The Asian-American population, a fast-growing minority group in America (1), is more likely to have type 2 diabetes compared with non-Hispanic whites despite having lower body weight (2–6). Among the diverse Asian immigrants, Chinese Americans make up the largest subgroup (1), of whom 50% live in linguistic isolation (7). Communication problems with health care providers (8) and the lack of culturally appropriate diabetes education (9), among other factors (10,11), may be important contributors to disparities in health (12–15) and diabetes control (16) in Chinese Americans.
In this study, we identified linguistic barriers to diabetes education and care in Chinese Americans and explored the appropriate venues to deliver diabetes information to Chinese-American communities.
RESEARCH DESIGN AND METHODS
Subjects were ethnic Chinese residing in the U.S. Participants (aged 18–70 years) had diabetes for at least 1 year and were taking oral agents and/or insulin. All volunteers can read, write, and speak at least English, Mandarin, or Cantonese. We recruited participants from local Asian community health centers in Boston, New York, New Jersey, and San Francisco, using fliers posted in the clinics, advertisements in local Chinese newspapers, mailings to patients from these clinics, and announcements during community outreach. Volunteers received monetary compensation and a bilingual (English/Chinese) diabetes guide for participation.
The institutional review board at Joslin Diabetes Center and the community health centers approved the study. Interested participants received a mailing of an invitation letter and an informed consent form. Having answered the questions and after signing the informed consent form, subjects selected a language preference and completed the presurvey and diabetes knowledge test in their preferred language. Afterward, subjects completed reading a bilingual diabetes guide within 4 weeks, repeated the diabetes knowledge test, and returned the postsurvey. The subjects obtained their HbA1c (A1C) levels from their primary care physicians at the time of the participation.
Two bilingual Chinese-American endocrinologists and a dietitian developed the knowledge test about the risk factors for diabetes and influences of diet and exercise. It included 12 questions, written at a 6th grade reading level, and was translated into Chinese of comparable level to the English version. The knowledge test has face validity and showed good internal reliability (Cronbach α = 0.81). The same endocrinologists also developed specifically for Chinese Americans the diabetes guide that includes the juxtaposition of English with Chinese content and ethnic-specific foods.
The subjects completed pre- and postsurveys through self-report that assessed demographics, health information, self-care behaviors, history of medical care, and frequency of medical visits. Thirty-eight of 40 physicians working in the participating community health centers are of Asian descents, averaging 6.6 years of providing service to the study population.
We compared each of the characteristics between language preference groups, English (EPG) or Chinese (CPG), using Student’s t tests and evaluated within-group pre- and postknowledge test score differences with paired t tests. Fisher’s exact test and χ2 were used to analyze categorical and frequency data.
We analyzed data from 52 subjects (40% women, 91% with type 2 diabetes, 22 in the EPG and 30 in the CPG). Compared with the CPG, the EPG was younger (aged 50 ± 14 vs. 63 ± 8 years, P = 0.002), lived in the U.S. longer (35 ± 18 vs. 16 ± 10 years, P < 0.0001), and was more educated (16 ± 2 vs. 10 ± 4 years, P < 0.0001) but had similar duration of diabetes (9 ± 7 vs. 8 ± 5 years, P = 0.62). Despite having comparable diabetes care and self-management behaviors (checking blood glucose, checking feet daily, having an annual eye exam, and attending doctor visits regularly, except for more physical activities in the CPG [P = 0.02]), the CPG scored lower on the pretest of diabetes knowledge (62.5 ± 22.5% vs. 84.5 ± 15.5%, P < 0.0003) and showed a trend toward higher A1C levels compared with the EPG (7.6 ± 1.4% vs. 6.9 ± 1.0% P = 0.09). Only the CPG improved in diabetes knowledge after reading the diabetes guide (prescore 62.5%, postscore 70.8%, P = 0.02). No sex differences were found in the measures mentioned above.
The EPG required translation from family or translational services provided by the community health centers less frequently during doctor visits compared with the CPG (4.5% vs. 34.5%, P = 0.01). Those who required translation (n = 11) scored lower on the pretest of diabetes knowledge than those who did not need translation (n = 40) (58.3 ± 21.7% vs. 76 ± 21.4%, P = 0.02). Overall, both groups obtained diabetes information mostly from the newspaper and their doctors; however, the EPG had significantly more exposure to diabetes educators (Table 1).
In this pilot study, we have shown that despite following standard diabetes self-management recommendations to a comparable degree and receiving health care in a culturally competent setting, individuals who spoke Chinese as their preferred language, even with the use of translation services, had less baseline diabetes knowledge and showed a trend toward higher A1C levels than those who spoke English as their preferred language. Reasons for these findings may be severalfold. More recent immigrants tend to prioritize social adaptation and economic survival over health-related needs (17), contributing to health disparities as seen in the CPG. Because of the scarcity of diabetes information in the Chinese language in the U.S. (9), language barriers further limited the CPG’s ability to access and comprehend diabetes information in English, leading to lower score in baseline diabetes knowledge. However, the disparity in diabetes knowledge was partly compensated by the reading of the diabetes guide, suggesting that education materials written in accordance to their culture, dietary habits, and language are important even when the CPG routinely receives diabetes care in a culturally and linguistically competent setting. In conclusion, Chinese immigrants who speak limited or no English may encounter more barriers to achieving optimal diabetes outcomes than English-speaking Chinese-American immigrants. Equally important to employing culturally competent health care providers or instituting interpreter services, health care institutions must utilize diabetes educational materials as an essential part of an overall approach to providing culturally oriented and linguistically appropriate diabetes care.
The authors thank the following community health centers for their generous contributions: Charles B. Wang Community Health Center, Asian Health Services, and South Cove Community Health Center.
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