education may also mean the individual came to the US with an immigration or work visa with better income as compared to refugees with lower incomes.2
Some communities receive lower quality of care due to various barriers, including infrequent medical visits. Native Hawaiians and other Pacific Islanders report they receive less prenatal care in the first trimester and have higher infant mortality than whites.1
As of 2021, the uninsured rate for Asian people was slightly lower than the rate for white people (7 percent), while the rate for native Hawaiian and Other Pacific Islander was higher. Across both groups, uninsured rates were lower for children compared to non-elderly adults. The share of Asian people with private coverage was higher than the share of white people, and the shares covered by Medicaid were lower. In contrast, Native Hawaiian and Other Pacific Islanders were less likely to have private coverage and more likely to be covered by Medicaid. 52 percent of Native Hawaiian and Other Pacific Islander children are covered by Medicaid or the Children’s Health Insurance Program (CHIP).2
Mental health is a growing concern in Asian and Native Hawaiian Other Pacific Islanders people given an increase in anti-Asian hate incidents. The COVID-19 pandemic and underlying racism and discrimination have contributed to a rise in hate crimes against Asian people in the United States, which has contributed to deteriorating mental health.2 During the pandemic, there were times I was scared to shop for supplies without my husband with me due to the angry looks toward me because of my Asian appearance. Moreover, there is an association between depression and diagnoses of diseases and management. Asian Americans often consider expression of mental illness a personal weakness and are more likely than whites to express emotional distress through physical symptoms.3
Foot health can be affected by the general health disparities faced by the AAPI community. For instance, lack of insurance and cultural barriers may prevent individuals from seeking specialized care like podiatry, leading to worsening of conditions. I recall that during my residency, a Chinese gentleman died of sepsis. He refused amputation for wet gangrene to save his life. Despite a psychological consult and counseling, he chose to die with his leg intact. He believed if we amputated his leg, he would be handicapped in the next life.
What can APMA and the podiatric community do?
- Education: Providing education about the importance of foot health and regular podiatric care can help in early detection and treatment. It is key for Asian Americans and Pacific Islanders to understand the importance of annual doctor visits and preventive care. Though there may be many challenging barriers to health care, AAPIs are encouraged to find health-care providers who speak the same language or understand specific cultural barriers and utilize on-site (or telephone) professional interpreter services.
- Data collection: Improved data collection and disaggregated data can help identify specific needs of AAPI subgroups and tailor interventions accordingly.
- Cultural competency: Training health-care providers in cultural competence can improve communication and trust between patients and providers.
- Genetic variance: Being aware of genetic differences between various racial groups will help us understand why a medication will work better in one group than another.
- APMA can reduce health disparities and improve health equity among Asian Americans and under-represented ethnic populations through intervention research, training, dissemination, and clinical support for patient navigation for culturally and linguistically appropriate comprehensive health services. APMA can highlight information from community needs assessment studies as well as NIH to encourage its members to engage in community partnership building and research.
APMA has taken the lead in educating our colleagues on diversity and cultural issues. APMA has and is creating webinars to address social determinants of health and diversity among our colleagues. APMA endorses the goal of embracing each other, including our patients, with kindness, respect, and acceptance of everyone’s unique background.
Jean Chen-Vitulli, DPM, MS, CDE
References:
(1) https://www.pfizer.com/news/articles/health_disparities_among_asian_americans_and_pacific_islanders#
(3) https://www.nimhd.nih.gov/news-events/features/training-workforce-dev/center-asian-health.html