Improving Public Health Surveillance About Asian Americans, Native Hawaiians, and Pacific Islanders

By the year 2043, the United States will no longer have any majority race or ethnicity, increasingly reflecting a vision of a multicultural society (bit.ly/1oyMzWB). Asian Americans and Native Hawaiians and Pacific Islanders (NHPIs) are among the fastest-growing racial and ethnic populations in the United States, with families coming from more than 50 countries and speaking over a hundred languages and dialects. As our nation increases in diversity, the specific races and ethnicities of our people will continue to change and deepen in complexity, with a large proportion who are immigrants and refugees from all parts of the world. In all fields, but particularly in public health and medicine, communicating effectively with diverse populations and understanding who they are—their family origins, languages, and cultures—are fundamental to our work. Comprehensive and granular data are the lifeblood of how to understand trends in morbidity and mortality and the curative possibilities of improving the health of our increasingly diverse nation.

This newly created AJPH section on Surveillance and Survey Methods—and specifically the report by Paulose-Ram et al. (p.916 in this issue) about the data on Asian Americans in the 2011 to 2018 National Health and Nutrition Examination Survey (NHANES)—is an important milestone for Asian American and NHPI epidemiologists, researchers, providers, and community leaders who have been calling for improved collection, analysis, and dissemination of data for our communities. We look forward to the publication of more articles that push the methodological envelope, improve understanding about the social determinants of health, liberate public data sets, and inform data-driven public policies for our Asian American and NHPI populations, and for all of our nation’s diverse population.

PUSHING THE METHODOLOGICAL ENVELOPE

Over the last 10 years, the methodological envelope has been pushed, particularly through community partnerships with the US Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), the Office of Minority Health (OMH), and the National Center for Health Statistics (NCHS). ASPE has regularly published data about the impact of the Affordable Care Act (ACA) on reducing the numbers of uninsured Asian Americans and NHPIs, highlighting the beneficial impact of the ACA on our communities.¹ As part of the implementation of the ACA, OMH established standards for disaggregating Asian American and NHPI data.² Adoption of OMH’s standards for disaggregating data for Asian Indians, Chinese, Filipinos, Japanese, Koreans, and Vietnamese, as well as for Native Hawaiians, Chamorros/Guamanians, and Samoans, will be critical for improving our understanding of our diverse Asian American and NHPI communities. However, additional disaggregation also is needed for some of the most rapidly growing Asian American populations, including Pakistani, Bangladeshi, and Sri Lankan populations, as well as refugees recently admitted from Burma, Bhutan, and Nepal.

For many years, small numbers in the individual cells of a data set resulted in the conclusion that the data could not be analyzed with enough statistical power, or without violating the privacy of the respondents. To escape this “tyranny of small numbers,” NCHS has been able to refine and advance methods to improve each step in the surveillance process, from data collection to analysis to dissemination, which has maintained both statistical power as well as privacy. NCHS has made great strides in oversampling methods and pooling data for analysis across data sets and years for Asian Americans and NHPIs, especially in NHANES.³ NCHS is to be commended for its outreach and partnership with community-based organizations and leaders to inform its efforts, and to maintain its accountability to the community.

More breakthroughs are needed, especially with emerging survey data collection methods using mobile phones and online responses. Increasing data collection using languages in addition to English and Spanish also will be important in our increasingly multilingual society. There also needs to be greater sophistication in our methods for examining the interrelatedness of race, ethnicity, language, and immigration status as demographic characteristics. Such methodological advancements will maintain the level of data granularity that is needed not only to understand disparities and inequities but, more importantly, to act on them, armed with the most specific and reliable data and analysis we can obtain.

IMPROVE UNDERSTANDING OF SOCIAL DETERMINANTS

There is increasing understanding about the importance of public health, and especially how socioeconomic factors determine the health of individuals and communities even more than medical care. We as a field also need to up our game on how to detect, reveal, and find solutions through the analysis of data that takes into account public health and health care data as well as data from other sectors, such as education, employment, housing, transportation, and criminal justice.

There also is an urgent need for better methods in using, linking, and analyzing multiple data sets. This will require increased data standardization and interoperability across current data and information systems. When our staff at the Asian & Pacific Islander American Health Forum finally passed the security clearances to obtain access to de-identified data to cross-tabulate US Census and American Community Survey data with National Health Interview Survey data, we were able to discover the statistical correlations between small business employment and uninsurance for specific Asian American and NHPI populations. Using our analysis, we were able to target our outreach, in specific Asian languages, to the Asian communities who had the highest rates of uninsurance,⁴ and to contribute to the largest decrease in uninsurance among any race or ethnicity in the country.⁵

LIBERATE PUBLIC DATA SETS

The conditions under which public data become available, including the levels of privacy and security, have a blunting effect on how public health professionals, and the public, understand and use data. As we advance methodologies that achieve greater granularity and precision, both for analysis and especially for solutions, we also need parallel advancement on the policies—both public and private—that guide and restrict data access and use. Former White House Chief Technology Officer Todd Park frequently called for the liberation of public data sets, for “freeing the data.”⁶ Just as our democracy rests on public education, civic engagement, and a free press, so public data can drive democracy in knowledge. We need advancements in the conditions and environments in which our public data reside, recognizing that public funds paid for the collection and analysis of that data. As taxpayers, those data are ours.

INFORM DATA-DRIVEN PUBLIC POLICIES

Public health data can be especially relevant as we debate and consider public policies from insurance coverage to value-based payment, from public education and revitalization of economic sectors to immigration and refugee policies. For example, to have a data-driven debate about immigration and refugee laws and policies, we need better data about immigrants and refugees, including their access to and utilization of health care, and their health status. However, we will never be able to gain the trust of immigrants and refugees to collect these data when there are threats of denial of services, denial of future legal immigration status, and deportation. Beyond usual concerns with privacy and data security, such public policies create additional barriers to collecting public health data. This new section on Surveillance and Survey Methods can make vital contributions to our understanding of these complex issues and can provide the missing data that can inform and support data-driven and commonsense public and private policies that will improve the health of our diverse communities. The health of our nation depends on it.