Essentials of Cultural Competence in Pharmacy Practice: Chapter 8 Notes Chapter Authors: Dr. Janie Pinterits and Mr. Joshua Voytek Asian American Patients

Learning Objectives 1. Identify the complex and heterogeneous nature of patients classified as Asian Americans. 2. Articulate the communication styles present in Asian culture and the impact on delivery of pharmaceutical care 3. Describe the holistic approach to medicine employed by some Asian American patients and the challenges it may pose to your role as a pharmacist. 4. Understand the family and work roles that may be present in Asian American patients and their effects on health care and pharmacy practice. 5. Identify the high risk behaviors present in some Asian American patients.

Who Is an Asian/Pacific Islander? The U.S. Census identified twenty-four Asian subethnic groups in the U.S. However, more than fifty identifiable subethnic groups exist. Asians and Pacific Islanders (API) are defined as “a person having origins in any of the original peoples of the Far East, southeast Asia, the Indian subcontinent, or the Pacific Islands. East Asian Americans consist of, for example, people of Chinese, Taiwanese, Japanese or Korean descent. Most Southeast Asian Americans are of Cambodian, Filipino, Hmong, Laotian, Thai or Vietnamese descent. South Asians are of, for example, Indian or Pakistani descent. Pacific Islanders are often of Native Hawaiian, Samoan, Guamanian, Chamorro, Tongan or Fijan descent. The largest group of Americans of Asian descent are the Chinese, with 23.1%. Filipinos comprise 18.5% and Asian Indians make up another 17%. Globally, Asians constitute more than 56% of the world’s population (China 21% & India 16%). According to U.S. Census data from 2000, the API population in the U.S. totaled 12,773,242 people (4.23 percent).

Within/Between Group Differences… Important between-group differences among Americans of Asian descent contribute to current and historical dynamics of Asian Americans. For example, East Asian groups such as Chinese, Japanese, and Korean Americans are strongly influenced by Buddhism and Confucianism, as well as by Taoism in China, Shintoism in Japan, and Christianity in South Korea.

Immigration The Chinese were the first to immigrate in large numbers, when an influx of almost 300,000 people, largely males, came to participate in the Gold Rush after Japanese immigration began after the Chinese Exclusion Act as a new source of cheap labor for the Hawaiian plantations. About 150,000 Japanese settled in Hawaii, and 30,000 went to California from 1882 to First large influx of Filipinos came after the Philippines was ceded to the U.S. after the defeat of Spain in the 1892 Spanish-American war. Vietnamese Americans first immigrated in large numbers in 1975 with the fall of Saigon. Approximately 131,000 Vietnamese arrived.

Communication Among Asian American groups, at least 32 different primary languages are spoken. Each Asian American ethnic group has its own dominant language and some groups have several languages. Within each group, there can be many dialects of the same language. In India the national language is Hindi, but English and fourteen major languages are spoken as well, in addition to hundreds of regional dialects.

Limited English Proficiency Proficiency in English varies greatly among the different Asian American groups. Generational effects: Most American-born Asians speak English fluently, with no accent, but may not speak their mother tongue at all. Second-generation Asian Americans may be required to be bilingual or multilingual to bridge the gap in their parents’ limited English proficiency (LEP). The majority of foreign-born Asians struggle with the English language and continue to speak their primary language at home.

President’s Advisory Commission on Asian Americans and Pacific Islanders (2001) Findings: 42% of Vietnamese American, 41% of Korean American, and 40% of Chinese American households are “linguistically isolated,” which means that no one in the household age 14 years or older speaks English “very well.”

Nonverbal Communication In Asian cultures, touch, eye contact and greetings comprise an important part of nonverbal communication

Eye Contact Rude and an indication of annoyance. Therefore, avoidance of eye contact demonstrates respect, rather than repression, especially toward authority and older individuals. Due to the value placed on conformity to normative behavior, Asian Americans are likely to increase eye contact in dealing with non-Asian Americans, since non-Asian Americans customarily maintain more eye contact than Asian Americans do. When interacting with other Asian Americans, they may unconsciously decrease eye contact to conform to Asian norms.

Touch For many Asian cultures, touch is very private, and many traditional Asian couples do not show love and affection physically in public or even in front of their children. Cambodian and Hawaiian culture--taboo and offensive to point at or touch another’s head because of spiritual beliefs that consider the head the most sacred part of the body. In some Asian cultures, avoidance of physical contact in social situations. Among some Pacific Islander cultures, touching is a sign of friendship and affection and occurs with immediate and extended family members as well as friends

Family Roles/Organization Patriarchal family hierarchy in which the males and older individuals hold a position of authority. Reinforced through philosophical and religious beliefs such as Confucianism and Buddhism. Within the immediate nuclear family, the father is the head of the household making important decisions for the family. Because of limited involvement with actual childrearing, which is seen to be the role of the wife, he may be more emotionally distant from his children. In many Asian cultures the emphasis is on the family as the basic unit of society, and this can include three or four generations who may live in the same household.

Family (cont’d) Even after marriage, the son is still expected to show allegiance to his parents. In many Asian cultures, the primary obligation for sons is to their family of origin, even at the expense of spouse and children. Since many Asian cultures traditionally operate based on a patrilocal system of marriage, as in India, in which the wife moves in with her husband’s family, the emphasis is on the males carrying on the family name and tradition. In addition, the allegiance of women is supposed to be to the household of their husband.

Healthcare Communication Two issues have been cited in the literature as potential sources of miscommunication between health care providers and Asian Americans: attitudes towards authority and health literacy. Many Asian Americans tend not to question authority and may refrain from contradicting a doctor’s misperception of pain level, for example. While this may “save face” in the health care provider-patient relationship, patient care may suffer. Doctor-patient miscommunication for immigrant groups may also be due to inadequate translation and exacerbated by low education levels. Chances of adverse medication interactions, overdose and underdose increase for older adults with the greater volume of medications prescribed.

Disease States The API population has comparatively longer life expectancy and lower mortality rate than any other ethnic group in the U.S., including Caucasians. Disease statistics show that there are certain diseases which affect API populations at a rate disproportionate to the U.S. non-Asian population.

Hepatitis B For example, of the 1.25 million Americans living with chronic hepatitis B infection, approximately half are Asian American. In 2002, the hepatitis B-related death rate among Asian Americans was six times higher than the rate among whites. In addition, in 2001, APIs aged 40 years and older were 2.5 times more likely to have Hepatitis B than non-Hispanic/Latino whites. The fact that Hepatitis B is more common among APIs than among other U.S. groups is not surprising considering that a majority of the over 200 million individuals chronically infected by this disease are in Asia.

TB In 2004, the Asian American incidence of tuberculosis (TB) was 5.6 times that of the total U.S. population. The TB rate in 2004 was 8.4 times higher in the U.S. Pacific Islands than in the mainland U.S.

Other Health Issues among APIs The incidence rates for liver and stomach cancer are substantially higher than among other races and cultural groups. Vietnamese American women have the highest rate of cervical and liver cancers of all women in the U.S. In 2002, Native Hawaiians, Japanese and Filipino residents of Hawaii aged twenty years or older were approximately twice as likely to have diagnosed diabetes than Caucasian residents of Hawaii of similar age. In 2002, the AIDS rate among APIs was 4.0 cases per 100,000 population. During 2003, 497 new AIDS cases were reported among APIs, an increase of 9.9 percent over 2002 and of 34.7 percent over the 1999 level.

Immigrants vs. U.S. Born Immigrants seem to enjoy better health than their U.S.-born counterparts, but these health advantages decrease with more time spent in the U.S. The health of some API immigrants, particularly Pacific Islanders and Vietnamese, is less favorable than average. API immigrants as a whole seem to have less adequate access to formal medical care. Among API groups, Chinese and Japanese generally have been found to have the lowest risk of hospitalization, while Filipinos, South Asians, and other Asians are more likely to report coronary, respiratory, gastrointestinal, and emotional problems. Filipinos and South Asian men have a higher risk of being hospitalized for asthma and coronary disease than Caucasians.

Psychotropic Dosage APIs respond to lower doses of psychotropic medicines than their Caucasian American counterparts. When starting an API patient on this medicine, begin with half the prescribed dose, and gradually increase from there. Other consistent findings in APIs’ response to neuroleptics, tricyclic antidepressants, lithium, and benzodiazepines. Among many Asian populations, the use of traditional herbal remedies is popular and some of these herbs have pharmacological properties that may either stimulate or inhibit the activities of enzymes responsible for the metabolism of psychotropics.

High Risk Behaviors Smoking, alcohol and illicit drug use are noted high risk behaviors among the Asian population. 1 in 3 Asian youths are smokers, a much higher proportion than in other American adolescents. Asian American youth overall have the lowest rates of alcohol and illicit substance abuse and dependency. Variations within Asian American subgroups exist, with Korean American youth and Korean and Japanese American adults abusing substances at higher rates than other Asian subgroups.

Reflection Questions 1. How will the varying communication styles present in some Asian patients impact the delivery of pharmaceutical care? 2. How might the practice of holistic medicine employed by some Asian American patients challenge your role as a pharmacist? 3. How can the information presented in this chapter be used to inform your pharmacy practice?