Abstract
Context:
Type 2 diabetes mellitus is a global health issue among Asians, with rising prevalence and increasing disparities in proper disease management. However, studies on the perceptions of and attitudes toward diabetes, conducted to improve diabetes disparities, are disproportionately limited in Asian populations compared with other minority populations in the United States.
Objective:
To determine Chinese Americans’ perceptions of and attitudes toward diabetes.
Methods:
Chinese Americans from the greater Los Angeles, California, area were asked to complete a survey. The survey was a self-administered 15-item true/false questionnaire to assess the respondents’ perceptions of and attitudes toward diabetes. The results of the questionnaire were grouped by age: younger adults (aged <55 years) and older adults (aged ≥55 years). A subset of respondents in each age group was matched based on gender and education, and their responses were analyzed for differences in attitudes toward diabetes. Two-tailed t test and χ2 test were used to compare continuous variables and categorical variables, respectively. Results with P<.05 were considered significant.
Results:
A total of 449 of 485 Chinese Americans (93%) completed the survey. Among matched respondents (n=91 in each age group), more older respondents than younger respondents believed that (1) research on diabetes is solely beneficial for profiting pharmaceutical companies (23.1% vs 6.6%; P=.002) and (2) health insurance policies should not cover any costs of diabetes-related illnesses (28.6% vs 15.4%; P=.032).
Conclusions:
Older Chinese Americans were more likely to hold stigmatized negative perceptions of and attitudes toward diabetes in relation to pharmaceutical companies and health insurance policies. Considering that an individual's belief system largely influences self-care behaviors, actions should be taken to minimize negative perceptions of and attitudes toward diabetes.
An estimated 16.6 million Asians reside in the United States, comprising 5.2% of the population.
1 Asians are the fastest growing racial group in the United States, outpacing the general US growth rate by 13%.
2 According to the US census 2016 estimates, Chinese Americans are the largest subgroup of Asians, numbering more than 3.9 million.
1 In addition, type 2 diabetes mellitus is a growing public health issue for Asians. Previous studies have shown that the age-, sex-, and body mass index–adjusted prevalence of diabetes in Asians was approximately 60% higher than in non-Hispanic whites.
3 Despite having a lower mean body mass index than whites, Asians have a greater prevalence of diabetes than whites, blacks, and Hispanics in the same body mass index category,
4 suggesting that Asians have a greater genetic predisposition to diabetes. Diabetes prevalence continues to rise in the Asian population, with 10% of Asians having diabetes, the majority of whom have type 2 diabetes.
5 Among patients with diagnosed diabetes, Asians are less likely than whites to receive diabetic services across all age, sex, and socioeconomic groups.
6 Therefore, studies on Asians’ perception and management of diabetes are crucial in understanding such a health care discrepancy.
Many studies have shown improved patient outcomes (eg, lower hemoglobin A1c [HbA
1c] levels, better self-care practices, increased health care satisfaction) from incorporating cultural and linguistic components with diabetes management.
7 For example, community-based, culturally tailored diabetes prevention programs for overweight Hispanic adults to improve weight loss, waist circumference, diet and physical activity self-efficacy, and diet behaviors resulted in significant improvements.
8 However, although many studies have focused on alleviating poor self-management practices and diabetes-related complications among Hispanic and black populations, little is known regarding these issues in Asian populations, whose prevalence of undiagnosed diabetes in the United States is 3 times higher than the national average.
9 Poorer diabetes management, with significantly less adherence to eye examination and monitoring of feet, HbA
1c levels, and glucose levels, have also been identified in Asians compared with blacks and Hispanics.
9 However, research conducted to improve diabetes disparities in Asians continues to be disproportionately limited considering the increasing population growth of Asians in the United States and the demonstrated need for reducing disparities.
10 Furthermore, Asians constitute a heterogenous group of diverse ethnicities, and studies specific to Chinese Americans are rare.
Even among the Chinese American population, there lies a vast heterogeneity in language, education, and socioeconomic status.
11 Immigration and reconciliation of traditional values with surrounding social change influence evolving cultural beliefs among Chinese Americans.
12 Lack of culturally appropriate diabetes education and communication contribute to disparities in diabetes control in Chinese Americans. For example, despite the presence of translated education materials and availability of English-Chinese translators in federally funded clinics, first-generation Chinese Americans find translated materials about diabetes to be culturally inapplicable and not useful in their daily lives.
13,14
In the present study, we aim to understand the perceptions of and attitudes toward diabetes among Chinese Americans. We specifically examine the older Chinese American population, whose longstanding cultural norms and beliefs may have a more substantial influence on the perceptions of and attitudes toward diabetes as compared with their younger counterpart. Language barriers and cultural, structural, and personal factors have been shown to contribute to health risks (missed diagnoses, disabilities, higher mortality rate) and affect health literacy in Chinese Americans with diabetes.
15,16 In this study, we identify barriers to improving diabetes management among Chinese Americans, particularly in older Chinese Americans.
Chinese Americans from the greater Los Angeles, California, area were asked to complete and return a paper survey at the beginning of a community health seminar in 2014 on the topic of aging and mental health. The seminar was advertised at churches, on the radio, and in newspapers. Inclusion criteria were providing informed consent (via signature on the front page of the survey), being literate in written Chinese, and being aged at least 18 years. All participants were self-reported as Chinese immigrants and were not born in the United States. Demographic characteristics, including age, gender, education, and years residing in the United States, were also collected. This study was approved by the institutional review board at the University of California, Los Angeles.
The survey was a self-administered questionnaire to assess respondents’ perceptions of and attitudes toward diabetes. It consisted of 15 true/false questions, which were written in traditional Chinese characters and adopted from a previously validated survey used for gaining insight into perceptions of dementia among Chinese Americans.
17,18 The following is a sample question used from the survey: “True or false? Diabetes is different from other physical illnesses (eg, high blood pressure).”
Results were evaluated by age group: those younger than 55 years and those aged 55 years or older. The age of 55 years or older has been used in previous studies to identify older adults in the Chinese American population.
19,20 Among the total number of respondents, a subset of younger respondents were matched with a subset of older respondents based on gender and education. Respondents were matched to reduce bias from confounding factors and analyze the comparison of perception outcomes based on age. The cross-sectional survey data were analyzed using 2-tailed
t tests and χ
2 tests to compare continuous variables and categorical variables, respectively. Results with
P<.05 were considered statistically significant. The statistical review of the study was performed by a biomedical statistician.
Of the 485 people invited to participate, 449 (92.6% participation rate) completed the survey. Among the 449 respondents, the mean (SD) age was 54.7 (8.9) years; 147 (32.7%) were men and 302 (67.3%) were women. A total of 290 respondents (64.6%) completed high school. The duration of US residence included 298 respondents (66.4%) residing in the United States for fewer than 20 years and 151 (33.6%) residing in the United States for at least 20 years. The mean (SD) age of the younger group was 51.0 (5.3) years and the older group was 64.2 (5.5) years.
Of the 91 pairs of matched respondents, 60 (65.9%) were women and 31 (34.1%) were men. A total of 59 respondents (64.8%) completed high school in each group (
Table 1). For the older group, the duration of residence included 10 respondents (11.0%) residing in the United States less than 5 years, 35 (38.5%) residing 5 to 19 years, and 46 (50.5%) residing at least 20 years. For the younger group, the duration of residence included 13 respondents (14.3%) residing in the United States less than 5 years, 47 (51.6%) residing 5 to 19 years, and 31 (34.1%) residing for at least 20 years (χ
22=5.07;
P=.0793).
Among the paired respondents, significant differences were found in the perceptions of and attitudes toward diabetes in older respondents compared with younger respondents for 3 of the 15 stigma items (
Table 2). The older group was more likely to report negative perceptions of and attitudes toward diabetes in relation to pharmaceutical companies and health insurance policies. In comparison with the younger respondents, significantly more older respondents agreed that “research on diabetes is nothing but a good way for pharmaceutical companies to make profits” (21 [23.1%] vs 6 [6.6%];
P=.002). Similarly, more older respondents agreed that “health insurance policies should not cover any costs of diabetes” (26 [28.6%] vs 14 [15.4%];
P=.032). More respondents in the younger population agreed that “only those with a low educational level would develop diabetes” (9 [9.9%] vs 0 [0%];
P=.002).
Over the next 50 years, the number of adults aged 65 years or older in the United States is estimated to increase 138%.
21 Adults aged 85 years or older use substantially more heath care services than the younger population, and they are currently the fastest growing segment of the older population.
21 Older adults, especially in minority populations, are also more likely than younger adults to have chronic illnesses, with approximately 84% of older adults having at least 1 chronic illness, such as diabetes or cardiovascular disease.
15,22
The anticipated growth of the elderly population will have an unprecedented effect on the US health care system, not only in regard to the demand for health care professionals, but also the types of the skills the health care workforce must be prepared to provide.
21 For instance, the elderly population will be increasingly diverse, both racially and ethnically. By 2050, minorities are expected to account for 50% of the elderly population, with the Asian elderly population projected to outpace the black elderly population in their rate of growth.
15,22 Furthermore, minority elders are less likely to receive routine medical care and are more likely to receive markedly lower quality of care than their white counterparts, exposing them to greater risk for missed diagnoses, disabilities, and higher mortality rates.
15 Therefore, it is crucial for health care professionals to be more culturally competent, especially in the geriatric community, to meet the demands of a diverse and changing demographic.
Although prior studies have aimed to better understand diabetes prevalence and risk factors in Asians, limited research is available on Chinese Americans’ perceptions of and attitudes toward diabetes, and no research, to our knowledge, has compared such perceptions in Chinese Americans younger than 55 years with those aged 55 years or older in a quantitative manner.
9,10 The current study aims to identify Chinese Americans’ specific negative perceptions of and attitudes toward diabetes and reduce the heterogeneity of their backgrounds during comparative analysis. The latter was accomplished by matching our survey respondents based on gender and education and comparing responses between the 2 age groups of Chinese Americans.
This study found that older Chinese Americans were approximately 3.5 times more likely than younger Chinese Americans to hold negative perceptions of diabetes in relation to pharmaceutical research and 2 times more likely to have a negative perception of health insurance coverage. More specifically, approximately 1 in 5 older Chinese Americans believed that research on diabetes is a frivolous means for pharmaceutical companies to make profits. Additionally, almost 1 in 4 older Chinese Americans believed that costs of diabetes-related illnesses should not be covered by health insurance.
One of the reasons for increased negative perceptions and attitudes by elderly Chinese Americans regarding pharmaceutical research and health care coverage of diabetes may stem from their low satisfaction with the US health care system in general. Previous studies have shown that elderly Asian Medicare beneficiaries receive poorer quality of care than their white counterparts.
5 Among Medicare managed care enrollees, elderly Asians rate their physicians and overall health care lowest of any group, and they report more problems with getting needed care and with physician communication compared with that of whites. Elderly Asians are also more likely than elderly whites to report that their physicians do not understand their backgrounds and values or listen to them.
23
Many elderly Chinese immigrants have chronic illnesses, such as diabetes, hypertension, and stroke, and their Medicare eligibility allows them to receive more health care and social services compared with their younger counterparts.
24 However, Chinese elders underuse health care and disregard routine checkups. One reason pertains to a fear and distrust of Western medicine, which is considered unnecessarily invasive or ineffective. Such distrust among older Chinese Americans may be strengthened by their strong level of identification with traditional Chinese health beliefs (eg, acupuncture, herbal medicine).
25 Combined use of traditional Chinese medicine and Western medicine has been shown to be common among elderly Chinese Americans, and Chinese Americans who do not assimilate to American culture may not seek medical care from Western-trained doctors.
26 In the case of diabetes, patients may be noncompliant with insulin and other medications. By contrast, Chinese Americans who are assimilated are more likely to have private health insurance and social support and to report better quality of life.
27
Fifty percent of Chinese Americans continue to live in linguistic isolation, which poses a barrier to health care access.
1,28 Limited English proficiency may further cause patients to decline preventive diabetes care and to seek care only in urgent situations.
28 Chinese Americans who speak Chinese, rather than English, as their primary language tend to have higher HbA
1c levels and less knowledge about diabetes.
10 The existence of various Chinese dialects is problematic in health care administration in Chinese Americans because it hinders the ability to find transportation, schedule appointments, and use appropriate interpreters.
24 Better communication through team-based care has long been recognized as an essential component of high-quality diabetes care and patient satisfaction.
29 Therefore, it would not be illogical to speculate that the limited patient satisfaction rate and cultural barriers experienced by elderly non–English-speaking Chinese Americans contribute to their negative perceptions of and attitudes toward diabetes overall.
In addition, Chinese Americans’ high regard for authority figures such as physicians has been shown to hinder the development of Chinese immigrants’ capacity to obtain additional information about their treatment regimen, communicate their needs and preferences with professionals, and seek clarification of explanations.
16,30 Chinese elders were also more likely to value self-care, peer advice, or expected care from their adult children over professional advice from a physician.
24 Their desire for a collective approach to health management in a supportive learning environment with peers may further prevent Chinese elders from independently seeking individual doctor's appointments.
16
The present study had several limitations. First, data were based on a cross-sectional survey that relied on self-reported data; thus, our findings are subject to report biases inherent in these approaches. Second, the survey was brief and excluded some specific aspects of diabetes. It also did not directly assess the stigma of diabetes. Third, the diagnosis of diabetes among respondents was not inquired; therefore, individuals with diabetes were not excluded from the study. Fourth, due to the true/false response format, there may be lower variance among the items. Future studies should use scales with established psychometric properties and cut-off scores. Fifth, there were no other differences in sociodemographic factors between the age groups. As such, we did not perform logistic regression to examine predictors. Future studies may focus on identifying additional sociodemographic characteristics with significant test of interaction and use logistic regression to examine whether perception of diabetes may be a useful predictor for high baseline diabetes knowledge. Last, with the possibility that people with bias about diabetes may have less interest in attending a community health seminar, this study may underestimate the bias by collecting data from seminar attendees.
The present study revealed a significant difference in attitudes toward pharmaceutical research and health care insurance coverage of diabetes in Chinese Americans aged 55 years or older compared with those younger than 55 years. Chinese Americans make up the largest subgroup of Asians in the United States, with 50% living in linguistic isolation and facing rising diabetes prevalence.
1,3 However, limited research has been conducted on their general health practices and perceptions and attitudes. Efforts to reduce the general public's negative perceptions of and attitudes toward diabetes are critical to reduce disparities in health care and diabetes control, especially in the older Chinese American community.
Reflective of the osteopathic philosophy of treating the whole person—body, mind, and spirit—and focusing on preventive medicine, it is crucial for physicians to understand patients’ perceptions of and attitudes toward their diseases.
31 The osteopathic philosophy of helping patients use their own self-healing and self-regulatory capabilities (eg, exercise, nutrition, lifestyle changes, community resources) also portrays proficient patient education as a collective and integral part of the management process.
32 As culture also affects the way patients communicate their health concerns and conduct self-care behaviors, it is crucial for health care professionals to understand the stigma and perceptions influencing ethnic minority populations.
33
We thank the survey respondents.