Customized Care
Responding to the health needs of a growing Asian population, nurses strive to provide culturally sensitive and relevant care

By Jessica M. Scully
December 26, 2002

Elizabeth Burton, RN, has been forced to rethink her approach when caring for foreign-born Korean Americans, who now make up more than one-quarter of her patients.

Especially in less-acculturated families, female patients aren't always the ones to make decisions about their own health, said Burton, program coordinator for cancer education and early detection at the Bergen County Department of Health Services in New Jersey. Sometimes, Burton said, that role goes to the woman's husband or her firstborn son.

"That's one of the things we have learned, we have to be sensitive to who makes the decision," she said.

It's been a challenge for Burton, who usually wants patients to feel empowered to make their own decisions. But she's learned a crucial lesson. Without that cultural sensitivity, sometimes women won't show up for their tests or follow-up appointments.

Activists and health workers who care for people of Asian and Pacific Islander descent point out that the myth of the "model minority" is just that-a myth. [This phrase has become a stereotype to describe Asian Americans as the hard-working, well-educated, successful minority race.] Asians have specific health needs that nurses and other health care providers need to be aware of, they say.

Population boom

In coming decades, that knowledge will be increasingly necessary as the number of Americans of Asian and Pacific Islander descent continues its rapid growth. From 1990 to 2000, the Asian American and Pacific Islander population grew at least 48 percent, according to the U.S. Census. The number of Americans of Asian and Pacific Islander descent aged 65 and older is projected to increase even more dramatically: 285 percent between 1999 and 2030, compared to 81 percent for the Caucasian population, according to a 2000 report from the U.S. Administration on Aging.

Medical professionals say Asian Americans and Pacific Islanders, especially recent immigrants, may need different care than patients of other ethnicities. Some suffer from diseases endemic to their countries of origin, like hepatitis B and tuberculosis. Others who have had little contact with Western medicine may rely on traditional medicine or have different social or cultural values that must be taken into account in treatment.

Many recent immigrants don't speak English or understand how to access health care. Asian Americans are exceptionally diverse, coming from many different countries and speaking hundreds of languages. Health problems can vary dramatically among people from different subgroups, like Indian, Japanese and Vietnamese.

In the past few years, medical research and cultural competency have improved, especially in areas with large Asian and Pacific Islander populations. But as the populations continue to grow, so too will the need for culturally competent health care. In coming decades, more and more nurses will need to learn how best to care for Asian Americans.

California, parts of Washington state and New York-areas with large Asian-American and Pacific Islander populations-have been on the forefront of caring for Asian Americans.

The Asian Counseling and Referral Service is one example in the Seattle area. The service operates from an office in the heart of the primarily Asian International District, and offers a continuum of services, including an emergency feeding program stocked with Asian diet staples, a substance abuse treatment program and programs for children, youth and families. The center began small but has grown dramatically, from 100 clients in 1973 to 15,800 clients in 2001.

Jeannie-Trang Nguyen, RN, and Hanh Lai, RN, are two of the six nurses working for the service. Nguyen has worked as a nurse consultant for the service for the past six years. Lai has worked in the same position for three years. Most of their patients do not speak English.

Both women are Vietnamese American and bilingual. That helps dramatically with Vietnamese-American patients, they said. But together, the nurses serve about 1,000 people who speak a total of 10 different languages.

In their home visits with clients, the nurses know that they will be asking very personal questions, and it's important that their patients trust them.

"Every time we go to see a patient when we don't speak the language, we ask the case manager to write down some basic questions [in the language], like 'How are you?' and 'Are you in pain?' and ways to address them appropriately," Lai said. "By doing that, we break the ice."

Distinct needs

Because they deal with various ethnicities, Nguyen and Lai know the special problems related to some. Respiratory problems, including tuberculosis, are significant problems for some Asian subgroups. For people coming from highland Laos, opium addiction can be an issue, they said.

The nurses may not speak all the languages of their patients, but they do have one thing in common with many of them-a shared understanding of war. Both nurses lived in Vietnam during the war, and Lai, for one, still has nightmares.

"Sometimes, I still have very bad dreams, so I can really understand where our patients come from, and why they [have] so much suffering and depression and other illnesses," she said.

Both nurses feel their experiences help them relate to people from Asian countries that underwent horrible strife and war.

"For every Cambodian family, we acknowledge they are survivors," Nguyen said. "We know that and we feel that for them."

Barbara Masterson, RN, a wellness nurse at Yu-Ai Kai, an organization in San Jose, Calif., that offers social services and assistance to elderly Asian Americans, primarily Japanese Americans who speak English, has had the opposite experience. She has found that not being Asian herself sometimes has been to her advantage.

Masterson said that because she isn't Asian, sometimes her patients are more comfortable talking about their health problems.

"It's a very small community, it's like a small town where everyone knows everyone," she said. "They know that I won't go and blab something accidentally, because I'm not a cousin of someone else."

Masterson also has helped Yu-Ai Kai bring attention to an increasing health problem among its patients: breast cancer.

Although breast cancer rates for Asian-American women of different ethnicities are lower than for other racial groups, they are increasing with every generation. A five-year study of women in Los Angeles published in a 2002 issue of the International Journal of Cancer found that breast cancer rates for Asian women older than 50 were increasing by 6.3 percent each year. Caucasian women were the only other group to show an increase, but it was just 1.5 percent annually, according to the study.

Japanese-American women now have nearly the same breast cancer risk as Caucasian women, according to studies from the Northern California Cancer Center.

Because a Western diet is thought to contribute to breast cancer, one of the things Masterson focuses on is nutrition.

"Although they eat the rice and the fish and things, they don't have a whole lot of fiber, so we try to increase the fiber in their diet," she said. She encourages patients to eat whole-grain breads and to eat less soy sauce to reduce sodium.

The San Francisco Bay Area and Seattle have developed programs like those Masterson, Nguyen and Lai work for, partially because the Asian-American population has been substantial there for decades.

But others have had to come up to speed more quickly. In Bergen County, N.J., for example, Burton said the Asian-American population has doubled in the last 10 years.

Because of the large Asian population, Burton applied and was accepted for a cultural competency training program run by the National Asian Women's Health Organization.

One of the first things the organization told her was that the idea that Asians are a model minority is a myth.

Culture shock

"There's a perception that they're a healthy group: they're thin, they eat vegetables, their kids go to Ivy League colleges," Burton said.

But besides increasing rates of breast cancer, Asian Americans have other health problems. For example, Vietnamese-American women have five times the cervical cancer rate of Caucasian women, according to the Northern California Cancer Center. The women tend to come in with more advanced forms of the disease with no prior Pap tests, according to the center.

Burton, who knows the importance of the Pap tests, mammograms and colorectal screenings, said she has found that although Asian Americans of different ethnicities vary dramatically, "a lot of the cultures value a group decision or group harmony over an individual decision."

Some, especially recent immigrants, stigmatize certain health conditions, like yeast infections.

"There are certain stigmas to these things, like 'Oh, maybe she's been fooling around,' whereas a yeast infection can happen to anyone," she said.

Burton and the county health department have identified other obstacles to patients coming to appointments, like a lack of transportation or lack of understanding of the system, and worked to solve them. When patients are given test results, the department uses three-way calling with a translator, the nurse and the patient, which allows patients to ask questions.

To encourage more Asians to come for testing, the department has chosen as interpreters leaders from the local Korean-American community, including one breast cancer survivor.

"We want people to come in every year, proactively," Burton said. "I think once they've come and they've had a good experience, they'll tell other people. We may not be perfect in our efforts, but I think they know we have a sincere heart and we try."

Contact Jessica M. Scully at Jessicam_scully@yahoo.com