CONTEXT: Primarily because of immigration, Asian Americans are one of the fastest growing and most ethnically diverse minority groups in the United States. However, little is known about their perspectives on health care quality.
OBJECTIVE: To examine factors contributing to quality of care from the perspective of Chinese- and Vietnamese-American patients with limited English language skills.
DESIGN: Qualitative study using focus groups and content analysis to determine domains of quality of care.
SETTING: Four community health centers in Massachusetts.
PARTICIPANTS: A total of 122 Chinese- and Vietnamese-American patients were interviewed in focus groups by bilingual interviewers using a standardized, translated moderator guide.
MAIN OUTCOME MEASURES: Domains of quality of care mentioned by patients in verbatim transcripts.
RESULTS: In addition to dimensions of health care quality commonly expressed by Caucasian, English-speaking patients in the United States, Chinese- and Vietnamese-American patients with limited English proficiency wanted to discuss the use of non-Western medical practices with their providers, but encountered significant barriers. They viewed providers' knowledge, inquiry, and nonjudgmental acceptance of traditional Asian medical beliefs and practices as part of quality care. Patients also considered the quality of interpreter services to be very important. They preferred using professional interpreters rather than family members, and preferred gender-concordant translators. Furthermore, they expressed the need for help in navigating health care systems and obtaining support services.
CONCLUSIONS: Cultural and linguistically appropriate health care services may lead to improved health care quality for Asian-American patients who have limited English language skills. Important aspects of quality include providers' respect for traditional health beliefs and practices, access to professional interpreters, and assistance in obtaining social services.
Little research has examined how people from different cultures assess the quality of their experiences with Western medicine. What do people from non-Western medical traditions think about their experience when they seek or need care from Western providers unfamiliar with their beliefs and practices? This question becomes more important with rising populations of immigrants from non-Western societies. Over the past 30 years, the migration of Asians and Pacific Islanders (API) to the United States has risen by more than 400%.1 API Americans are one of the fastest growing minority groups in the country. Many Asian medical beliefs and practices differ significantly from standard Western approaches. Most Western-trained clinicians know little about such beliefs and practices. For example, some Chinese- and Vietnamese-Americans believe that health and illness reflect the internal balance of “yin and yang,” hot and cold forces within the body. Others believe that certain illnesses are caused by spirits or ghosts. Some patients use acupuncture or herbal medicine to supplement Western therapies. Others practice “coining” or “cupping,” medical practices that leave bruises on the skin.2 Western clinicians may mistake these bruises for indications of abuse or signs of hematological diseases. Providers may need to be able to talk about these deeply held, health-related beliefs and practices to effectively care for their patients.
Previous research showed that Asian Americans reported worse health care experiences than white, African-American, or Latino patients,3,4 that they were more likely to be dissatisfied with care, and that they rated primary care performance lower than did other racial/ethnic groups.5–7 We sought to understand more about how Asian-American patients perceive the quality of their health care, especially as it intersects with their culture. Although substantial patient-centered research on quality has been done, patients who speak little or no English have often been excluded.8 Asian-American immigrants who speak limited or no English may encounter more barriers to quality care than other Asian-American immigrants. Our study aimed to measure patients' perceptions of health care experiences by examining the views of Chinese and Vietnamese immigrants who have no or limited English language proficiency. We chose to study these 2 groups because they are the largest subgroups of Asian Americans in Boston and also because they have high percentages of recent immigrants with limited English proficiency.9 Large numbers of new Chinese immigrants came to Boston in the 1970s, '80s, and '90s after the 1965 Immigration and Nationality Act amendments lifted restrictions on immigration.9 Vietnamese immigrants came to Boston in multiple waves after the end of the Vietnam War in 1975. They were more likely than the Chinese immigrants to have suffered premigration trauma, which occurred during the Vietnam War and afterward in refugee camps or Communist “re-education” camps.10,11 The most recent Vietnamese immigrants are primarily Amerasians (children of American soldiers and Vietnamese mothers born during the Vietnam War) and political detainees (former South Vietnamese army officers sent to Communist labor camps for collaborating with the United States during the war).12 We examined the perspectives of these recent immigrants with limited English language proficiency who may be more vulnerable to poor quality care.
Our focus group results show that Chinese and Vietnamese immigrants with limited English proficiency have some concerns that their providers and health care systems must address. Some needs are unique to their cultures; other needs are similar to those of other new immigrants with limited English skills; while other needs are shared with all patients. Newly described aspects of quality include providers' respect for patients' traditional beliefs and practices, access to trained interpreters, and the availability of social services.
Traditional treatments such as coining (cao gio) and cupping (giac hoi) and the use of herbal medicine are part of the cultural practices of many Chinese- and Vietnamese-American patients. We found that patients used traditional remedies and herbs either before seeing a Western provider or concurrently. This finding is consistent with other studies on the use of folk remedies among Puerto Rican and Mexican immigrants in the United States.2,23 Previous research has documented the use of folk remedies among Vietnamese immigrants.24 However, to our knowledge, our study is the first to find that these patients wanted to discuss their beliefs and practices, but were reluctant because of previous negative responses from their providers. They viewed providers' knowledge, inquiry, and nonjudgmental acceptance of their beliefs and practices as being a part of effective patient–provider communication.
The quality of interpreter services was another key concern of the patients in our study. They preferred using professional interpreters rather than their own family members or ad hoc bilingual personnel, which could result in inaccurate translations.25 Furthermore, patients were acutely aware that much of what they say to providers, and much of what is said to them, may be censored by the interpreter. Although quality measures such as the Health Plan Employers Data and Information Set (HEDIS 3.0) now include an indicator for the availability of interpretation services, the quality of the services is not considered. Patients also preferred gender-concordant interpreters, especially when discussing sensitive issues. This finding is consistent with studies of LEP Latino patients that found similar concerns and preferences.26,27 However, the study conducted by Kuo and Fagan showed that some Spanish-speaking patients may prefer using family and friends to translate rather than using an unfamiliar interpreter.27
The availability of social support services was a new quality dimension found to be important to LEP Chinese and Vietnamese patients. This dimension may reflect a need or expectation that is similar to that of other vulnerable patients who may have problems navigating complex medical and social service institutions. Previous research conducted among patients who are not Asian Americans found that patients at an urban, inner-city clinic may require more social support than do more affluent patients who obtain care at a suburban health center.28 In our study, the participants did not read or speak English well and relied on providers and clinic staff to assist them in other areas of life, such as housing or immigration. In addition to having limited English proficiency, our study participants had low levels of education and low income. The need for more social services may have been primarily related to their low socioeconomic status. Because of the qualitative nature of our study, we could not differentiate whether patients' perceived needs for social services were related primarily to cultural, linguistic, or socioeconomic factors. Additional research using quantitative methods may be able to clarify how low socioeconomic status interacts with culture and language to shape patients' health care needs.
Limited English-proficient Chinese- and Vietnamese-American patients identified some quality domains that are similarly important to all patients. These domains are measured by existing surveys such as the Picker and CAHPS instruments.15–18 However, the Picker instrument does not contain questions about cultural issues or interpreter services. It has been tested primarily among white, English-speaking populations. CAHPS 2.0 is currently being tested among Spanish-speaking patients.20 Its supplemental item set contains questions about the availability of interpreters, but does not ask about interpreter quality.18 Using information obtained from our focus groups, we are currently developing and validating a structured survey to assess quality of care among Chinese- and Vietnamese-American patients with limited English proficiency.29
Our study has 2 types of limitations: the first group of limitations is inherent in qualitative research; the second group of limitations is related to the lack of generalizability to other Asian-American populations. First, although focus group research is an effective method for identifying and exploring health-related perceptions and needs, results can be biased and may not represent all patients' experiences. Patients who do not regularly visit a health center are unlikely to be asked to participate, and the views of more articulate members are more likely to be represented. We also may not have elicited all quality domains important to patients, although we used open-ended questions to lead the discussions.
Second, our study population was limited to patients of Chinese and Vietnamese origin, whose views may not generalize to other Asian-American populations. As noted previously, the Chinese and Vietnamese have different migration patterns and may differ in other ways.9 However, because of the qualitative nature of our study, we could not quantify any significant differences between the results obtained from the Chinese focus groups as compared to the Vietnamese focus groups. Third, the respondents in our study were primarily recent immigrants, had limited English proficiency, and had lower socioeconomic status. Therefore, their views cannot be generalized to more-educated Chinese and Vietnamese immigrants or to immigrants who have resided in the United States for longer periods of time and who may be more fluent in English and have higher socioeconomic status. Furthermore, the respondents were all first-generation immigrants, and their views cannot be generalized to second- or third-generation Chinese- and Vietnamese-Americans who may be more acculturated. Fourth, we did not measure the acculturation levels of our study participants. Degrees of acculturation to Western culture may affect how patients view non-Western medicine and how they perceive their health care in the United States. Finally, the focus groups were all held in Massachusetts in community-based health centers with relatively large proportions of Asian-American patients. These patients' experiences may not generalize to Asian-American patients who obtain care in other settings.
Despite these limitations, our study provides new knowledge about the health care needs of populations that have historically been under-studied. The patients who participated in this study may be more vulnerable to poor quality care because of cultural, linguistic, and socioeconomic barriers. Addressing these barriers, at both the provider and system levels, can lead to improved care for these patients and their families.
In our study, patients wanted providers to respect their culturally based health beliefs and practices. Clinicians should be aware of potential differences between the biomedical model of disease and a patient's belief systems. Providers should ask patients directly about their health beliefs and their use of non-Western therapies. The best source of information regarding their beliefs and practices are the patients themselves. Asking the patient directly would prevent any assumptions or stereotyping. Our study found that patients welcome provider initiatives in opening the lines of communication around these issues. Providers should also ask patients about social factors that are most pertinent to the medical encounter. Previous research has shown the inextricable link between social factors and patients' health status.30–33 Defining the patient's social context may include questions about education, employment, migration history, social networks, and literacy (in English and in the patient's native language).34 These questions allow providers to assess patients' needs that may affect their ability to participate in the treatment plan (financial ability to obtain medication, ability to read medication labels, etc). Taking a comprehensive social history would enable clinicians to provide appropriate health education materials and appropriate referrals to social services, aspects of care important to patients.
Limited English-proficient Chinese and Vietnamese patients voiced the need for help in accessing social services and navigating complex medical and social service institutions. Bilingual, bicultural social workers and health care advocates may play key roles in improving patient care. These community health workers may work as members of the health care team to facilitate patient and community access to the health care systems, educate providers about cultural concerns, and improve the continuity and coordination of care.35 If a health care facility does not have adequate resources to provide such programs, it is crucial that referrals be made to other agencies that may be helpful to patients.
Health care systems must also recruit bilingual, bicultural personnel and professional interpreters. If individual medical facilities lack the resources to have on-site professional interpreter services, multiple institutions can combine resources to support community-sponsored interpreter banks.36 Although using professional interpreters is the highest quality standard of care, institutions that use ad hoc bilingual staff to interpret must design ways to formally assess and advance the skills of their bilingual employees utilized as interpreters.36 The quality of interpreter services should be continually monitored by obtaining structured feedback and evaluations from the patients and their providers. Monolingual providers must also receive training in how to most effectively use interpreters and how to assess problems that may arise in the provider-interpreter-patient interaction. This training is especially important given previous research showing that less communication is taking place between patient and clinician during encounters requiring interpreters.37 For many health care facilities with limited budgets, finding ways to financially support quality interpreter services may be difficult. States with large numbers of LEP patients should follow the example of Washington state, where Medicaid reimburses for outpatient interpreter services, and hospitals are required to provide trained interpreters.38 A recent report released by the Commonwealth Fund profiles 14 programs around the country that provide interpretation services, and also identifies public and private funding sources for interpretation services in the health care setting.39
On a system level, it is important to train clinicians and other staff to increase their understanding about the history, culture, and health beliefs and practices of Chinese and Vietnamese immigrants. However, rather than simply learning the stereotypical cultural traits of specific ethnic groups, clinician training should focus on how to ask appropriate questions to obtain information on each individual patient's cultural and social factors. Clinicians must be taught how to handle conflicts that may arise when provider and patient disagree on the role of traditional practices. Cross-cultural medical education curricula have been developed to address these issues.34,40 Further research is needed to evaluate the effectiveness of these curricula, and to evaluate how culturally sensitive medical care affects patient satisfaction and outcome.
More research is needed to better understand how cultural and linguistic concerns can guide quality improvement efforts. Providing quality care to culturally diverse patients who have limited English skills is a challenge. Finding ways to overcome cultural, linguistic, and other social barriers may lead to improved care and a more satisfying encounter for patients and their providers.