The Perception of the Accessibility of the American Healthcare System to Asian Immigrant Mothers

In this research paper, Madison Zhan, a high schooler, studies how Asian immigrant mothers are impacted by racism within the American healthcare system. Read on to learn more about it and ways to improve.

The Perception of the Accessibility of the American Healthcare System

to Asian Immigrant Mothers

Madison J. Zhan

Barnard Pre-College

Health and Society Institute

Professor Maxine

July 12, 2023

Author Biography

Madison Zhan is a junior at Stuyvesant High School, located in New York City. She is passionate about the psychological and anthropological view of geriatrics and gender equity. She is heavily involved in the non-profit sector, pursuing her passion at school as president of a volunteer club named GlamourGals and as president of a human rights club called Girls Learn International. GlamourGals has the specific goal of ending elderly isolation. Every week, Madison leads a rotating group of teen volunteers into several different senior homes throughout Manhattan, offering conversation and companionship. Being president of Girls Learn International allows her to empower and educate her peers to advocate for human rights, equality, and universal education. During the summer before her junior year, Madison conducted original research regarding the perception of the accessibility of the American healthcare system for Asian immigrant mothers under the mentorship of Professor Maxine of Columbia University.

Abstract/Description

This research aims to identify existing discrimination against Asian immigrant mothers. Resources include already published research papers and interviews with Asian immigrant mothers and a healthcare professional about their experiences and perspectives on the American healthcare system. This research reveals English speaking informants do not have difficulty accessing the American healthcare system, unlike non-English speaking older family members. I propose added education in communication skills and cultural competency to medical students, in addition to outreach of healthcare services to immigrant families, may counter the lack of accessibility to the American healthcare system and improve effective delivery of care.

Keywords

Immigrant, women, parents, Asian, mothers, language barrier, reliance, and lack of support, children, culture competency, culture, racism, discrimination healthcare, American healthcare system.

Introduction

According to the American Heart Association, there is a lower incidence of survival in Asians post-hospitalization compared to other races despite similar pre-hospital care. Asians are less likely to survive post-hospital discharge and also have increased incidence of neurological sequelae. Despite similar rates of pre-hospital access to bystander CPR, survivorship is 8% less (Gupta et al., 2023). If an Asian does survive, they have 15% higher rate of neurological issues than white peers. The study above cites that Asian American women who experienced cardiac arrest have worse outcomes than Asian American men. This healthcare disparity is often overlooked. My research highlights the inequity faced by Asian immigrant mothers in the American healthcare system.

Research Question

What is the perception of the accessibility of the American healthcare system to Asian immigrant mothers?

Literature Review

Parker, V. A. (2010). The Importance of Cultural Competence in Caring for and Working in a Diverse America. Retrieved from https://www.jstor.org/stable/26555751

The U.S. Department of Health and Human Services’ recent request for the public to provide input on Culturally and Linguistically Appropriate Services (CLAS) standards suggests that tackling the diverse range of encounters that occur in healthcare settings requires the need for cultural competence to broaden and elaborate. The term cultural competence refers to “culturally appropriate attitudes and behaviors between and among workers, and residents or patients in health- and long-term care settings.” (Parker, 2010, p. 99) Based on 2000 census data, from 2000 to 2030 the percentage of minority elders will increase. Specifically for Asian and Pacific Islanders, this increase is predicted to be a 285% rise (Parker, 2010, p. 98). A difficulty arises when dealing with non-white elders in long-term care facilities, as there are problems with meeting the multitude of language, cultural, and religious needs. The majority of the time, organizations use a narrow definition of cultural competence and “emphasis [is] placed on translation-interpretation services as the key element in culturally competent care” (Parker, 2010, p. 99). This sole focus on language is an issue as language differences are not the only obstacle faced with cross-cultural understanding for Asian immigrant women. However, it has been found that training targeted at the idea of educating healthcare workers about the different cultural groups’ beliefs, experiences, and values has proven to lead to stereotyping and being largely ineffective. Training healthcare providers about specific cultures is also impractical because cultures evolve over generations. Instead, there is a larger need to improve overall communication skills, reflection, and self-awareness to allow for understanding between Asian immigrants and healthcare workers. It is important for healthcare workers to acknowledge that race and ethnicity are just two of the many diversity factors at stake (Parker, 2010, p. 99).

Horner-Johnson, W., Fujiura, G. T., & Goode, T. D. (2014). Promoting a New Research Agenda: Health Disparities Research at the Intersection of Disability, Race, and Ethnicity. Retrieved from http://www.jstor.org/stable/24465881

Those in other racial and ethnic groups besides non-Hispanic whites are less likely to receive sufficient health insurance coverage and less likely to obtain a usual healthcare source. Minorities frequently face discrimination, language barriers, and cultural misunderstandings in healthcare settings (Horner-Johnson, 2014, p. S1). This contributes to the recorded difference in preventive healthcare for members of underserved racial/ethnic groups.

Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., Smarth, C., Jenckes, M. W., Feuerstein, C., Bass. E. B., Powe, N. R., & Cooper, L.A. (2005). Cultural Competence: A Systematic Review of Health Care Provider Educational Interventions. Retrieved from http://www.jstor.org/stable/3768438

This research paper mentions the definition of cultural competence as “‘the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences’ by recognizing the importance of social and cultural influences on patients, considering how these factors interact, and devising interventions that take these issues into account.” (Beach et al., 2005, p. 356). Data studied in this paper demonstrated strong evidence that cultural competence training affects healthcare providers’ knowledge, as well as impacting the satisfaction of patients. Interestingly, there is weak evidence that treatment compliance or health outcomes are impacted by cultural competence. Positive outcomes are associated with interventions that teach general cultural concepts, specific cultures, or both. All cultural competence training should aim at improving health professionals’ knowledge, skills, and attitudes of healthcare professionals. Notably, it is plausible that healthcare professionals who possess cultural competence may be more skilled in eliciting patient histories, and therefore more accurate diagnoses. However, the most effective training interventions are difficult to conclude due to the diversity of curricular content and methods.

Lauderdale, D. S., Wen, M., Jacobs, E. A., & Kandula, N. R. (2006). Immigrant Perceptions of Discrimination in Health Care: The California Health Interview Survey 2003. Retrieved from http://www.jstor.org/stable/41219540

This research paper provided insights into how immigrants perceive discrimination in health care in California. For all races/ethnicity groups studied, the percentages that reported lifetime discrimination were around double the percentages that reported recent discrimination (Lauderdale et al., 2006, p. 916). Asians had a percentage reporting (for 5-year discrimination reports) of 3.9%. This number is lower than the percentage reporting of Latinos, blacks, and Native Americans, which was 6-7%. One and a half percent of Whites reported discrimination, the lowest percentage reporting (Lauderdale et al., 2006, p. 916). Being of foreign birth itself increases the odds of reported discrimination greatly for Asians and Latinos. Foreign-born Asians, along with foreign-born blacks and Latinos, are much more probable to report discrimination after adjustments are made to care access, socioeconomic status, and home language.

Foreign borns’ sources of usual care are linked to discrimination reports, especially those whose usual source is the emergency room. Intriguingly, “respondents were asked whether there was ever a time when they thought they would have received better medical care had they belonged to a different race/ethnic group. Sixteen percent of blacks, 15% of Latinos, 13% of Asians, and 1% of whites reported this perception” (Lauderdale et al., 2006, p.918). Those born in a foreign country, especially those who are Asian or Latino, report a significantly larger amount of discrimination. This suggests that being foreign-born itself may increase the risk of encountering or perceiving discrimination in the healthcare setting. This is likely due to conflicting cultural beliefs regarding health care or due to structural barriers to access.

Surprisingly, the author notes “For Asians and Latinos, however, race/ethnicity in itself is less likely to be the reason for discrimination; our analysis suggests that factors unique to being foreign-born influence the manner in which U.S. health care is experienced. For the foreign-born, higher [social economic status] is only weakly protective. These data cannot identify what the key cultural, structural, or psychological factors are that increase perceptions of discrimination among the foreign-born, or the extent to which the reports are accurate or reflect differences in expectations or sensitivities.” It would be misleading to omit immigration status in discussions regarding discrimination in health care as nativity plays a pivotal role in how Asians and Latinos perceive discrimination (Lauderdale et al., 2006, p. 919).

Methodology; Ethical Considerations

I gathered information to further my depth of knowledge on this topic by researching the healthcare disparities that Asian immigrant women face, such as language barriers, cultural differences, limited health literacy, lack of awareness of available services, and discrimination. I acquired qualitative research by interviewing three Asian immigrant mothers and one Asian female health care professional who works as a child and adolescent psychiatrist at a hospital. I asked the immigrant women about their experiences on the accessibility of American healthcare when first immigrating, how understandable the American healthcare system was when they first immigrated compared to now, how adjusting to the American healthcare affected their motherhood, what barriers they faced when accessing the American Healthcare, and their overall perception of the American Healthcare system. I also asked them what they thought were possible solutions to making the American healthcare system more accessible.

The interview with the healthcare professional centered on her experiences dealing with families with immigrant Asian mothers, what the American healthcare system is already doing to accommodate immigrant Asians and immigrants in general, what boundaries to accessing healthcare are most pronounced, what the American healthcare system can do in order to improve eliminating these boundaries, and her opinion on non-government organizations that strive to help immigrant Asian mothers achieve better healthcare.

All interviews were done on Zoom, and all the interviews were transcribed and coded. An ethical consideration is the possible triggering of traumatic memories of events from the participants' life. To minimize the risks and discomfort, I informed the informants of the questions beforehand and affirmed that they are free to decline to answer any questions and take a break from the interview at any time.

Data Management, Security, Anonymity of Informants

I stored all the data collected while conducting research on my laptop and paper notes. I made sure to take out all names and any information that could be used to identify an informant.

Data analysis

From my interviews, I coded and organized my data and observations into the themes/ideas: cultural differences, feelings of discrimination, perception of American Healthcare, access to American Healthcare, and possible advancements to making the American healthcare system more accessible. Under each of these sections, I wrote specific details that I gathered from my interviews. I then analyzed similarities and differences between what the informants and the healthcare professional told me, and what implications from their perceptions arise about possible improvements/what is working in the American healthcare system.

Results

While conducting my interviews, I noticed a lot of common topics touched upon by multiple, if not all, informants. All of the informants mentioned the differences between Asian medical philosophies and Western medical philosophies. One example of this is when one informant expressed, “[Chinese] don't like to take so many medications. And then, of course, here in America, people sometimes joke ‘No, darling, you're popping a Tylenol like it's candy.’ You know, you can turn around and just ask anybody, ‘Do you have Tylenol?' and a lot of times people have a bottle in their bag, which was really surprising to me, at least when I first started in nursing school.” It was surprising to learn about the difference in the use of painkillers in Asian countries versus in America. This philosophical difference was also referred to in the journal article Immigrant Perceptions of Discrimination in Health Care: The California Health Interview Survey 2003 by Diane S. Lauderdale, Ming Wen, Elizabeth A. Jacobs, Namratha R. Kandula: a reason for immigrants encountering/perceiving discrimination in America’s healthcare may be contrasting cultural beliefs concerning health due to a lack of cultural competency.

One notable difference I saw between what the informants felt versus what the literature I studied mentioned regarding Asians and healthcare is that all of the informants felt as though they did not face discrimination for being immigrants/Asian/women when accessing healthcare. One thing to note, however, is all my informants contribute this to being able to speak English on at least a conversational level. This implies that language plays a significant role in accessing American healthcare to immigrants.

All the informants noted they felt as though the American healthcare system was effective in providing good health services. One of my informants mentioned when asked how accessible the American healthcare system was to her, “I was pretty amazed at how quickly you could actually get the service. And it was interesting, because I came from a family that has doctors. My mom's a doctor in China and so I'm pretty familiar with the healthcare kind of system, you know, going to hospital in China. So, I was amazed by how quickly I was able to enter the ER and do all the tests and everything.” Although my informants did not have major issues when communicating with doctors, their parents did. Many of the informants’ parents did not speak English and relied on professional translators or family members to communicate effectively with their doctors. This is seen in one informant’s comment: “So every time when [my mom or mother-in-law] has a doctor's appointment, they don't even answer their phone because they're afraid that they won't be able to talk and then therefore they don't, they don't even answer their calls and then they put my number down. The doctor's office always has to call me.” The reliance on family members to serve as translators continued to persist throughout the interviews, signaling that there are not enough translation-interpretation services accessible in the healthcare setting.

When asked what were possible improvements to make American healthcare more accessible, the informants stated a need for more translation services, multi-language medical forms, transportation services for elderly between their homes and doctor offices and hospitals, guidebooks to help immigrants learn the differences between the American healthcare system and their ethnic country’s healthcare system, more outreach by healthcare service organizations to spread awareness to immigrants of available resources, and more inclusive free healthcare.

The healthcare professional expressed similar problems. She stated: “Most Asian families or Asian moms that I work with can speak English. If they speak Cantonese, I am able to converse with them in Cantonese, but not Mandarin – my Mandarin is not great. Interpretation is available, and there are three versions of it: via telephone, in-person – which is really hard to come by now so it should be pre-arranged. And now they have these iPad rovers. The iPad sits on a rolling stand, and it is rolled into the patient's room and then there's an actual video and audio interpreter going on. Sometimes the rover has specific Asian dialects like maybe Fujianese, but beyond that it is limited so you just hope that they speak Mandarin!” The healthcare professional brings light to the point that there are thousands of languages spoken by Asians, and on top of that thousands of dialects. For example, Chinese itself has between seven to ten main language groups, with each group having a number of sub-dialects depending on region (Bolotnikov, 2023).

When asked more about how the language barriers affect Asian immigrant mothers when obtaining medication, the healthcare professional explained: “It's important to be able to find someone that speaks your language. And then there’s insurance, and not knowing if insurance will cover different parts of the process or a procedure. The patient will need to figure out how to call the insurance company and ask all the right questions. Hopefully someone at the insurance company speaks your language and can clarify the situation.” She noted that instead of going to English speaking pharmacies, many immigrant Asians go to “smaller local pharmacies that speak Asian languages and can give them some guidance on medication or answer any questions they have. It's always challenging when they have acute needs and end up being in the hospital.”

When I asked the healthcare professional if she ever experienced any cultural barriers, especially Asian immigrant mothers who did not want to use Western medicine, she exclaimed, “Yes! Especially with my field like psychiatry. There's a negative stigma about mental health. A lot of times I will tell the Asian mother, ‘Your child is really depressed, and we have medications for it. It really works!’ And they're like, ‘No, I don't want medications.’... And a lot of times I let them know they have high blood pressure and will need to take medications for blood pressure. It's the same thing for depression. There’s a need to educate and give information. Some of them hold on to old cultural values, like those around giving birth and not getting up to do stuff.” This lack of willingness for some immigrant families to use Western medicine interferes with their children receiving the best care. The healthcare professional gave an example regarding her attempts to treat children with ADHD, stating “The kids really struggle with sitting still, learning, and doing their homework. Once you treat their condition, the kids are really good at school! They're able to follow instructions and do really well in class. It’s better to acknowledge a mental health condition like ADHD instead of saying “my kids are just lazy; he doesn't do anything and just plays video games.” I point out to them I don't think he's lazy, it's hard for him to focus so they give up. And then after we treat that condition and you see a big turnaround, they're able to follow instructions, do their homework, study and they get the grades. You know it's not laziness per se, it's just that he has problems focusing.” Her answer highlights how cultural differences can make it difficult for doctors and parents to agree about medicine given to their children, which may interfere with children receiving the proper medical care.

When asked what the American healthcare system is already doing to accommodate Asian immigrants and immigrants in general, the healthcare professional responded “First, interpretation services are huge. You need to ensure health care providers like nurses, occupational therapists, doctors, physical therapists, speech therapists, and pharmacists can all provide services in Asian languages as all this is really important. There needs to be diversity in the medical field.” On top of language services, she also advocates for Asian healthcare professionals to “help non-Asian healthcare professionals to better understand Asian patients so instead of blaming these patients for being difficult, it’s really because they are scared about the whole process. [The patients and their families] don't know what's going on.” She has personal success in helping her colleagues deal with Asian immigrant women, as it is “easier for them to learn from a colleague who has had a similar experience rather than from a patient. Doctor versus experience. This helps colleagues better understand the motivation behind certain behaviors.”

Important to note is the lack of independence the language and cultural barrier brings to immigrant Asian mothers: “Because of the language and cultural barriers we talked about, Asian mothers may not be in a position to advocate for themselves. They may be fearful of asking questions because culturally you just listen to what the doctor says. You don't know better. A lot of times, Westerners who are more educated and more tech savvy would have already done some research on their own. They would raise issues and tell the doctor I did all this research online and I did X and Y and here's what I think is going on. Without a language barrier, Westerners are often more effective at advocating for themselves. I often go to great lengths to ensure Asian immigrants … they tend to say: ‘I will just listen to whatever you think is best.’ It's like I have a role in their decision-making, but all I should be doing is giving them the information they need so that they can make the best decision for themselves and their family. This is often new to them because they are more inclined to just think whatever the doctor says.”

When discussing how American healthcare can be made more accessible, the healthcare informant communicated how restrictive access to healthcare is: “I think the whole healthcare system is broken. Resources are limited. Really good cutting-edge quality treatment and quality care is limited. Facilities that are predominantly white people, English speaking, seem so inaccessible to someone who is Asian or another minority group. Focusing on access to care is important. How do we ensure everyone gets access to those cutting-edge treatments? Why is it restricted to places like the upper east side where it's much easier for people with privilege and no language barriers to access it? Sometimes the language barrier prevents you from knowing about better services, you only know Chinatown. So, things like that.”

Lastly, I inquired the healthcare informant about her opinion of nonprofit organizations that strive to help immigrant Asian mothers achieve better health care. She responded, “They are well intentioned, but resources are always limited.” Aligned with what my informants said, “sometimes it’s logistical issues that get in the way. For example, we arrange for a mom to receive care at a hospital, but they live so far away that it would take them a whole day to get there and back by train. They need to take time away from work, and if they don't work, they need to think about feeding and caring for family members at home. So maybe it is just audio social services that you can provide. Or possibly car service to reduce their travel time from 90 minutes to 30 minutes each way. Or sending a bilingual person to attend an appointment with an Asian immigrant woman and act as an advocate for them. Or ensuring non-government agencies can help a family make phone calls to insurance companies and walk them through the process, like how to sign up for something. Those are important.”

Limitations and Delimitations

Limitations include a small informant pool and a lack of standard definition of cultural competency.

Plan for Action, and Need for Further Research

After analyzing the interviews and literature, I believe the most realistic and helpful policies to be passed to make American healthcare more accessible for Asian immigrant mothers would be more medical forms in languages besides English, better advertisement of healthcare service-providing organizations, and more comprehensive education on communication skills and cultural difference regarding different medical philosophies in medical school to ensure doctors are more capable of understanding the point of view of patients coming from a multitude of cultures. Increased research should be done regarding the extent immigrants actively seek out and utilize healthcare services dedicated to educating and providing assistance to immigrant populations. Task forces inclusive of Asian American representatives on cultural competency should help drive those studies. Cross-institution discussions would be beneficial in standardizing a definition of cultural competency.

References