Some medical problems prevail within the Chinese Canadian population.
Traditional Chinese cultural beliefs and understandings have a strong influence on the Chinese population regarding health, illness, and use of preventative care.
Care providers for this group should take into consideration the specific predisposing, enabling, and reinforcing factors that affect how this group approaches health services, and the kinds of health interventions that are required.
Cancer
Liver cancer (hepatitis B)
The hepatitis B virus (HBV) is highly predominant among many Asian immigrants to Canada (Thompson et al., 2003). The HBV is endemic in most Asian countries (Nguyen & Keeffe, 2003). About 15% of immigrants to Canada from Asian countries are carriers of HBV (Thompson et al., 2003).
And chronic HBV infection is the most common cause of liver cancer for this population (Merican et al., 2000). In North America, the Chinese are more frequently affected by liver cancer than the general population (Hislop et al., 2007). Chronic HBV is responsible for approximately 80% of all cases of hepatocellular carcinoma (HCC) worldwide (Thompson et al., 2003).
Intervention
Intervention is needed within Asian communities in Canada to increase educational health promotion materials regarding HBV. Such materials must be contextually and linguistically appropriate for the population it intends to serve (Thompson et al., 2003).
Many Asian Canadians lack knowledge about the risks of transmission of the disease. For instance, qualitative and quantitative reports show that many Chinese immigrants do not know how the disease is transmitted; do not know the infection is life-long; and many fail to recognize the differences between hepatits B and hepatitis A (Hislop et al., 2007).
The groups most in need of such outreach services are the less acculturated, less educated Asian immigrants, who are most at risk of untreated, undiagnosed, HBV infection (Thompson et al., 2003).
Other strategies for control include routine testing and screening of all immigrants and vaccination for those who have not yet been exposed to the virus (Hislop et al., 2007).
Cervical cancer
Invasive cervical cancer is the second leading cancer among women in mainland China and is also an important issue to address among Chinese immigrant women to North America.
Cervical cancer within this population group, when diagnosed, is often at a more advanced stage than that seen in the general North American population (Hislop et al., 2004).
A lack of knowledge about cervical cancer risk factors amongst Chinese Canadian women have contributed to inadequate Pap screening, resulting in higher incidences of mortality and morbidity within this population (Hislop et al., 2004).
Inadequate Pap screening is most prevalent in less acculturated Chinese women who do not speak English, a finding that is also commonly observed among other new immigrant groups (Hislop et al., 2004).
Some barriers to Pap testing appear to be universal for most women, such as the perception that the test is unnecessary, or fear of cancer diagnosis; but individual barriers to screening and their relative importance dramatically differ between population groups (Hislop et al., 2004). Knowledge about cervical cancer risk factors varies with age, marital status, educational level, income, fluency in English, having a doctor for usual care, and the gender and ethnicity of the doctor (Hislop et al., 2004). Exposure to prenatal care or family planning services in North America is also a contributing factor (Hislop et al., 2004).
For Asian North Americans the most significant predictor of knowledge about cervical cancer is education level, and having a doctor for usual care who is female and not Chinese. In general, having a male doctor is seen as being a poor predictor of knowledge for Chinese women regarding the disease (Hislop et al., 2004).
It is important to note, however, that knowledge of Pap testing may not always translate to women completing the actual test (Hislop et al, 2004).
To increase screenings, culturally and linguistically appropriate educational interventions addressing Pap testing and risk factors for cervical cancer are needed within the Canadian Chinese community.
Intervention materials that cover a combination of enabling factors, (such as key facts concerning cervical cancer risk factors and pap testing procedures, and logistic information — location of clinics and Chinese language facilities), predisposing concerns that address the barriers to screening through testimonials, and reinforcing factors (such as social referents, i.e. encouragement from Chinese herbalists) increase the likelihood of regular testing within the Chinese Canadian population (Hislop et al., 2004).
Effective mediums for intervention materials include video and pamphlets with home-based visits, as opposed to direct mail (Hislop et al., 2004).
Breast cancer
Breast cancer is one of the most frequently diagnosed cancers and, next to lung cancer, causes the most deaths among the Chinese female population in North America (Liang et al., 2004).
The increase in breast cancer incidence is proportional to the length of one’s residence in North America (Liang et al. 2004). For example, compared to the Chinese population in Taiwan where lung and liver cancers account for the majority of cancer deaths, North American Chinese women have higher breast cancer incidence and mortality rates (Liang et al., 2004).
US-born Asian women have a breast cancer risk approximating that of US-born Caucasian women, which is about 60% higher than foreign-born Asian women (Liang et al., 2004). Furthermore, female migrants who have resided in North America for over a decade are 80% more likely to develop breast cancer than recent immigrants (Liang et al., 2004).
And even though the Chinese female population is at high risk of breast cancer, breast cancer screenings within this population are underutilized (Liang et al., 2004).
Studies show that Asian women are 3.7 times more likely than Caucasian women to have late stage breast cancer, since Asian American women are less likely to receive regular mammograms than non-Asians — with Chinese women having the lowest screening rate among the Asian groups (Japanese, Korean, Vietnamese) (Liang et al., 2004).
Although the number of reported screenings by Chinese American women over 50 has increased from an estimated 32% of the population in 1987, to 72% in 1996; the regularity of these screenings remains a problem (Liang et al., 2004).
Other factors that influence cancer screenings amongst the Chinese female population include: perceived level of risk; personal attitudes towards cancer screening; regular access to healthcare, and level of encouragement or frequency of physician recommendations to get regular screenings (Liang et al., 2004).
The referral system of care, where approval from a primary care physician is required, is also an obstacle to screening, since referrals often result in long wait times and several visits before an appropriate specialist becomes available.
Obstacles to disease prevention
Observations have shown that traditional Chinese women can be passive and subordinate during their dealings with health providers. For some, certain health-related topics may be considered inappropriate – such as their breasts, or female-specific issues. This lack of discourse and interaction with health and service practitioners can leave many problems undetected, and can discourage disease-prevention behaviours (Liang et al., 2004).
Also, the social status of physicians within conservative Chinese culture – physicians being high social authority figures — may prevent some from expressing relevant health concerns, or asking pertinent questions due to a fear of embarrassment (Liang et al., 2004).
Levels of acculturation amongst Chinese women can also influence illness-prevention practices such as cancer screenings.
Language ability and use is a key component of acculturation that influences this sub-population’s ability to obtain health-related information and access to health services (Liang et al., 2004). One’s level of language proficiency is a significant predictor of whether they receive mammograms or clinical breast examinations (Liang et al., 2004).
Mental Illness
Also impacted by levels of acculturation are Chinese Canadian conceptions of self and social functioning (Lin, 1994). The extent of traditional Chinese cultural influence can affect how such individuals think about mental illness and mental health, the psychiatric symptoms they experience, their reporting and help-seeking behaviour, and even the conditions they develop (Lin & Cheung, 1999).
In general, Chinese populations have traditionally low rates of documentation within mental health institutions and services.
This population tends to defer service intervention until severe episodes call for immediate and invasive attention. (Lin & Cheung, 1999).
Familial influences
Chinese families are more likely to isolate ill family members from the public community, in attempt to shield and/or “protect” them from public opinion (Ryder et al., 2000).
Studies have shown that Chinese families have a higher tolerance for psychotic symptoms than Euro-Canadian caregivers during the early stages of illness. Such acceptance declines after the introduction of extra-familial treatment interventions (Ryder et al., 2000).
Treatment delays after initial onset of psychotic symptoms are significantly longer for Chinese than Euro-Canadian families (Ryder et al., 2000).
Chinese caregivers are more heavily influenced by the social stigma of mental illness than Euro-Canadian caregivers. Overall, Chinese caregivers tend to show more negative attitudes and feelings towards the mentally ill (Ryder et al., 2000).
This attitude is influenced by central features of Chinese culture: a strong sense of family and collective responsibility; high emphasis on the parent-child bond; the belief that social interactions should remain within the personal family network; emphasis on emotional control and morality; and the high valuation of education and intellectual achievement (Ryder et al., 2000).
The first onset of symptoms of mental illness disrupts these cultural ideals and expectations common within Chinese family networks.
Chinese caregivers also generally view mental illness as a family problem as opposed to an individual one, and this may push them to manage the issue within the family for as long as possible (Ryder et al., 2000).
Conversely, Western families may be more predisposed to perceive psychotic mental illness as a situation calling for medical and/or psychiatric intervention, and are more inclined to seek out external treatment strategies promptly (Ryder et al., 2000).
Inadequate treatment
An additional treatment barrier is the quality of care offered to ethno-cultural groups by Western mental health facilities.
Deficiencies in the delivery of mental health services to Chinese North Americans have been reported. This includes poor forms of assessment and treatment; therapist preferences for client characteristics that place minorities at a disadvantage; high premature termination rates, and overall ineffectiveness (Ryder et al., 2000).
These factors may partially explain why Chinese caregivers take longer than Euro-Canadian caregivers to obtain treatment.
A lack of knowledge of services offered beyond the family physician may also contribute to treatment delays for this group (Ryder et al., 2000).
Somatization
Another obstacle to receiving proper mental health treatment is the inability of medical practitioners to recognize symptoms of illness in Chinese patients.
Common with Asian Americans is the presentation of mental distress through somatic symptoms (Tseng et al., 1990; Kleinman & Kleinman, 1985).
In these cases, such individuals focus solely on the physical discomforts of their ailments and repress any emotional symptoms.
Chinese cultural sanctions generally enforce the belief that emotional symptoms are inappropriate for discussion in the healthcare setting – a realm for bodily treatments only (Cheung, 1985, in Lin & Cheung, 1999).
Additionally, the common Chinese belief that the body and mind are one can influence patients to express emotional ailments through physical complaints (Lin & Cheung, 1999).
Elderly and Depression
Despite their reluctance to seek aid and report mental illness, the prevalence of depressive symptoms amongst ethnic minorities – especially the elderly (Japanese, Korean, Mexican, Native American, and Chinese) is higher than that among the general elderly population of Canada (Lai & Chau, 2007).
Level of acculturation and command of the English language determines the level of risk that an individual will suffer from depressive symptoms (Bowman & Singer, 2001).
Also, one’s degree of involvement within the Chinese cultural community (seeing friends, attending functions, community participation, etc.) is a predictor of life satisfaction and positive experiences amongst the elderly (Chappell, 2006).
Overall, a higher prevalence of depressive symptoms occurs in individuals who have a lower level of social support and financial adequacy.
Treatment
One’s extent of acculturation plays a large role in the treatment of depression, especially amongst the older Chinese population.
Currently, this population is underserved due to the perception that the health service system is culturally incompatible and inaccessible.
And furthering their disadvantage, the older Chinese population has a tendency to avoid seeking treatment due to sociocultural norms and personal attitudes. As noted above, some believe they need to refrain from treatment to “save face;” to avoid bringing shame to themselves and to their families – such stigma ingrained into their belief system (Lai & Chau, 2007).
In addition, combined ethnic and age discrimination is also an underlying problem experienced by older Chinese Canadians attempting to use health services (Lai & Chau, 2007).
Enhancing cross-cultural communication and counseling skills so that health service providers can become more effective and culturally sensitive in their assessment and treatment will help reduce health disparities and improve health equity and the patient experience for racial and ethnic minorities (Lai & Chau, 2007).
Chronic Conditions
Rheumatoid arthritis
For chronic conditions such as rheumatologic diseases (rheumatoid arthritis), respiratory problems (asthma), digestive problems, fatigue, and stress, Chinese immigrants are more likely to seek out and depend on traditional Chinese medicines for treatment (Wong & Tsang, 2004).
In general, Chinese immigrants believe that Western medicine is more effective in the treatment of acute diseases (Zhang & Marja, 2002).
A variety of factors influence the path of illness management for many Chinese individuals, such as; the seriousness of arthritic symptoms; individual beliefs about arthritis; treatment experiences with Western medicines in Canada; beliefs about Chinese medicine; perceived barriers to using Chinese or Western medicine, and social support (Zhang & Marja, 2002).
“Being chronically cold and getting wet” are believed to be contributing factors to arthritis (Zhang & Marja, 2002). Many women also believe that inadequate pre and post-natal care causes arthritis.
These beliefs determine the type of self-care remedies chosen by members within the population.
In general, amongst Chinese immigrants, arthritis is considered to be a complicated chronic disease with an unknown cause (Zhang & Marja, 2002). Most believe that Chinese medicine is more effective than Western medicine in treating this ailment because of its holistic approach to improving the function of the immune system and restoring the energy imbalance that potentially causes the disease (Zhang & Marja, 2002).
The perceived side effects of Western medicines arthritic treatments (analgesics, anti-inflammatory drugs, methotrexate, and cortisone), such as pain to internal organs, are considered a more serious problem than the arthritis itself (Zhang & Marja, 2002). Chinese healers are often consulted in response to the perceived ineffectiveness of Western medicine (Zhang & Marja, 2002).
The major reason why many Chinese use Chinese medicine is due to the belief that Chinese healers have the ability to produce miracles, using secret therapies that they have inherited or created (Zhang & Marja, 2002). However, compared to China, the effectiveness of traditional Chinese medicine is hampered in Canada due to the cost; the lack of qualified and skilled Chinese healers; ineffectiveness in treating critical patients, and discontinuous or short-term treatment terms (Zhang & Marja, 2002).
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