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ARTICLE |
a Department of Pediatrics, University of California, San Francisco, California
b Department of Orthopaedics, Harvard University, Boston, Massachusetts
c Biostatistics and Data Management Core
e Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
d Chinatown Medical Services, Philadelphia, Pennsylvania
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. A 3-stage mixed qualitative-quantitative design consisting of exploratory focus groups, a survey, and explanatory focus groups was used to ensure that all of the ideas were generated, prioritized, and explained by youth. Adolescents of Chinese and/or Vietnamese descent and aged 13 to 18 years were recruited in community centers and schools. In stage 1, 55 adolescents in 8 focus groups shared their views on factors that attract or deter them from seeking care. In stage 2, youth responded to a survey including 27 teen-generated items regarding clinicians and sites. In stage 3, 87 teens in 11 groups explained the top-rated items and offered suggestions on how to meet their needs. All of the stages were conducted in English, Mandarin Chinese, and Vietnamese.
RESULTS. Most of the 245 survey respondents (77%) were born in Asia, and 70% had lived in the United States for <3 years. The 27 items were divided into 6 priority ranks by the marginal homogeneity test. Clinician cleanliness and experience shared first rank. Second rank was shared by Asian teens being treated like other teens, site cleanliness, clinician honesty, and clinician friendliness and attitude. The third rank was shared by respect, privacy, completeness, clinicians explaining their actions, and lower health care costs. Interspersed among ranks 5 and 6 were items specific to the needs of Asian youth: the clinician would offer more explanation because Asian families might not ask questions; the clinician would not assume that Asian teens are drug and sex free; the clinician would understand that Asian families may use traditional healing; the clinician would not assume that Asians do not know English; adolescents would not translate for parents; and the teen would be able to choose an Asian clinician. There was little variation in ratings by age, gender, ethnicity, or socioeconomic status. However, 11 of 27 items differed by acculturation. Examples include the greater importance ascribed by more acculturated youth to not being judged, to not having to translate, and to the clinician addressing behavioral issues. Acculturation also affected the youths' views regarding confidentiality and translation.
CONCLUSIONS. Asian American adolescents value the same concerns as all adolescents: respect, honesty, competency, cleanliness, privacy, and nonjudgmental service. However, they also have unique perspectives, and youth at varying levels of acculturation differ in some of their views.
Key Words: Asian • Asian Americans • race • ethnicity • ethnic disparity • adolescent health • qualitative research • focus groups • surveys • disparities • cultural competence • multiculturalism • physician-patient relations • culture • patient satisfaction
Adolescents who forego health care are at increased risk for poor outcomes, and factors associated with lower health use among youth include minority race or ethnicity.1 The Institute of Medicine and the American Academy of Pediatrics have both called for the elimination of widespread and pervasive disparities in access to and quality of health care by race and ethnicity.2,3 To reduce these disparities, clinicians must be able to provide effective services to culturally and ethnically diverse populations.2,3
Asian Americans are a rapidly growing segment of the US population, with 
12.1 million (4.2%) living in the United States in 2004.4 Disparities in access and perceived quality of care have been reported for ethnic minority youth in general5 and Asian American youth in particular.6,7 Asian American immigrant youth have particular needs regarding a variety of health and psychosocial issues, including health risk behaviors; adjustment difficulties, including anxiety and depression; acculturative stress; social isolation; and dealing with language barriers, family conflicts, and racism.8–16 Researchers and advocates have called for culturally competent services for these youth.14,17 However, little is known about what these youth want or expect from health care.
Because Asian American youth are heterogeneous and at varied levels of acculturation, it is unlikely that any single approach will suffice to reach this segment of our population. The process of acculturation has been shown to have complex effects on health behaviors and psychosocial well-being for immigrant youth. Increased acculturation has been linked to a variety of health risk behaviors.12 Acculturation has also been shown to have a significant role in mental health18,19 and family relationships10,20–22 among Asian immigrant youth.
In an effort to learn how to best serve adolescents, previous teen-centered research has explored factors that affect adolescents' decisions on whether to seek health care, how they respond to services, and how they desire to be treated.23–25 Although Asian American adolescents were included in these previous studies, field notes revealed that they were relatively silent during the generation phase of ideas, and, therefore, ideas of particular importance to them may not have been considered.
The objective of this study was to give Asian American youth an opportunity to generate, prioritize, and explain their ideas regarding factors that are important in their health care experiences and decisions to seek health care and to do so in a safe setting that reduced language and cultural barriers. Given the influences of acculturation on Asian American youth, the second objective was to explore the role of acculturation on Asian American adolescents' views and priorities regarding health care. We approached these objectives by using a teen-centered method, a staged, mixed qualitative-quantitative study design in which each stage built on the previous stage. Here we report the quantitative data from the study, with key findings supplemented by selected qualitative data. In-depth qualitative data and discussion will be reported separately.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Study Design
The study design was based on a teen-centered method that has been previously used to investigate factors that impact adolescents' interactions with health care.23–26 The 3-stage, mixed qualitative-quantitative study design involved focus groups and a survey and allowed adolescents to generate and frame the issues, prioritize their ideas in order of importance, and then clarify and explain their ideas.
In both stages involving focus groups, the groups were facilitated by 1 or 2 members of the research team. Each group consisted of 5 to 10 youth, was mixed-gender and single ethnicity (Chinese or Vietnamese), and lasted 45 minutes. All of the group discussions were conducted in the language or languages in which the youths were most comfortable (English, Mandarin, or Vietnamese). Participants were assured that, although the group discussions were being recorded for future analysis, no comments would be associated with any individual. Field notes were taken for each focus group. Demographic information, including age, gender, ethnicity, country of birth, and years spent in the United States, was collected.
In stage 1 exploratory focus groups, youth generated issues of concern and framed the study questions in age- and culture-appropriate language. Focus-group participants were asked the open-ended question, "What do you want from health care?" This was followed by open-ended discussion on important characteristics of providers and sites.
In stage 2 surveys, the participants completed a survey to prioritize the issues raised in stage 1 and to assess attitudes toward health care. Transcripts from stage 1 exploratory focus groups were analyzed for themes, and recurring or important themes were incorporated into the survey, using the wording of the adolescents. In addition, interviews with 5 community experts who worked extensively with Asian American youth in health care or social service settings allowed their views to be incorporated into the survey. The survey was initially developed in English. It was then translated into Chinese and Vietnamese and then back translated into English by a separate translator. The study team and translators reconciled any differences that emerged from this process.
Survey participants were asked demographic questions, including age, gender, ethnicity, mother's and father's highest level of education (as a proxy measure of socioeconomic status), country of birth, number of years spent in the United States, and language spoken at home. Participants' choice of language for their surveys was recorded as a measure of acculturation. To assess exposure to Western medicine and traditional Asian healing methods, respondents were asked 3 questions: (1) "When did you last see an American-style doctor or nurse for a health visit (not counting an emergency department)?" (2) "When did you last see a traditional Asian healer outside of the home?" (3) "When did you last use traditional Asian healing at home?"
The final survey contained 13 demographic questions, 27 Likert-scale items in which participants were asked to rate the items from "extremely important" to "not at all important," and 7 multiple-choice questions designed to measure attitudes concerning health care. In stage 3 explanatory focus groups, participants were presented the results of the stage 2 surveys and asked to clarify survey responses and offer meaning and context, as well as to offer recommendations to health care professionals caring for Asian American youth populations.
Analysis
A mean Likert-scale rating was calculated for each Likert-scale survey item. The marginal homogeneity test was applied to rank the items by comparing each consecutive rating until a statistically significant difference was found (P < .05). The Kruskal-Wallis test was used to compare differences in ratings by demographic subgroups and by acculturation categories. The 
2 test was used to examine possible associations between multiple-choice items and the acculturation category.
The focus-group data were analyzed qualitatively. Transcriptions of the focus groups were reviewed for consistent themes. Direct quotations were selected to reflect, as accurately as possible, the views of the youth.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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For stage 3, 87 adolescents participated in 11 explanatory focus groups, 7 of Chinese and 4 of Vietnamese ethnicity. Two groups were conducted in English, 1 in Vietnamese, 3 in Vietnamese and English, 4 in Chinese, and 1 in Chinese and English.
Participants were recruited for stages 2 and 3 from the same target populations as stage 1 participants; however, the recruitment effort was broadened considerably for stages 2 and 3, resulting in partial but incomplete overlap among participants between the stages. Youth were not asked which health care sites they used; however, during the course of discussions, both sites that served predominantly Asian Americans and general community-based clinics were mentioned.
Survey Results
The themes that arose during stage 1 exploratory focus groups are best represented by the items included on the survey, because those items were selected based on their prominence in stage 1. Table 2 lists the 27 Likert-scale items on the survey by descending mean Likert ratings, with their respective ranking by the marginal homogeneity test. The marginal homogeneity test divided the 27 items into 6 distinct ranks. Each ranking had between 2 and 8 items that were not significantly different from each other but were significantly different from items in adjacent ranks.
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The Kruskal-Wallis test compared item ratings by demographic subgroups. Age was divided into 3 subgroups (13–14 years, 15–16 years, and 17–18 years) and made a difference in responses to 4 items. Younger respondents rated more highly the items referring to cleanliness and hand-washing (P < .001) and health workers not judging or criticizing (P = .005). Older respondents rated more highly the item, "I would be able to get health care without missing school" (P = .003). Nearly 64% of respondents ages 15 to 16 years rated confidentiality between patient and clinicians as "extremely important" compared with 51% of respondents ages 13 to 14 years and 40% of respondents ages 17 to 18s (P = .01). Only 1 item differed by gender: 34% of girls rated being able to choose the gender of their clinician as "extremely important" compared with 25% of boys (P = .002). There was little variation by indicators of socioeconomic status.
Five items varied by ethnicity. Vietnamese teenagers were less likely to rank as "extremely important" the items referring to the clinician respecting the patient and family (P = .041) and having a nice and friendly attitude (P = .24). Chinese teens were more likely to rate cleanliness and hand-washing of providers as "extremely important" (81% vs 61%; P = .014).
Participants who had seen a Western medicine provider within the past year were less likely to rate highly the item referring to the clinician respecting the patient and family (P = .01) and more likely to highly rate provider experience and competence (P = .02). Participants who had seen a traditional Asian healer outside of the home within the year were more likely to value being able to choose an Asian health professional (P = .003), and "the health worker would understand that my family may use traditional Asian healing" more highly (P < .001).
The Effect of Acculturation on the Adolescents' Perspective
The Likert-scale data were analyzed further to look for differences by acculturation status. The acculturation indices that were measured included country of birth, years of residence in the United States (for first-generation immigrants), language used to complete the study survey, and language spoken at home. Language spoken at home was less useful in differentiating acculturation status, because 222 of 245 participants answered a language other than English.
The survey population was divided into 3 acculturation categories: (1) born in the United States and used the English survey; (2) born in Asia and used the English survey; and (3) born in Asia and used the non-English survey. The first category was assumed to be the most acculturated and the third category the least acculturated.
Table 3 presents the 27 Likert-scale items in order of relative priority, broken down by the 3 acculturation categories described above. Ideally, we would determine statistically significant different rankings as we did for the whole population as reported in Table 2. However, the differences in sample size in the acculturation categories make rankings difficult to compare side by side. Therefore, to reasonably approximate the relative differences in priorities, Table 3 lists the order of Likert-scale mean value ratings for each item within each acculturation category. To show which items may be affected by acculturation, items that had significant differences in priority rating by youth in different acculturation categories are noted (Kruskal-Wallis test, P < .05). The ordering of mean value ratings within each acculturation category, unlike the statistically significant rankings reported in Table 2, are included as descriptive data to help illustrate the direction of the statistically significant differences found.
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When Likert-scale data were analyzed using survey language alone as a marker of acculturation, 19 items varied significantly. English-language participants were significantly more likely to rate the item "my information should be kept private between me and the health worker" as "extremely important" (58% vs 44% for Chinese-language and 32% for Vietnamese-language participants; P = .021.) English-language participants also gave higher ratings to being respected by their health worker (P = .003), not having to translate for their families (P = .012), health care sites being clean (P < .001), Asian teens being treated like all other teens (P = .024), and not being judged or criticized (P < .001).
Multiple-Choice Item Results
The survey included 8 multiple-choice items to further assess perceptions of health care on topics where stage 1 focus-group discussions suggested that differences of opinion may exist. The multiple-choice items revealed wide differences of opinion among the youth regarding issues such as desirability of professional translators, confidentiality with clinicians, and views on Asian clinicians. Multiple-choice results were further analyzed for differences by the 3 acculturation categories described above. Table 4 presents responses to selected multiple-choice items from the total population, as well by acculturation category, with significant differences by acculturation category indicated.
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Concerns Not Directly Related to Ethnicity Receiving the Highest Priority
Focus-group participants agreed that some of the most important clinician or site characteristics were not specifically related to Asian American youth, per se. They agreed with the primary importance of cleanliness, for example, as 1 girl said, "because doctors are around germs all day and washing hands will prevent transmission of disease. We are afraid of contagiousness."
Focus-group participants also agreed with the high priority given to clinicians' competence and respect for youth. Teens feared that incompetent providers would hurt them through medical mistakes and measured competence by resolution of illness and by thoroughness of follow-up on the part of clinicians.
Participants agreed with the importance of clinicians having a nice and friendly attitude and offered insight into how they judged this, as follows:
Female 1: "Like, greet you when you sign in. Don't look mad and stuff."
Female 2: "Smile."
Male 1: "They should make you feel welcome to the room, and say ‘hi’ when they enter."
Female 1: "Remember your name."
Male 2: "Don't jump to personal questions real fast. Cause, I don't know you like that."
Some Chinese-speaking participants reported that the facial demeanor of their clinician was important to assessing their clinician's attitude.
Male (Chinese): "As long as their face isn't dark."
Female (Chinese): "He means that you can see their face and know their attitude."
Male: "Yeah, it's about their attitude. If they smile, I don't feel as scared."
Female: "If the doctor's attitude is bad toward sick people, then you think it's too serious and you get scared. You don't know what kind of disease you have if he can't smile anymore."
Participants also agreed on the critical importance of respect from clinicians. Youth offered insights into how clinicians could show respect to Asian American youth. Some youth reported that it was important to be addressed directly, as 1 teen explained, "That shows the doctor how much respect he has for us by going to us first before going to our parents." Respect was also conveyed by speaking clearly and calmly, spending adequate time with the teens, and not making them feel rushed. Many participants noted that respect for the teen and the teen's family is intimately related: "I think if [clinicians] respect the patient, they're going to eventually have to respect the family also. I find no really big difference between respecting the patient himself and the family."
Asian Teens Would Be Treated Like All Other Teens
Participants cared deeply about being treated equally to other youth. Some youth described suspicion of being discriminated against, for example, "...and since sometimes some of them are racist, since we're Asian, I don't know, they just never even help us." Youth did not want clinicians to presume that they did not speak English, and worried that "[clinicians] see us differently, because we don't speak English, or quote ‘don't speak English.’" Participants also worried about both positive and negative stereotyping of Asian American youth; for example, they wanted clinicians to "not always assume that all Asian teens stay away from sex and drugs."
Confidentiality
The topic of confidentiality between youth and their clinicians generated lively discussion, and sometimes debate, in each focus group. Some youth felt that confidentiality was a necessary part of the relationship with their clinician, as 1 youth put it, "Trust comes first...If I don't trust them, I'm just going to transfer to another doctor." This view was expressed in both English as well as Chinese- and Vietnamese-speaking groups, for example, as 1 Vietnamese-speaking youth said, "If I want to tell [my parents], I will tell at home. That's a family problem."
On the other hand, some youth felt strongly that parents had a right to know all of their children's health information. This view was also expressed in English-, Chinese-, and Vietnamese-speaking groups. One English-speaking male said, "They own you. Your parents own your life up until you're 18." Similarly, 1 Chinese-speaking male reported, "But parents should know everything."
In Chinese- and Vietnamese-speaking groups, some teens desired confidentiality to protect their families from potentially distressing information. One typical exchange in a Vietnamese-speaking group follows:
Male: "Our family would worry too much."
Female 1: "Because the family will be sad, and we don't want to be a burden to our family."
Female 2: "If we don't tell them what is wrong, then it's less of a burden for the family."
Views on Having an Asian Clinician
Although having an Asian clinician was ranked the lowest priority in the survey, some focus-group participants voiced the desire to have an Asian clinician, citing shared language, shared cultural understanding, and understanding of traditional Asian healing, as follows:
Male: "If you go to Asian doctor, it's easier to talk."
Male: "Easier to relate."
Male: "Cause like they speak your own language, it's easier."
Male: "And they might know some of the stuff you do at home, like things, like herbs and stuff."
Focus-group participants were not specifically asked whether their views on Asian clinicians referred to clinicians of an Asian ethnicity in general or specifically Chinese or Vietnamese clinicians, respectively. However, some youth described a higher comfort level with clinicians of the same ethnicity, as follows:
Female: "They are Chinese and we are Chinese. So there is a relationship."
Female: "Because they understand me better."
Some youth also felt that having an Asian clinician would make their families be more comfortable. For example, one female said, "It's just like, a typical Asian parent, they don't really trust white people and stuff. Like someone who actually knows how to speak their language, they kind of feel comfortable with them."
On the other hand, some participants preferred not to have an Asian clinician. These youth worried about being judged more by Asian clinicians and not being spoken to directly. For example, one female reported, "I don't like the Asian places, because they always speak in a different language and then just talk to my parents instead of me."
Language and Translation
Issues regarding language and translation generated lively discussion in every focus group. Some youth worried that their parents would not be able to understand their clinicians, as one youth explained, "Asian parents, especially, their English isn't as great, and then you come out with all these big words, and they don't really understand."
Youth's views and needs regarding desirability of professional translation services varied widely and frequently generated significant debate. Some teens felt valued and competent when they translated but others described discomfort with translating and worried about doing it incorrectly. As one English-speaking male said, "It's better for a professional translator to do it. Because this protects us, because I don't know the terminology."
On the other hand, some non–English-speaking youth worried that professional translators might violate confidentiality or would bring shame to the family:
Female (Vietnamese): "If there is another person translating for us, we cannot trust them. For example, if someone in our family has an illness, or a problem, and then that person would talk to another person."
Male (Vietnamese): "[The translator] is not a family member, they don't respect us, don't keep it confidential, they would go and tell other people. And that would make our family even more sad."
In addition, some non–English-speaking teens preferred to translate so that they could intentionally mistranslate to hide difficult or sensitive information from their families. For example, a Vietnamese-speaking male said, "If my parents' illness is too serious, I would not tell the truth, I would lie. Because I don't want them to be sad and worry too much, and die faster."
Family Dynamics
Some participants felt that that clinicians should know that Asian youth sometimes have difficulty communicating with their parents. For example, some youth felt that Asian parents are "really strict" or "hard to talk to." Some youth also desired clinicians to mediate communication with their parents:
Male 2: "Parents trust the doctors more than the kids, so the doctors."
Male 1: "Be a judge, basically."
Female 1: "I don't know, it seems like if it's really that bad, yeah they should be in the middle of it."
Female 2: "Like, just to let the child get their point across."
Male 2: "Doctors could tell them how you feel."
Female 1: "Tell them not to assume things."
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In general, the youth in this study highly valued many of the same concerns as all adolescents. The importance of a clean health professional with appropriate hand hygiene is consistent with previous research, in which youth placed the most important value on cleanliness and infection control.23,24,26 Respect, honesty, competence, showing concern, privacy, and a nonjudgmental attitude have also been prioritized highly in previous teen-centered research with other groups of adolescents.23,26
The Asian American youth in this study also voiced special needs and concerns, and our data underscored that some of these needs may be related to acculturation. For instance, language barriers and issues related to translating were a prominent theme in the focus groups, although they were not among the most highly prioritized survey items. Other concerns were related to fear of being treated differently, being discriminated against, or being victims of racism. These concerns were reflected in several survey items, including the highly prioritized desire that Asian teens would be treated like all other teens, as well as health information and posters including Asians, clinicians not assuming that all Asian American teens avoid sex and drugs, and clinicians not assuming that Asian American adolescents do not know English.
The youth also wanted clinicians to be competent in culturally specific aspects of caring for Asian American youth. For example, the youth wanted health professionals to help Asian American teens communicate better with their parents, because many youth described family conflicts and communication difficulties. Youth also wanted clinicians to understand traditional Asian healing practices and to spend more time offering explanations, because they felt Asian families may be less likely to ask questions. Barriers to access related to socioeconomic status were also prominent concerns.
Findings from this study raise the possibility that views and expectations among Asian American adolescents regarding confidentiality may be different from other groups of youth. Previous research with teens has consistently found that confidentiality with providers is highly valued.1,23,26,37,38 Among the Asian American youth in this study, the concern for confidentiality was also voiced, but the relative priority of confidentiality (in the third rank among Likert items) was lower than in previous studies.23,26 Data from the multiple-choice section of the survey also revealed wide differences of opinion among the youth regarding confidentiality. These differences were reflected in the focus-group discussions, with some participants feeling that confidentiality was a vital element of trust with their clinician, whereas other participants felt that parents had a right to know their teens' private issues regardless of the teens' wishes.
With regard to language and translation, the literature on culturally competent health care has consistently called for language-competent providers or the use of professional medical interpreters.2,3,39 The youth in this study also voiced concerns regarding language barriers. The Likert-scale item referring to teens not having to translate received a relatively lower priority, and the multiple-choice section of the survey, as well as focus-group data, revealed differences of opinion regarding whether teens preferred to translate for their families. The teens' views regarding translation are discussed in further detail below, in particular with regard to the role of acculturation.
Previous studies with ethnic minority adults have found that race concordance between patients and providers is associated with perceived increased satisfaction and improved communication.40–42 Although some of the youth in this study voiced a desire to have an Asian clinician, this concern was ranked last. The majority of responders to the multiple-choice questions indicated that the race of their clinician (Asian or non-Asian) would make no difference in their expectation of being judged or in their quality of relation with their clinician. This is consistent with previous teen-centered qualitative research in which teens stated that they did not need to be matched by race to a clinician to trust that they would be treated fairly and without prejudice. Rather, they needed to see that the health care setting had diverse staff at all of the levels of service and care and that they all seemed to get along.24 However, in this study, differences were found in views of provider ethnicity by acculturation, which is discussed below. Our findings suggest that, overall, Asian American youth want clinicians who are knowledgeable and competent regarding ethnic and cultural issues but that having an Asian clinician, per se, is relatively less important.
Role of Acculturation
Acculturation is a complex process of adaptation to a new cultural environment, involving modifications in attitudes, values, beliefs, and behaviors that result from contact with the new dominant culture.43,44 Although little variation was found in survey results by major demographic characteristics, such as age, gender, ethnicity, or socioeconomic status, we found that acculturation was an important variable affecting the needs and expectations of health care among Asian American youth.
In Asian American youth, increased acculturation has been linked to a variety of health-compromising risk behaviors.12,45–51 Acculturation has also been shown to have significant and complex effects on mental health and psychosocial well-being in immigrant youth. Some studies have found that greater acculturation is positively predictive for indicators of psychological well-being, such as life satisfaction and self-esteem.10 Other investigators have found that less acculturated youth are at increased risk of psychosocial risk factors, such as bullying, social isolation, lack of confidence, not feeling safe, less parental support, and suicidality.19,52,53 On the other hand, some investigators have found increased acculturation to be predictive of mental health problems, such as suicidality54 and eating disorders.55
In addition, acculturation has been found to have significant and complex effects on family relationships among immigrant youth. Some investigators have found that greater acculturation has been linked to increased family conflict and less parental involvement,19,56 but other investigators have found that more acculturated youth report less family conflict.21,22 These seemingly conflicting findings may be understood in terms of an "acculturation gap" (the differences in acculturation between parents and children), because studies have found that larger acculturation gaps are associated with more family conflict.20,22
Several theoretical and methodologic issues have complicated the conceptualization and measurement of acculturation. Some authors have argued that traditional unidimensional, or linear, models of acculturation can be incomplete or even misleading because of the implicit assumption that acculturation takes place along a continuum and that the dominant culture and cultural of origin are, therefore, mutually exclusive.57,58 In contrast to this concept of acculturation as assimilation, these authors have advocated for multidimensional models of acculturation to better reflect various independent and nonmutually exclusive components of acculturation, such as language/communication, customs, racial/ethnic identity, preferences, attitudes, values, and cultural orientation to the culture of origin and dominant culture.57,58
A variety of proxy indicators have been used to measure acculturation. The most common indices have been related to language, such as language spoken at home,45,48 English proficiency,45 self-reported native language,46 language of reading and writing preference,59 and language used to complete the study survey.56 Variables related to immigration have also been used as indices of acculturation, including immigration or generational status (ie, country of birth, and first- or second-generation immigrant),48,60 years of residency in the United States,49,61 and age at immigration.45 Other indices of acculturation have included choice of friends or clothing,62 preference of recreational activities,63,64 and ethnic identity and ethnic pride.65 In addition, several standardized scales have been developed to measure acculturation in immigrant populations.59,64,66,67
Our study divided the youth into 3 acculturation categories, using immigration status and choice of language for the survey as markers of acculturation. Significant differences in perspectives were found among the groups. The most acculturated youth placed a higher value on cleanliness of the clinician, consistent with previous research with other groups of youth.23,26 More acculturated youth also seemed to value more highly competence of the clinician, not being judged or criticized, and not having to translate.
Youth in the less acculturated group placed relatively higher value on several items. They more highly valued having an Asian clinician. They also placed a higher value on clinicians respecting them and their families, which may reflect values more predominant in their Asian countries of origin or increased adjustment stress and fears of discrimination and racism among less acculturated youth. Less acculturated youth also placed a relatively higher value on being able to access health care without missing school, which is a concern that has not been reported previously. Findings from the multiple-choice section indicated that more acculturated teens expected to be judged more if their providers were non-Asian, whereas less acculturated teens expected to be judged more by Asian providers.
Acculturation seemed to have a strong impact on teens' views regarding language and translation. Survey data from the multiple choice section revealed that more acculturated youth were less likely to want to translate for their families in health settings (see Table 4). This finding was also reflected in focus groups. Some youth who spoke predominantly English feared translating incorrectly and preferred having language-competent providers or professional translators. In contrast, some Vietnamese- and Chinese-speaking youth reported that they actually preferred to translate for their families, both to protect their families from perceived shame (in the eyes of the professional translator, who is presumed to be a member of their ethnic community), as well as to filter or change information to protect their families from difficult news. Further qualitative insight and discussion regarding the role of acculturation on language and translation will be presented separately. In general, our findings support the importance of having language-competent providers or professional medical interpreters. In addition, clinicians should be aware that the use of adolescents to translate for their families may potentially have significant unintended consequences, such as intentional mistranslation.
The issue of confidentiality also seemed to be related to acculturation. In the analysis of Likert-scale items by demographic subgroups, English-language survey respondents (who were assumed to be more acculturated) were found to value confidentiality significantly more than Chinese- or Vietnamese-language respondents. A corresponding trend (although not statistically significant) was also seen among the 3 acculturation categories (see Table 3). Similarly, a significant difference was found in the multiple choice results, in which teens from the most acculturated group were more likely than teens from the least acculturated group to feel that providers should share personal health information with parents only when given permission by the teens (see Table 4). These findings suggest that more acculturated youth seem to have views more consistent with other groups of youth, whereas less acculturated youth may be expressing views more consistent with cultural norms from their countries of origin. Our findings may also be understood in terms of the acculturation gap: if, indeed, increased youth acculturation or the acculturation gap is associated with increased family conflict and poor parent-child communication, this dynamic could explain why more acculturated youth placed a higher value on confidentiality.
Study Limitations
This study had a number of limitations. First, because of logistic considerations, the study population was a convenience sample. Youth were recruited from a variety of school-based and community-based sources that serve Asian American youth, which may have introduced selection bias into the study. Second, the subject population in this study was limited to only youth of Chinese and Vietnamese ethnicity in Philadelphia. Because Asian American youth are heterogeneous, it is unknown whether Asian American youth from other ethnic or geographic backgrounds would share the same views.
There was partial but incomplete overlap among participants between the study stages. Because stage 1 participants were generally more acculturated than stage 2 and 3 participants, the survey may not fully reflect the views and needs of the less acculturated participants.
Regarding potential preference for Asian clinicians, the survey did not clarify whether the question referred specifically to same-ethnicity clinicians (ethnicity concordance) or simply to Asian clinicians in general (race concordance) and also did not separate the preference for language competence from preference for race concordance. Although our qualitative data suggest that language competence and shared ethnicity affected youths' views about Asian clinicians, it is unclear from our results whether some youths' attitudes toward Asian clinicians were driven primarily a desire for race concordance, ethnicity concordance, or simply language competence. Because of this, nuanced conclusions regarding workforce policy and race or ethnicity of clinicians cannot be drawn.
Because we only measured proxy indicators of acculturation, such as language use and immigration status, our conceptualization and measurement of acculturation were limited. However, previous researchers have found that language use and immigration status (the measures in this study) have remained major components of acculturation measures and scales, accounting for the majority of variances in the acculturation construct.58,60,68
Perhaps most importantly, this study reveals the views and perceptions of youth, but it is not an outcomes study. Additional work is needed to explore whether efforts to meet the needs of these youth would change access to or satisfaction with health care.
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Incorporating the views and wisdom of the youth in this study will allow providers to more effectively reach out to Asian American youth and to better anticipate their concerns and needs. Findings from this study support the vital importance of cultural competence and, ideally, language competence of providers working with diverse youth populations. Health professionals should not assume that Asian American youth are homogeneous with regard to their experiences, views, or concerns. In particular, providers should consider the role of acculturation in the experiences and perspectives of immigrant youth.
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ACKNOWLEDGMENTS |
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We thank Irena Tsui, MD, for helping to facilitate several focus groups, as well as Han X. Vo, Ngoc Y. Do, S. Daniel Lee, and June H. Lee for their expertise and assistance in Vietnamese and Chinese language and translation. In particular, we thank our partners in the Philadelphia school district for their support, as well as our partners in health care, advocacy, education, social service, and religious organizations serving the Asian American community in Philadelphia. Above all, we thank the Asian American youth in Philadelphia for sharing their wisdom with us.
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FOOTNOTES |
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Address correspondence to Dzung X. Vo, MD, Department of Pediatrics, University of California, 505 Parnassus Ave, Room M691, San Francisco, CA 94143-0110. E-mail: dzung{at}alumni.upenn.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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This article has been cited by other articles:
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  D. X. Vo and M. J. Park Racial/Ethnic Disparities and Culturally Competent Health Care Among Youth and Young Men American Journal of Men's Health, June 1, 2008; 2(2): 192 - 205. [Abstract] [PDF]
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