Advancing Community and Health Equity: Health and Wellbeing of U.S. Chinese Populations

This JGMS special issue is designed to challenge the Asian American model minority myth, widen our knowledge base, and recommend research, practice, and policy changes regarding the health and wellbeing of the U.S. Chinese population through our collaborative Chinese Health, Aging, and Policy Program (CHAPP), within the context of two ongoing population-based epidemiological studies (the PINE study and the PIETY study) in the Chicago Chinese community. CHAPP is the result of a community-academic partnership founded on the guiding principles of community-based participatory research (CBPR). The research team is a result of a synergistic collaboration between academic partners and over 20 community-based organizations in the greater Chicago area. This approach has permitted us to implement and sustain multiple research studies and foster a continued reciprocal relationship between academic institution and the greater Chinese community. The PINE study—the Population Study of ChINese Elderly in Chicago (松年研究, sōng nián yán jiū)—is a longitudinal study initiated to investigate aging issues among Chinese older adults aged 60 years and older. With the first wave of PINE data collection from July 2011 to June 2013, 3,157 community-dwelling Chinese older adults were interviewed about a wide variety of health and wellbeing indicators (1). Of those 3,157 participants, 115 (3.6%) died, 186 (5.9%) were unable to be re-contacted, and 143 (4.5%) refused follow-up participation. As a result, we were able to complete follow-up interviews with 2,713 (85.9%) individuals from 2013 to 2015. Both waves of the PINE study assessed an extensive range of health, cognitive, functional, psychological, social, and cultural determinants of health and wellbeing, using a state-of-science web-based technological platform where survey data were collected simultaneously in Chinese (simplified and traditional characters) and English according to participant’s preferences. To our knowledge, this is the largest longitudinal study of U.S. Chinese older adults regarding the health and wellbeing of an often-forgotten immigrant population. In addition to the PINE study, CHAPP initiated an epidemiological study of U.S. Chinese adults—called the PIETY study—of PINE sample’s adult children’s perspective to understand this population’s experience of intergenerational relationships, cultural values, health, and wellbeing, as well as their perspective of their elderly parents already enrolled in PINE study. Similar to the PINE study, the PIETY study implemented a CBPR design. Adult children aged 21 years and older, lived in the greater Chicago area, and had at least one parent who is Chinese aged 60 years or older were eligible to participate in the study. Face-to-face interviews were conducted in the participant’s preferred dialect with multilingual and multicultural research assistants between 2012 and 2014. Importantly, we have an instrumental dyadic (parent–children) perspective about health and wellbeing of both older adults and adult children across intergenerational domains through the social and cultural lens. Moreover, in order to further bridge cancer disparity, qualitative focus groups were conducted to deepen our understanding of issues and beliefs relating to cancer and biomarkers among U.S. Chinese women. Focus group participants were recruited from community partners and PINE/PIETY study. Six focus groups were conducted, and groups were segmented based on preferred Chinese dialect of Cantonese or Mandarin. With the support and involvement of trust community partners and positive experiences from our previous participants, we were able to successfully conduct in-depth conversations among Chinese women with diverse experiences and gain insight into their thoughts, experiences, and opinions regarding health care utilization and research. The Chinese population is the largest and oldest subgroup of Asians in the United States (2). However, few studies have disaggregated Asian American subgroups and concerns have been raised about extrapolating findings from studies that have grouped Asian Americans together (3,4). Asian Americans are a diverse ethnic group due to country of origin, socioeconomic status, language, cultural values, employment, and health (5), and aggregated studies are unable to capture the experiential nuances of specific cultures and ethnicities. Further, high levels of physical and psychological distress challenge the model minority myth (6–13) about the U.S. Chinese population and prompt further exploration into the health and wellbeing of the Chinese population, especially with respect to health care utilization, physical function, cognitive function, intergenerational relationships, elder mistreatment, and psychosocial wellbeing. In addition, there are significant gaps in understanding the experiences of U.S. Chinese adults through quantitative and qualitative methods, especially with respect to cultural influences of health equity. This research has the potential to improve the approaches toward necessary intervention, outreach, and research participation for these understudied and underserved populations. As the older adult population in the U.S. rapidly grows (14), intergenerational relationships between older adults and their adult children, and related physical and psychological outcomes for both, warrant greater attention from epidemiological research. In particular, family violence and its perpetuation are growing global health issues, with wide implications for health and wellbeing (15). With the Chinese population in particular, there are cultural beliefs and practices, like filial piety, which previous research has shown are related to health outcomes among Chinese (16–18). As many Chinese adult children provide instrumental, emotional, and financial support for their aging parents, particular issues pertaining to these intergenerational relationships may influence the health and wellbeing of multiple generations of U.S. Chinese. However, further in-depth examinations into the health and wellbeing of the U.S. Chinese population are lacking, though still necessary to provide evidence-based programs toward improving the lives of this rapidly growing and graying population. In the United States, minority immigrant older adults suffer from significant health disparities, including cancer, losing contact from their native support network, family conflicts, and psychological distress. The Chinese community represents the largest and oldest Asian population in the United States, with an estimated population of 4 million (2). However, participation of Chinese Americans in epidemiologic research has been low in the past decades (20). Thus, the PINE study is designed to advance knowledge pertaining to health status, medical conditions, and wellbeing of U.S. Chinese older adults. We organized five themes for this JGMS special issue: Geriatric syndromes, Cancer, Intergenerational relationships, Elder mistreatment, and Psychosocial wellbeing. The 20 articles in these five themes highlight the salient role of the immigration experience for Chinese older adults and adult children. The articles advance knowledge regarding aging, immigration, and the health of U.S. Chinese older adults. This theme of geriatric syndromes elucidates the physical and cognitive function trajectories among Chinese older adults in the context of immigration. We adopted directly observed physical function tests to measure the decline in physical function and examined the risk and protective factors for physical function decline. Results indicated older age and higher education were significantly associated with faster decline over a 2-year period (21). Li et al. (22) detailed decline in cognitive function by different domains, such as episodic memory, working memory, and perceptual speed. They found differences in the rates of cognitive change by age, sex, education, and income. A noteworthy finding was that the effects of education and sex on baseline cognitive performance versus cognitive change differ, which suggest a role for life experiences in cognitive decline. Regarding cancer, this special issue sheds light on health care services utilization disparities in terms of cancer screening preventive care services. Li et al. (23) analyzed the chronic smoking behavior and eligibility for low-dose computed tomography for lung cancer screening among older Chinese male smokers. Findings suggested chronic smoking behavior was associated with lower levels of education and fewer number of children. Correspondingly, Simon et al. (24) investigated breast cancer screening beliefs among older Chinese women and highlighted the barriers of using breast cancer screening included language, time, not wanting to burden their adult children and transportation. In addition, we examined the association between various sources of social support and use of cancer screening. Our study provided evidence that different types of social support were associated with increased or decreased utilization of cancer screenings (25). Together, these investigations stress the role of intergenerational and familial relationships with respect to cancer screening behaviors. Within the theme of intergenerational care, Xu et al. (26) examined role enhancement and role strain theories in grandparent caregiving. Both theories were supported as spending more time caregiving for grandchildren was generally beneficial to grandparents’ psychological wellbeing, while simultaneously depending on whether these experiences were also deemed burdensome. Guo et al. (27) systematically analyzed personal coping resources by evaluating individual, family, and community coping resources, including sense of mastery as cognitive appraisal. Findings supported the protective role of coping resources in family and marital conflict. In addition, we investigated the association of overall and six domains of filial discrepancy with depressive symptoms among U.S. Chinese older adults, finding greater receipt than expectation in care, make happy, greet, obey, financial support, as well as overall filial piety were associated with lower risk of depressive symptoms (28). These examinations into intergenerational relationships highlight both the importance of intergenerational relationships and the possibility of shifting roles due to the processes of immigration and acculturation to mainstream U.S. culture. Our theme of elder mistreatment provides a comprehensive framework to understand elder mistreatment in the context of multiple generations and to explore how immigration might weaken the status of older adults within family and increase vulnerability to mistreatment. Thus, articles within the elder mistreatment theme examined risk factors and health implications of elder mistreatment. From life course perspective, childhood abuse experience may lead to greater risk of abusing their aging parents after transition to adulthood, also known as a cycle of violence. We tested the association between childhood abuse and elder abuse which supported this hypothesis (29). Additionally, we examined the association of self-reported and directly observed physical function with elder mistreatment. Findings suggested that greater levels of physical function impairment were a protective factor associated with elder mistreatment among U.S. Chinese older adults (30). With respect to psychological distress, we found that elder mistreatment and self-neglect were associated with suicidal ideation among Chinese older adults (31,32). Last, we developed a longitudinal study to investigate the risk factors for elder abuse incidence. Results revealed female sex, longer duration of residence in the United States and preference of speaking Mandarin or English were significantly associated with risk of abuse incidence and these relationships differed by types of elder abuse (33). Using PINE and PIETY study data, we were able to show the risk factors, protective factors, and health outcomes associated with elder mistreatment. We were able to further elucidate the role of intergenerational relationships across the lifespan in perpetuating abusive behaviors. The psychosocial wellbeing theme discusses the effects of individual-, family-, and community-level factors on psychological wellbeing. At the individual level, Chen et al. (34) found conscientiousness moderated the relationship between perceived stress and depressive symptoms. Additionally, we identified trust in physician and improvement in trust in physician were protective factors associated with depressive symptoms (35). At the family level, Liu et al. (36) supported socioemotional selectivity theory by testing the moderating role of gender between social support from adult children and spouse and depressive symptoms. At the community level, Tang et al. (37) investigated the relationship of social engagement and social support with sense of community. The 20 articles in this special issue from our CHAPP studies aim to fill a vast gap regarding geriatric syndromes, cancer, intergenerational relationships, elder mistreatment, and psychosocial wellbeing among U.S. Chinese older adults. We hope these studies may provide insight into cultural aging research. The physical and cognitive trajectory of U.S. Chinese older adults enables a cross-cultural comparison between U.S. Chinese older adults and U.S. white older adults to identify any differential functional decline patterns among Chinese older adults. A comparison between Chinese older adults in the United States and in China would illustrate the impact of immigration on the health outcomes of older Chinese immigrants. This special issue also shed light on how immigration impacts the U.S. health care system and patterns of use. The analysis on the beliefs and utilization of preventive health care services provides an approach to understand health system barriers among minority older adults in the United States. In addition, the world today is challenged by population aging and inadequate provision of elder care services. Research based on the PINE study reveal that despite limited access to health care services, older adults can maintain optimal level of psychological wellbeing through family care. The experience in family care could be beneficial for dealing with the shortage in the supply of elder care services in the world. However, this special issue also points highlights the potential burden and negative effects (psychological distress, violence) of relying solely on intergenerational care. In order to move the needle on health equity across all populations, we call for culturally and linguistically appropriate services for underserved populations. These studies are important for health care professionals, social workers, and policy makers to identify immigrants who are vulnerable to social isolation, family conflict, elder mistreatment, physical and cognitive impairment, depressive symptoms, and suicidal ideation. Given the linguistic and cultural barriers, U.S. Chinese older adults, in particular, have limited access to health care services, whereas their use patterns are largely influenced by their caregivers. It is necessary to increase outreach and education regarding preventive health care services utilization and connect U.S. Chinese older adults and their caregivers with resources to navigate the health care system. State and federal programs should create opportunities for U.S. Chinese older adults to participate in social activities and rely on supportive social network to enhance a sense of community to protect their psychological wellbeing. Policies on supporting the care work of adult children in immigrant families, improving mental health, and preventing older adults from family violence are needed to create an age-friendly environment for Chinese immigrants. Despite cultural similarities, prior studies also suggested various Asian American ethnic groups differ with respect to chronic diseases, mortality, elder mistreatment, risk factors, and health care services utilization (38,39). Ethnic-specific data will be beneficial to enhance an in-depth understanding for minority immigrants through describing the complexity of aging embedded in a unique sociocultural context. Chinese Americans are the largest Asian ethnic group and have the longest history in the United States. Like many Asian ethnic groups, the Chinese American population continues to grow in the past decades. However, existing studies suggest cardiovascular symptoms, pulmonary symptoms, and musculoskeletal symptoms are highly prevalent among U.S. Chinese older adults (6,12). Meanwhile, they are additionally vulnerable to depressive symptoms and loneliness (8,13). Linguistic and cultural barriers and differences limit access to health care services (24). In addition, acculturation leads to vast heterogeneity within Chinese American population. Chinese-specific aging research is needed to capture the dynamics of health and wellbeing of Chinese older adults aging in the United States. These articles set the stage for future research on how immigration experiences affect the intergenerational perspective of aging process and can serve as a model for sustainable population-based research for other vulnerable communities. Future studies are needed to more rigorous quantify the mediating and moderating risk or protective factors associated with adverse health outcomes. Longitudinal analyses are needed quantify the incident conditions of physical, cognitive, and psychosocial decline of U.S. Chinese older adults. In addition, with a strong sense of filial piety in Chinese culture, future studies are needed to quantify the multilevel cultural determinants of health and wellbeing of Chinese older adults. Future research will attempt to combine PINE and PIETY study to understand the dyad relationship between older adults and their adult children. Moreover, with the improved understanding of these determinants, rigorously designed intervention and prevention approaches are needed to conduct linguistically and culturally sensitive methods to reduce these health disparities toward health equity in this immigrant population. Specific funding from federal government and state government need to advance research and support etiological, prevention, and intervention research projects targeted for U.S. Chinese older adults. We call for National Institute of Health (NIH), Centers for Medicare and Medicaid Services (CMS), Substance Abuse and Mental Health Services Administration (SAMHSA), Patient-Centered Outcome Research Institute (PICORI), and other federal and private philanthropic organizations to set their strategic priority on health disparity acknowledging and identifying Chinese as a vulnerable and disenfranchised population. Moreover, we call for these government and nongovernment bodies to set targeted funding to promote Community-Based Participatory Research in diverse immigrant communities. Furthermore, over the last decades, there has been enormous medical and scientific advances in prevention, cure, and intervention of health conditions. Nevertheless, we should not assume that they are just as effective in Chinese populations, as we have different genetic, social, cultural, dietary, and environmental predispositions which may alter the mechanism of these advances. Last, academic institutions shall be held accountable to our communities by leveraging models of sustainable community engagement to enable both scientific endeavors as well as community needs. Collectively, we must pursue the goal of NIH to advance population and community health in all populations.