The health needs of Chinese Canadians continue to evolve as waves of migration and settlement bring individuals from different countries, socio-economic backgrounds, education levels, and age groupings.
Perceptions of health care access, treatment and efficiency vary between individuals who are born in Canada and those who are naturalized. This is due in part to individual characteristics such as age, gender, and language fluency, and situational factors such as length of stay in Canada or level of social support that influence acculturation.
For instance, the length of one’s residency in Canada as well as their level of English-language proficiency has an impact on patient satisfaction, regarding the quality of primary care and healthcare system performance (Liu & Quan, 2007).
Non-English speaking Chinese and recent arrivals to Canada are generally less likely to be satisfied with General Practitioners (GPs) than Chinese born in Canada. Recent immigrants are also far more likely to rate GPs lower in terms of their perceived clinical experience, clarity of physician communication, and adequate time spent with them, in comparison to Chinese born in Canada (Liu & Quan, 2007).
In Canada, where physicians are seen by appointment and act as the gateway to referrals, prescription of drugs and diagnostics, regular interaction and continuity of care are important. Low patient satisfaction is associated with lower levels of trust in caregivers and contributes to a greater likelihood of physician change, resulting in discontinuity of care.
It is interesting to note, however, that the level of patient satisfaction within this population does not necessarily correlate with compliance of physician advice (Liu & Quan, 2007).
Disease management strategies among Chinese immigrants are influenced most by type of disease, personal beliefs and cultural factors.
Barriers to care
Chinese Canadians identify the following factors as the main barriers to accessing care and determining the quality of health assessment across different conditions:
- Language differences between the patient and health service provider.
- Failure (on the part of Western systems) to incorporate culturally sensitive and appropriate health education, information, and services.
- Lack of training provided to medical professionals regarding the patient’s total health needs beyond symptoms – cultural values (non-Western medical beliefs/practices) and social factors influencing and impacting health assessment – to determine appropriate treatment plans (Ngo-Metzger et al., 2003; Lai, 2004).
- Lack of assistance, either direct or through referral, provided to patients to help them navigate complex medical and social service institutions (Ngo-Metzger et al., 2003).
The elderly
For the aging Chinese population in Canada such barriers to care are intensified. Aging puts further strain on ethno-racial groups, exacerbates vulnerability and social alienation (Toronto Central LIHN, 2006).
For the elderly Chinese subpopulation in Canada, major obstacles to healthcare are primarily due to communication difficulties: language differences, and cultural insensitivities on the part of service providers (Lai & Chau, 2007).
Other barriers include waiting lists associated with service delivery, lack of knowledge about existing health services, and difficulties accessing transportation services.
These barriers can cause the elderly Chinese population to develop negative attitudes towards service providers and the service system, and can influence the quality of their care in general.
Often this subpopulation will forgo care given the difficulties against them (Lai & Chau, 2007).
Not surprisingly then, the elderly Canadian Chinese population remains underserved by the current health system, notably for cancer prevention and screening, and for the treatment of depression.
Improving health outcomes for this group requires a preventative approach to health and a healthcare delivery system that is more sensitive to unique ethnic and cultural differences.
Specific interventions to address the health needs of Chinese Canadians are required.
Health interventions
Translation services
Chinese Canadians with limited English language proficiency are hindered in their ability to participate in their overall health plan. Many Chinese Canadians indicate language as a common barrier to obtaining accurate and timely care (Ngo-Metzger et al., 2003).
The availability of bilingual and bicultural personnel and professionals to communicate with Chinese patients during health assessment is important.
However, in some cases, even when translation services are available – provided by caregivers (family or support networks) — as many patients discuss, this is not always effective.
Whether such services are useful depends on the translator’s ability to explain medical conditions; availability to accompany them during medical visits; the level of trust and objectivity related to their care; and cultural values which predicate access to care (Ngo-Metzger et al., 2003).
Culturally sensitive practices
Understandings of illness
Culturally sensitive practices require practitioners to be aware of the diverse understandings that different groups have of medicine and medical symptoms (Wang et al., 2008).
For instance, Taoism — the belief in the balance of the yin-yang forces in the body — is a key component of Chinese health understandings and traditional Chinese medicine (Payne et al., 2008; Wang et al., 2008).
In accordance with traditional Chinese medicine, illness and disease of the body is a result of the body’s yin/yang forces being out of balance or in disharmony (Wang et al., 2008). Some Chinese patients may only know how to describe their illness symptoms in these terms, using words such as “yin/cold” or “yang/hot” (Wang et al. 2008).
In addition, within Chinese medicine certain foods and herbs are considered to have medicinal properties (Payne et al., 2008). This is related to their perceived ability to influence vital energies (Payne et al., 2008). Specific foods and herbs are believed to have strong therapeutic contributions (Payne et al., 2008).
Dietary choices in health and illness for Chinese people are often impacted by perceptions about hot/cold food, flow of bodily energies, and traditional models of disease causation, treatment, and prevention (Payne et al., 2008).
These are some of the cultural factors that must be considered by western health practitioners when assessing the diverse needs of their patients.
Some Chinese patients (mainly recent immigrants) who recognize great differences in Western medicine compared to traditional Chinese healing often report resorting to self-diagnosis and self-management strategies to manage their health (Wang et al., 2008). Mistrusting of Western physicians, some prefer to use traditional herbs imported from China to treat specific ailments and disease (Wang et al. 2008).
Role of the family
In addition to illness understandings, the level of family involvement is a culturally sensitive factor for practitioners to consider when interacting with Chinese patients. The role of the family plays a central role in patient care within traditional Chinese understandings (Garrett et al., 2008).
In some cases families can assume complete responsibility for the decision-making of the patients (Garrett et al., 2008).
The high level of family participation within health practice and communication for Chinese clients may be an outcome of patient difficulties with the national language, and/or patient fears about ability to understand procedures or sufficiently communicate symptoms and needs.
Sometimes cultural gender roles or sociocultural mores can also influence family behaviours (Garrett et al., 2008).
End of life decisions
Such knowledge is particularly important for service providers managing end of life patient care within Chinese families.
Family involvement plays a central role in end of life decisions for the Chinese elderly. Especially for the less acculturated Chinese seniors — they believe that their children have the ability to make health related decisions on their behalf (Bowman & Singer, 2001).
Others may feel that the doctor, in consultation with their families, should make their decisions for them, i.e. deciding whether or not to forgo treatment (Bowman & Singer, 2001).
In many cases, for Chinese elders, medical decision-making is viewed as a rational process – having a right or wrong answer independent of the value the patient might place on the potential treatment outcome (Bowman & Singer, 2001).
Identifying a formal proxy is not usually considered useful for this group, since many figure the proxy to lack medical knowledge, and there is the fear that this third party could be a potential source of family conflict (Bowman & Singer, 2001).
Thus, the best time for health care workers to assess the interest of patients and their families for advance care planning is when Chinese seniors first acknowledge the onset of an identified serious illness (Bowman & Singer, 2001). And incorporating a family-centred model of collective decision-making at the time of diagnosis may also resonate more effectively cross-culturally (Bowman & Singer, 2001).
In general, non-Western cultures place greater social and moral meaning on interdependence, which overrides the self-determination and autonomy that typifies conventional North American values (Bowman & Singer, 2001).
Breaking down barriers
Overcoming health barriers requires a multi-faceted strategy consisting of the development of outreach services, educational programs, and enhanced internal and external communication networks between service providers and the Chinese population (Lai & Chau, 2007).
Specifically, overcoming barriers related to personal attitudes, such as fears, stereotypes, and misconceptions about using formal health services involve providing culturally relevant psychosocial community education programs that are language appropriate (Lai & Chau, 2007).
The objective of these programs being to enhance the potential users’ understanding of the services available to them; the importance of seeking help; facilitating access (e.g. assistance with transportation arrangements) — overall ensuring them of the ways in which the health service delivery system can better meet their needs (Lai & Chau, 2007).
Overcoming administrative barriers to accessing health services involves making sure administrative details and operational procedures are culturally appropriate, easy to understand and use by the Chinese population (Lai & Chau, 2007). This approach should be translated to other ethno cultural clients as well (Lai & Chau, 2007).
Capacity training, particularly around culture-specific influencers such as communication, family roles and organization are also important to improving communication effectiveness (Lai & Chau, 2007).
References:
Bowman, K. & Singer, P. (2001). Chinese seniors’ perspectives on end-of-life decisions. Social Science and Medicine, 53, 455-464.
Garrett, P.M. Dickson, H.G. Lis-Young & W. Klinken, A. Roberto-Forero. (2008). What do non-English-speaking patients value in acute care? Cultural competency from the patient’s perspective: a qualitative study. Ethnicity & Health, 13, (5), 479-496.
Lai, W.L. & Chau, S.B. (2007). Predictors of health service barriers for older Chinese immigrants in Canada. Social Work, 52, (3), 261-269.
Lai, W.L. (2004). Impact of culture on depressive symptoms of the elderly Chinese immigrants. Canadian Journal of Psychiatry, 49, (12), 820-827.
Liu, R. Lawrence, S. & Quan, H. (2007). Chinese and white Canadian satisfaction and compliance with physicians. BMC Family Practice, 8, (11).
Ngo-Metzger, Q. Massagli, M.P. Clarridge, B.R. Manocchia, M. Davis, R.B. Lezzoni, L.I. & Phillips, R.S. (2003) Linguistic and cultural barriers to care – perspectives of Chinese and Vietnamese immigrants. Populations at Risk, 18, 44-52.
Payne, A. Seymour, J. Chapman, A. & Holloway, M. (2008). Older Chinese people’s views on food: implications for supportive cancer care. Ethnicity and Health, 13, (5), 497-514.
Toronto Central Local Health Integration Network. (2006) 2007-2010 Integrated Health Service Plan. Toronto, ON.
Wang, L. Rosenberg, M. & Lo, L. (2008). Ethnicity and utilization of family physicians: A case study of Mainland Chinese immigrants in Toronto, Canada. Social Science and Medicine, 67, 1410-1422.
