Health providers helping Chinese-speaking Asian American immigrants with diabetes better control their disease to avoid complications need to do more than just have translators and bi-lingual staff in hospitals or doctors’ offices. While that’s a start, these patients also need comprehensive patient education materials written in Chinese and a medical staff thoroughly versed in the customs and cultural issues that may impede their diabetes care, according to a new study by researchers at Joslin Diabetes Center.

The Chinese-speaking immigrants who were surveyed at community health centers in Boston, New York City and Oakland, Calif., were found to have less knowledge of how to manage their diabetes - and generally had a trend toward poor blood glucose control - compared with Asian American immigrants who preferred to speak English, according to William C. Hsu, M.D., who led the pilot study along with his colleagues in Joslin’s Asian American Diabetes Initiative (AADI).

But after being given a bilingual diabetes education book, the participants showed improved understanding of their disease and a trend toward improved blood glucose control in laboratory tests.

The study, which appears in the February issue of the American Diabetes Association’s journal, Diabetes Care, is among the first of its kind to explore language barriers to diabetes management among Chinese-speaking immigrant populations.

“The study is particularly important because Asian Americans have at least a 50 percent greater risk of developing type 2 diabetes and pre-diabetes than Caucasian Americans,” says Dr. Hsu, Co-director of Joslin’s AADI. This fact is little known among both Asian Americans and physicians because Asian Americans are less likely to be overweight or obese. More than 10 percent of Asian Americans have diabetes. If poorly controlled, diabetes can lead to costly and devastating complications, especially stroke and kidney disease in Asian Americans.

“The health policy implications of the study are broad for immigrants and other non-English speaking people and should be explored in other populations as well,” Dr. Hsu says. “Even in culturally competent healthcare settings like community health centers, our study shows the importance of having materials written in the native language to improve non-English speaking patients’ understanding of the disease and reduce disparities in healthcare.”

Translators Not Enough
In the Joslin study, the researchers surveyed 52 Asian American immigrants with type 2 diabetes at three community health centers. The patients, aged 18 to 70, had diabetes for at least a year and were taking oral medications or insulin. They were asked if they preferred to speak Chinese or English and then were quizzed by the researchers about their diabetes knowledge. Twenty-two of the patients preferred to speak English, having immigrated at an early age or been born in the United States; the remaining 30 preferred Chinese. The Chinese-speaking group scored an average of nearly 63 percent vs. 85 percent for the English-speaking patients on a test of diabetes knowledge. In their dealings with healthcare professionals, the Chinese-speaking group reported requiring translation 35 percent of the time. The 11 patients that required translation scored lower than the others on the diabetes knowledge test.

The investigators then provided both groups with a book on diabetes written in English and Chinese. After reading the book, only the Chinese-preferring group showed an increased knowledge of diabetes. The researchers concluded that the English-speaking group already understood this information better than the Chinese speakers due to more access to diabetes information from their health providers and from newspapers, magazines and Web sites.

The researchers found differences in diabetes control occurred despite the fact that both groups followed standard diabetes self-management recommendations and received competent care in a culturally appropriate setting. They found a trend toward higher A1C levels in those who preferred to speak Chinese than among the English-speaking group.

“The traditional thinking that we just have to hire translators for non-English speaking patients is challenged by our study,” says Dr. Hsu, Instructor of Medicine at Harvard Medical School. “Even if the physician is culturally competent, other staff members, such as nurses or dietitians, may not be. For instance, a dietitian not familiar with the food preferences of Asian Americans may recommend that the patient eat foods that Asians don’t eat, such as cheese, cereals and pasta and not address other foods more central to the Asian diet.

“Even in a model setting like community health centers, which provide culturally competent care, their mission can advance to a higher level if they consider the importance of adopting more written diabetes education resources in Chinese,” he adds. Doctors spend an average of 15 minutes with diabetes patients, so having written educational materials in the patients’ language is paramount. “There is a general paucity of any culturally-focused educational materials written in the Chinese language. If any materials exist, it is often materials translated from other English literature without modifications specific to the reader’s culture,” Dr. Hsu says.

Other customs and cultural factors contribute to the mix. Asians often are reluctant to talk about diabetes with family, friends or co-workers. “If you are a person with diabetes in ‘hiding,’ you are not going to ask around for resources,” Dr. Hsu says. The same prejudice discourages Asians from seeking care. “This problem is complicated by the fact that diabetes is not one of those diseases where you just take a pill,” says Dr. Hsu. “Treatment involves modifying the lifestyle of the whole family.”

Other researchers participating in the study include George L. King, M.D., Director of Research at Joslin and Co-director of the Asian American Diabetes Initiative; Sophia Cheung, M.S., R.D.; Emmelyn Ong, M.A.; Kathy Wong, M.S.P.H.; Susan Lin; Kenneth Leon; and Katie Weinger, Ed.D., R.N., Director of Joslin’s Center for Innovation in Diabetes Education.

About Diabetes in Asian Americans

According to Census 2000, the Asian American population increased by 3.3 million, or 48 percent, between 1990 and 2000, which is a faster rate of increase than the general U.S. population experienced during the same period of time. Type 2 diabetes, the most common form of the disease, now affects 10 percent of this population in the United States and, in some cities, its prevalence has skyrocketed to 20 percent. According to World Health Organization (WHO) estimates, roughly half of the more than 300 million individuals with diabetes in the year 2025 will be of Asian decent. WHO predicts that diabetes will increase most significantly in India, followed closely by China.

A recent series of newspaper articles shed light on the plight of Asian American immigrants with type 2 diabetes in New York City. According to the article, Asians are the fastest growing ethnic population in that city. The article highlighted what happens when these immigrants switch from a traditional Eastern diet, where food may have been scarce, to a Western diet laden with plentiful inexpensive fast food. The article stated 14 percent of Asian children in New York City are obese and developing type 2 diabetes -traditionally considered a disease of middle-aged and older adults - at more than double the rate of their parents. Other issues spotlighted in the series ranged from impact of the more sedentary American lifestyle, increased exposure to television and advertising, and reduced physical education programs in schools.

About Joslin’s Asian American Diabetes Initiative

Joslin’s Asian American Diabetes Initiative (AADI), co-directed by Drs. King and Hsu, was established in 2000 by Dr. King and Joslin supporters who were concerned about the increasing incidence of diabetes among Asian Americans. In addition to Joslin’s Asian Clinic in Boston, the AADI includes local and national educational presentations for health professionals and outreach programs for the public and conducts research into insulin resistance, blood vessel disease and other factors related to diabetes in this population. One of the centerpieces of the AADI is a colorful, interactive Chinese-English diabetes Web site (http://aadi.joslin.harvard.edu . The AADI site, featuring content from Joslin’s Web site (http://www.joslin.org) translated into traditional and simplified Chinese, is believed to be one of the most extensive of its type devoted to helping Chinese-speaking individuals manage their diabetes. In addition, Drs. King and Hsu and dietitian/diabetes educator Sophia Cheung are the authors of a Joslin publication, Staying Healthy With Diabetes: A Guide for the Chinese American Community, available for purchase on Joslin’s Store at: https://store.joslin.org/815_2821.asp. For more information about AADI programs, please call (617) 732-2606.