tips for working with asian american populations · tips for working with asian american...

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The term Asian Americans refers to peopleof Asian descent who are citizens or per-

manent residents of the United States. Theyreside in many communities, mainstream to small, isolated enclaves, and consist of many subgroups, such as Asian Indians,Cambodians, Chinese, Filipinos, Hmong,Japanese, Koreans, Laotians, Thais, Vietnamese,and “other Asian,” with 32 linguistic groups.Among this group, the Chinese and Filipinosare the two largest subgroups. There has beena lack of awareness of various health-relatedproblems specific to this population, owing tothe convention of aggregating health data. Thestereotypes that Asian Americans are hard-working, intelligent, successful, and mentallyhealthy have masked social, economic, andmental health problems of the Asian Americanpopulations. It is critical for the health pro-moter to recognize the great diversity in cul-tural beliefs and practices, history, language,and generational differences characterizingeach subgroup.

This brief “tips” chapter provides somefundamental information, suggestions, and rec-ommendations for working with these differentgroups in health promotion and disease preven-tion (HPDP) activities. These tips have been dis-tilled from the preceding three chapters and othersources (English & Folsom, 2007; English & Le,1999; Green & Kreuter, 1991, 2005; Hiatt et al.,1996; Inouye, 1999; Ishida, 1999; Kline, 1999;McPhee et al., 1996; Pasick, D’Onofrio, &Otero-Sabogal, 1996; Pasick, Sobogal, et al.,1996; Sobogal, Otero-Sabogal, Pasick, Jenkins,& Perez-Stable, 1996; Chapters 1, 2, 6, 7, and21–23, this volume). They are offered as generalstarting points that need to be considered forthose involved in assessing, designing, imple-menting, and evaluating HPDP programs forAsian American population groups.

CULTURAL COMPETENCE

The health promoter needs to develop cul-tural competency skills for working across

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Tips for Working With Asian American Populations

M I C H A E L V . K L I N E

R O B E R T M . H U F F

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Tips for Working with Asian American Populations 475

multicultural population groups. This is anespecially important issue to be consideredwhen working with Asian American popula-tions characterized by such great diversity anddifferences connected to health practices andhealth-related problems. The following tipsfor the health promoter can help facilitateprocesses that will contribute to more effectiveHPDP programs:

• Seek to learn the history and immigrationpatterns of the specific ethnic group you willbe targeting for HPDP interventions.

• Be aware that most new immigrants comefrom homogeneous ethnic countries and havebeen thrust into heterogeneous surroundingswhere their self-identity may be threatenedand where they must often deal with this“differentness” as well as prejudices andracial bigotry.

• Become familiar with the particular targetgroup’s specific cultural values, beliefs, andways of life. These include forms of addressand other verbal and nonverbal communica-tion patterns, food preferences, attitudestowards health and disease, and related cul-tural characteristics that differentiate thisgroup from other Asian American populations.

• Become familiar with the language differ-ences within each group and how languageadjustment was another stress that had to beovercome to function in a new country.

• Engage in active listening (rather than talk-ing) and be alert to nonverbal cues becausesome Asian American populations tend notto disagree openly with health serviceproviders, thereby avoiding conflict andembarrassment so as to maintain harmony.The nodding of heads might mean they arehearing but not necessarily agreeing withwhat is being said.

• Be alert to the correspondence between verbaland nonverbal behaviors, being careful to askopen-ended questions that elicit what the indi-viduals or groups think about the situation,resources, or suggestions, as well as how com-fortable they are with the available choices interms of what they want and can live with.

• Be aware that although in many AsianAmerican families one adult might be thespokesperson for the family, all membersshould be encouraged to voice their opinions.

• Be aware of the dynamics within the AsianAmerican family. Because problems are gen-erally handled within the confines of thefamily, concerns may not be shared with thehealth care provider unless there is a trustingrelationship established.

• Seek to incorporate or assist planners inincorporating these cultural values, beliefs,and ways of life into the HPDP program orservice where appropriate.

• Be aware that many different Asian Americangroups refer to their generational differencesaccording to the arrival or birth in the UnitedStates and are, with your exploration, distin-guishable by their various ages, experiences,languages, beliefs, and values.

• Recognize that acculturation is a critical fac-tor in explaining risk behavior and healthstatus. The more traditional the individual orgroup, the less likely the individual or groupis to know about, understand, or practiceWestern approaches to HPDP.

• Be aware that for many Asian Americansubgroups, immigration caused a number ofadjustment and acculturation stresses thatmight be related to their overall health andhealth practices, such as being forced to leavetheir homes, facing political exile, or beingseparated from family members.

• Seek to learn how differences in beliefs andvalues among different subgroups may helpidentify some of the possible areas of conflictand frustration experienced by new immi-grants and sometimes later generations.

• Be aware that all the groups represent vary-ing degrees of acculturation and assimilationin their current country of residence.

• Be aware that beliefs and values play animportant role in acculturation and integra-tion of Asian Americans into Western cultureand that the process of integration differs foreach of the Asian groups.

• Acknowledge that the measurement of accul-turation is an important activity for under-standing how traditional, acculturated, and

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assimilated a specific ethnic group may be.There are a variety of scales that can be used,and the reader is urged to read Chapters 1, 6,7, and 8 for a more detailed discussion of thisprocess.

• Be aware that two beliefs that are prominentin Asians, especially those from SoutheastAsia, are kinship solidarity and equilibriumor balance. Kinship solidarity refers to theview that the individual is subservient to thekinship-based group or family.

• Be aware that most Asian family patterns arecharacterized by filial piety, male authority, andrespect for elders and that this pattern some-times determines decision-making practicesrelating to health care for recent immigrants.

• Appreciate that family support is one of themost important core values among AsianAmerican population groups. Be aware howdevastating separation from family memberscan be to a culture that values the nuclearand extended family.

• Remember that decisions associated withseeking medical care and/or participatingactively in a prescribed treatment or healthprogram might involve the head of the house-hold or other family members, whose deci-sions will be based on what they feel is bestfor the family.

• Be aware that avoiding conflict and achievingharmony in interpersonal relationships is astrong cultural value among Asian Americans.

• Show respect for Asian American beliefs andvalues because they are an extremely impor-tant factor in all relationships and especiallyin HPDP encounters.

• Recognize that the diverse circumstancesunder which Asian Americans live and workrequire you to appreciate the impact thatethnic and social ties might have on healthbehavior choices and the need to use thesefactors effectively in developing HPDPprograms or services.

HEALTH BELIEFS AND PRACTICES

There are a variety of health beliefs and prac-tices that characterize the many different Asianpopulation groups residing in the United States.

The health promoter needs to understand andbe sensitive to the differences he or she is likelyto encounter. The health promoter needs to beaware of how to use this knowledge and howto incorporate these differences into HPDPprograms and services. The health promotershould keep the following tips in mind:

• Recognize that belief in folk illnesses still isa strong cultural characteristic among manytraditional Asian population groups. Developingan understanding of some of these illnessesand their traditional treatments can help youto be more effective in the design of specificHPDP intervention and treatment services.

• Remember that it is often assumed by healthcare workers that everyone embraces theWestern biomedical model. However, withinAsian cultures, traditional or cultural beliefsof spiritual or supernatural forces and bal-ance with nature are often overlooked, andtraditional practitioners may assist the indi-vidual in achieving this energy balance.

• Understand that there are a number ofexplanatory models used to make sense ofhealth and disease and that these are gener-ally associated with the social, psycholo-gical, and physical domains. Recognize thatalthough health is defined in the UnitedStates as a state of complete physical, mental,and social well-being, and not merely theabsence of disease, Asians view it as a state ofharmony with nature or freedom from symp-toms or illness.

• Remember that the need to achieve a harmo-nious relationship with nature might be acentral concept of the traditional health caresystem still used today. This system often isthe first one used when an illness or other dis-order is detected in a family member, andthose who use this system are generally notinclined to discuss this with a Western healthcare practitioner.

• Be aware that beliefs and expectations abouthealth care treatment may enhance or impedeAsian groups’ participation in the health pro-gram or service. There is a need to explorethese beliefs and expectations in the assessmentor initial health care encounter phase.

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• Be aware that although there are wide varia-tions in health beliefs and practices shaped bycultural values in determining what is impor-tant in one’s life, many Asian groups mayshare some similarities based on their reli-gious background and on the influence ofChinese culture throughout Asia.

• Recognize that the prominence of Confucianideology, Buddhism, and Taoism in Asianculture focuses on the upholding of a publicfacade and against public admission of men-tal or physical illness or any admission ofpersonal weakness.

• Be aware that, to a large extent, culture andlanguage influence how one conceptualizesetiology, symptoms, and treatment of illnessesand may influence how one is to interact withhealth care providers and organizations.

• Recognize that because of language difficultiesand cultural differences, many Asians, espe-cially the newer immigrants, might still preferthe traditional forms of Chinese and nativemedicine and seek help from Chinatown“physicians” or “masters,” who treat themwith traditional herbs and other methods.

• Be aware that Asians often do not seek helpfrom the Western system of medicine becauseof painful diagnostic tests and lack of infor-mation and understanding about what isbeing done to them.

• Be sensitive to the effect of abrupt culturalchanges among an immigrant communityintroduced to medical pluralism. An eclecticmedical culture that blends influences frombiomedicine, Christianity, and Chinese medi-cine could result in a selective loss of medicalor religious concepts and practices that nolonger “fit” their new situation and collectiveidentity.

PROGRAM-PLANNINGCONSIDERATIONS

The health promoter must be aware thatplanning HPDP programs or services for AsianAmerican population groups, given theirtremendous diversity, requires systematic iden-tification and selection of tailored coursesof action related to achieving or improving

health-related behaviors. Such programmingalso will require the planner to be culturallycompetent and sensitive to the differences inhow the planner views and operates in theworld and how his or her target group seesthis same process. Thus, the health promotershould consider the following comments andsuggestions relevant to the program-planningprocess:

• Be sensitive to indiscriminately applyinghealth care and programs to all groups in thesame manner. Also, recognize that becauseall Asian Americans do not have similarbeliefs and health practices, health profession-als cannot assume that programs for one Asiangroup will work for another similar group.

• Be sure that the program or service beingdeveloped will be culturally acceptable to thetarget group and will not come into conflictwith the target group’s values, beliefs, atti-tudes, or knowledge about the problem.

• Clearly identify potential barriers that mightbe encountered that would impede participa-tion in the HPDP program or service andidentify how you might overcome these.

• Wherever possible, seek to eliminate obsta-cles to participation in the HPDP program orservice. This may involve simplifying how thetarget group enrolls in or accesses the serviceor program, bringing the program or serviceto the target group, making sure that the pro-gram or service is offered in the language ofthe target group, and making sure that anyfollow-up activities that the participantsmight need to do are simplified, relevant, andeasily understood.

• Consider employing the principles of rele-vance and participation when designing theprogram or service—that is, starting yourprogram or service where the target group isand involving its members’ active participa-tion throughout the entire process, fromdesign through evaluation.

• Make sure that the organization or agencyinvolved in designing the program or servicehas a mission, goals and objectives, policy,procedures, an organizational structure, andstaff that reflect a sense of cultural competence


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and sensitivity to the target group on whichthe program or service is being focused.

NEEDS ASSESSMENT

The extensive data that serve as the founda-tion of Asian American HPDP programs andservices can assist the HPDP planner to betterunderstand and address the specific healthneeds and interests of the planner’s targetpopulation. It is critical that the health pro-moter take the time to adequately determinethe characteristics of the target group he or shewill be serving, including factors such asmorbidity and mortality, historic and immi-gration patterns, specific cultural characteris-tics, demographics, health care access and usepatterns, and related variables. Huff and Klinein Chapter 6, this volume, present a CulturalAssessment Framework that can help provideguidelines for the assessment areas that shouldbe considered when preparing to develop theneeds assessment component of the program-planning process. In addition, the followingsuggestions may be useful in the needs assess-ment process:

• Remember that conducting a thorough needsassessment is critical to identify communityissues and problems in the Asian Americancommunities, formulate relevant objectives,and determine what educational interven-tions are appropriate.

• Be aware that regardless of the planningmodel used (e.g., PRECEDE-PROCEED) forAsian American health promotion programs,you must be extremely conscious and sensi-tive to the need for building a cultural assess-ment component into the planning process.

• Be aware that aggregating Asian Americanhealth data might mask differences in diseasepatterns for specific subpopulations and couldresult in an erroneous portrayal of the overallAsian American population as healthy and atlower risk for death and illness.

• Remember that needs assessment informa-tion should seek to identify local mores andcustoms. This is particularly true if the target

group is located within an ethnic enclave, asin the case of many new Asian immigrants.

• Where possible, involve community represen-tatives who can function to help identifypersons in the community already recognizedby other community members as sources ofassistance and support regarding issues andproblems.

• Where possible, train and use communitymembers to assist in the data collectionprocess because this can help facilitate com-munity ownership of the program or servicebeing developed and can provide perspectivesthat might have otherwise been missed by anon–community member.

• Recognize that, at the very least, outreachworkers (e.g., lay health advisors) who areinvolved in obtaining assessment informationand who may ultimately introduce the healtheducation program to the community shouldbe perceived as nonthreatening and nonintru-sive. They should be drawn from the sameethnic group and preferably be from thatcommunity.

• Be aware that contacts during the assessmentprocess should be linguistically appropriatewhen working in established communitiesor with recent immigrants. For some groups,such as Chinese or Filipinos, the language of the assessment process might have to deal with more than one language or severaldialects.

• Be sure to include key community members(both formal and informal) in the communityneeds assessment process.

• Recognize that survey or interview data withcommunity members from similar genera-tions may reveal “generation gaps” in valuesor expressed health beliefs and behaviors.

• Consider including acculturation measures inthe needs assessment instrument.

• Be sure to assess the types of media usedwithin the community because this might bea critical factor when the program or serviceis ready to go online and marketing activitiesare being planned. It also relates to accultur-ation levels in the community.

• Be sure that assessment and evaluationefforts reflect the needs, interests, and valuesof the stakeholders within the community.


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• Be aware that at the outset of an HPDP pro-gram, baseline data for establishing the scopeand seriousness of the problem might not bereadily available. Initial assessment informa-tion might need to be based in part on demo-graphic data, morbidity and mortality data,and (in large part) key informant information.

• Be aware that key informants might not haveknowledge of or represent all elements in thecommunity or group. If these persons repre-sent the intended program users (or targetedgroup) or already provide services to thedesired users, then so much the better.

• Understand that an extensive baseline surveyconsisting of core questions covering demo-graphics, health beliefs and practices, andcultural values might need to be administeredto target groups after an exhaustive effort ismade to ensure the appropriateness of eachquestion to that group.

• When designing questions for survey instru-ments or interviews to be administered toAsian American subgroups in a languageother than English, recognize that translationand adaptation are part of a complex processthat requires an understanding of each lan-guage and culture and might require iterativepretesting in all groups and subgroups (byage, language, ancestry, etc.).

• Focus groups can be a useful and effectiveapproach to determining the knowledge, attitudes, behaviors, and felt needs of thecommunity.

• The PRECEDE model can be helpful becauseit guides you to consider relationshipsbetween and among particular health behav-iors and their predisposing, enabling, andreinforcing factors and can provide convinc-ing evidence regarding the need for early edu-cational interventions designed to affect thesefactors positively.

INTERVENTION CONSIDERATIONS

Well-planned and culturally appropriate inter-ventions are critical to the successful implemen-tation of HPDP programs and services for AsianAmerican population groups. Cultural tailor-ing urges the planner to develop interventions,

strategies, methods, messages, and materials tobe adaptable to the specific cultural character-istics of the target group (Pasick, D’Onofrio,et al., 1996). The health promoter might wishto consider the following comments and sug-gestions as he or she begins the design phase ofthe program-planning process:

• Be aware that new immigrants may differ onmany social and health-related issues. Youalso should be aware that those at high riskwill more likely include individuals with thefollowing characteristics: low socioeconomicstatus, uninsured, limited English proficiencyand/or linguistically isolated, foreign born orrecently immigrated, and rigid adherence tocertain cultural health beliefs and traditionsthat might conflict with some proven effec-tive Western practices.

• Understand that an effective program mustspecifically address the health needs of thesegment of the population targeted (e.g.,women at risk for cervical or breast cancer,male smokers) within the Asian Americancommunity. You also need to deal with theseneeds as they result from the target group’sdiversity and collective history and culture.

• Recognize that the development of culturallyappropriate interventions requires considera-tion of available community resources andinclusion of important cultural themes of thetarget group. For example, family is one ofthe strongest core values of traditional Asianculture, so interventions that have a familyfocus may prove more effective than thosethat focus on the individual.

• Remember that members of the communityfor whom the program is intended shouldparticipate, and they can help provide an“insider’s” perspective on issues and insightsinto local social norms and structure. Thisparticipation increases the likelihood that theproject will not conflict with any fundamen-tal cultural values and that it will be credibleand well received.

• Recognize that a formal community advisoryboard used earlier in the planning stages alsocan provide valuable information, feedback,support, and resources during the educa-tional intervention activities.


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• Be aware that program results may beenhanced if there is a concerted effort to inte-grate the services into the social frameworkof the community.

• Be aware that interventions such as role mod-eling and use of community social networksmay be useful approaches for demonstratingand reinforcing individual behavior change.

• Consider that developing partnerships withthe local media (e.g., radio, television, news-papers) for the dissemination of health edu-cation and health promotion information canbe a valuable and effective approach for bothmarketing programs or services and reinforc-ing the successes of program participantswho may be recruited as role models for thecommunity in which the program or servicehas been targeted.

• Be aware that the utilization of behavioraltheory to guide development of interventionapproaches is central to well-conceived andappropriately designed intervention strategies(see Chapter 4, this volume).

• Be aware that a multiphased and multifacetedintervention might need to be used, forexample, to (a) initially raise the awarenessconcerning the importance of preventive careand screening, (b) help motivate the targetgroup to seek screening, and (c) use neighbor-hood connections because they can providebehavioral modeling and social reinforcementthrough familiar communication channels.

• Recognize that the recruitment and training ofa group of community peer networkers whocan distribute program materials and reinforcemessages can be an extremely effective methodfor maintaining community involvement andsupport for the HPDP program or service.

• Recognize that employing and trainingcommunity members to facilitate educationalprograms in the community is a valuable andeffective approach for implementing anHPDP program or service.

• Seek to develop interventions that focus onpositive health changes rather than on nega-tive or fear-arousing consequences.

• Remember that development of educationalmaterials must reflect relevant the culturalvalues, themes, and learning styles of thetarget group for which they are designed.

• Recognize that all materials used in theHPDP program that are written in a languageother than English must be back translatedand pilot tested to ensure that they say whatis meant and that the messages are clear andunderstandable to the target group.

• Always assess the cultural appropriateness ofany pictures, models, dolls, manuals, video-tapes, messages tailored for the community(e.g., billboards, newspapers, radio, and paidtelevision advertisements), or other educa-tional materials prior to their inclusion in theprogram because some materials may makethe target group uncomfortable.

• Be aware that special training manuals can bedeveloped for participating physicians andlay health workers for use in presentationsand the subsequent discussions, videotapes,and other material for the participants andphysicians. These should be linguistically andculturally appropriate.

• Consider selecting methods and events ledby trained neighborhood leaders or similarlyrecruited individuals. Such events couldinvolve informal and small-group educa-tional events in private homes and commu-nity health fairs centered on the traditionalNew Year’s festivals.

• Consider techniques that are more personaland centered on traditional characteristics ofsocial solidarity and mutual assistance.

EVALUATION CONSIDERATIONS

Evaluation is central to understanding howwell a program or service is doing in meetingthe needs of the clientele it is serving. For thisreason, the health promoter is urged to con-sider the following recommendations:

• Evaluation of HPDP programs and servicesshould include culturally relevant measuresfor evaluating the impact of the program orservice on the target group.

• Assessment and evaluation items must betailored to the educational and linguisticcapabilities of the target group for which theyare intended. Here, again, back translation ofitems will be an important consideration in


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the development of the assessment and eval-uation instruments.

• Be aware that evaluation and assessment areprocesses that frequently are difficult to gainsupport for, even from the most sophisticatedof groups. Efforts to explain the underlyingassumptions governing these processes, aswell as the methods and anticipated out-comes from these activities, can help makeexplicit what is often unclear to those inexpe-rienced in evaluation and can help motivateincreased interest and support for evaluationand assessment methods and procedures.

• Providing evaluation and assessment trainingfor community members who will beinvolved in the provision of the HPDP pro-gram or service can help promote increasedinput and support for evaluation efforts. Thisalso can extend the number of staff and com-munity supporters who can be involved indata collection activities related to assessmentand evaluation activities.

• Consider administering surveys or conductingoral interviews before and after the interven-tions to assess whether there was an increasein screening or other target behaviors follow-ing participation in program activities or therewere positive changes in target group knowl-edge, attitudes, and intentions toward thetarget behaviors. In reality, this can be diffi-cult outside a classroom setting.

• Be aware that participants might have limitedtest-taking and literacy skills or time, orphysical difficulties such as poor eyesightor uncomfortable testing conditions. Thus, itmight be more appropriate, in some instances,to forgo a time- and item-intensive evaluationof outcomes and process until such problemscan be overcome.

The next section of the book considersPacific Islander population groups. Thissection includes three chapters followed bya customized “tips” chapter. The first chap-ter in this section presents an overviewdevoted to understanding this special popu-lation from a variety of perspectives andincludes terms used to define the subgroupswithin the broader population, historical and

demographic characteristics, immigrationpatterns, health and disease issues and con-cerns, and health beliefs and practices. Thesecond chapter of the section is concernedwith how to assess, plan, implement, andevaluate programs for Pacific Islander popu-lation groups, including tips, models, andsuggestions for more effective programdesign. The third chapter in this section pre-sents a case study to emphasize points madein the overview and planning chapters. Thissection begins with Chapter 25.

REFERENCES

English, J. G., & Le, A. (1999). Assessing needs andplanning, implementing and evaluating healthpromotion and disease prevention programsamong Asian American population groups. InR. M. Huff, & M. V. Kline (Eds.), Promotinghealth in multicultural populations: A hand-book for practitioners (357–374). ThousandOaks, CA: Sage.

Green, L. W., & Kreuter, M. W. (1991). Healthpromotion planning: An educational andenvironmental approach. Mountain View,CA: Mayfield.

Green, L. W., & Kreuter, M. W. (2005). Health pro-gram planning: An educational and ecologicalapproach (4th ed.). New York: McGraw-Hill.

Hiatt, R. A., Pasick, R. J., Perez-Stable, E. J.,McPhee, S. J., Engelstad, L., Lee, M., et al.(1996). Pathways to early cancer detectionin the multiethnic population of the SanFrancisco Bay Area. Health EducationQuarterly, 23(Suppl.), S10–S27.

Inouye, J. (1999). Asian American health and dis-ease: An overview of the issues. In R. M. Huff& M. V. Kline (Eds.), Promoting health inmulticultural populations: A handbook forpractitioners (pp. 337–356). Thousand Oaks,CA: Sage.

Ishida, D. N. (1999). Promoting health amongAsian American population groups: Case studyfrom the field. In R. M. Huff & M. V. Kline(Eds.), Promoting health in multiculturalpopulations: A handbook for practitioners(pp. 375–381). Thousand Oaks, CA: Sage.


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Kline, M. V. (1999). Planning health promotionand disease prevention programs in multiculturalpopulations. In R. M. Huff & M. V. Kline(Eds.), Promoting health in multiculturalpopulations: A handbook for practitioners(pp. 73–102). Thousand Oaks, CA: Sage.

McPhee, S. J., Bird, J. A., Ha, N. T., Jenkins, C. N.H., Fordham, D., & Le, B. (1996). Pathwaysto early cancer detection for Vietnamesewomen: Suc Khoe La Vang (health is gold!).Health Education Quarterly, 23(Suppl.),S60–S75.

Pasick, R. J., D’Onofrio, C. N., & Otero-Sabogal,R. (1996). Similarities and differences across

cultures: Questions to inform a third generationfor health promotion research. Health EducationQuarterly, 23(Suppl.), S142–S161.

Pasick, R. J., Sabogal, F., Bird, J. A., D’Onofrio,C. N., Jenkins, C. N. H., Lee, M., et al. (1996).Problems and progress in translation of healthsurvey questions: The pathways experience.Health Education Quarterly, 23(Suppl.),S28–S40.

Sabogal, F., Otero-Sabogal, R., Pasick, R. J., Jenkins,C. N. H., & Perez-Stable, E. J. (1996). Printedhealth education materials for diverse communi-ties: Suggestions learned from the field. HealthEducation Quarterly, 23(Suppl.), S123–S141.


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PART VI

Pacific Islander Populations

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