Research Strategies: Lessons Learned From the Studies of Chinese Americans and Korean Americans

Abstract

Given the increasing population of Asian Americans in the United States, there is an urgent need for culturally and linguistically sensitive and appropriate research to validate research findings, particularly with respect to health care. Although increasing attention is being focused on ethnic minority-group studies, few research reports concentrate on research strategies with respect to Asian American populations. This article describes the importance of language in culturally informed research for ethnic minorities and explores the paradigm for Asian American research methods. Finally, this article makes use of six research projects to discuss practical issues that help produce culturally and linguistically appropriate research on Asian American populations. Cultural diversity issues in patient care need to be included in the health care–related curriculum. Cultural interpretation programs should be facilitated in hospital settings.

Global migration has resulted in ethnic minority groups acculturating with the mainstream group and, as a consequence, threatening the validity of research findings (Devins, 1999; R. M. Lee, Falbo, Doh, & Park, 2001). This is because immigrants typically start to adopt some of the behavioral patterns of the host country’s mainstream society once they emigrate. Researchers are therefore not necessarily able to base investigations on comparisons between individual ethnic groups. Acculturation is the process of adapting to a new culture, and it may involve learning the dominant language and adopting new values and behaviors (Berry, 2006). Differences in language, one of the most important factors affecting an individual’s acculturation, offers researchers a real challenge with respect to achieving valid research within ethnic minority groups. For the past two decades, language has been described as the central component of culture (Stevens, 1985), in that it serves as an organizer of knowledge that affects one’s perceptions (Hamers & Blanc, 2000). To validate research findings about a particular ethnic minority group, the researcher must adopt a culturally sensitive and linguistically appropriate research method (Van de Vijver, 2001).

The U.S. Census Bureau (2000) showed that in 2000 more than 4% of the total American population was of Asian origin. By 2100, the number will have risen to approximately 13.2%. Given this increasing population, there is a great need for studies relating to health care that focuses on this ethnic minority group. The purpose of this article is to share our experiences in studying two of the largest Asian American populations: Chinese Americans and Korean Americans. The specific aims of the article are the following: (a) to discuss the importance of language in culturally informed research for Asian Americans and (b) to discuss practical issues, including educational programs, that help promote culturally appropriate research with Chinese and Korean Americans.

The Meaning of Language in Culturally Informed Research

Language is a form of activity that makes it possible for us to think and make plans (Hamers & Blanc, 2000). Although language is a mode of thought, it is not simply an instrument that conveys and receives message (Ji, Zhang, & Nisbett, 2004). It enables individuals to communicate with and stimulate responses from other people and other linguistic communities. In general, fluency in English is a prerequisite for participating in most research projects in America. As a result, non-English-speaking Asians in the United States may be inadequately and/or inaccurately studied. Because of the language barriers and differing cultural backgrounds, messages that are passed between English-speaking researchers and non-English-speaking research participants do not always lead to increased understanding.

In addition to the barriers of language itself, individuals tend to express emotions more easily in their native tongue (Lassiter, 1995; Lipson & Dibble, 2005). This is because some life experiences are best first reexperienced in an individual’s native language to reach that individual’s deeper affective level of comprehension (Speicher, 2000). It is therefore often necessary to use translated questionnaires when English is not the research participant’s first language or when the participant is unable to read or understand English. In addition, researchers have suggested adopting acculturation theory as a framework for designing cross-cultural studies to validate research findings (Tanaka, Ebreo, Linn, & Morera, 1998). This is due to varying cultural perceptions with respect to certain concepts that may threaten construct validity if researchers simple choose to use the standardized questionnaires. For example, to show parental affection, less acculturated Chinese American parents tend to express their affection by doing something for a child, whereas Caucasians—and consequently, Chinese Americans who are more acculturated—tend to convey their feelings by holding and hugging their children (Alkon, Tschann, Ruane, Wolff, & Hittner, 2001). If we simply use “holding” and “hugging” as the assessment of parental affection, the categories may threaten the study’s internal validity and mislead researchers into concluding that Chinese American parents have less affection for their children than do Caucasians.

Suggestions for Research With Chinese American and Korean American Populations

Over the past several years, the authors have conducted six studies within Chinese American and Korean American populations. In the following section, we would like to present an overview of the studies and then provide some practical recommendations that we have drawn from our experience for researchers, educators, and family clinicians.

Overview of the Studies

A cross-sectional survey design was used to assess the reliability and validity of the English and translated Chinese versions of the Suinn–Lew Asian Self-Identity Acculturation Scale (SL-ASIA; Suinn, Rickard-Figueroa, Lew, & Vigil, 1987) within a community-based sample of 195 Chinese Americans from three areas: the Metro Atlanta Area, Houston, and the San Francisco Bay Area (S. Y. Lee & Rankin, 2004). The SL-ASIA was then included in a descriptive correlational study in the San Francisco area to explore the relationships between acculturation, stress perception, sleep disturbance, and fatigue among Chinese American families with an infant in an intensive care unit (S. Y. Lee, 2004; S. Y. Lee, Lee, Rankin, Alkon, & Weiss, 2005). The third study examined the relationships between acculturation level and perceptions of access to health care, health beliefs, health practices, and knowledge of breast cancer risk among Chinese American women from the New York City metropolitan area (Chen, 2009; Chen & Bakken, 2004). The final three studies involved Korean Americans. One study examined the relationships between parenting and adolescent children’s developmental outcomes (E. Kim, 2001; E. Kim, Cain, & McCubbin, 2006), the second study examined the first-generation parents’ perceptions with respect to discipline (E. Kim & Hong, 2007), and the third study pilot-tested the feasibility and effectiveness of the parenting program with Korean American parents (E. Kim, Cain, & Webster-Stratton, 2008).

Using the Participants’ Primary Language as a Key to Engaging

The authors have found that using participants’ primary language was the key to engaging, enrolling, and retaining participants in our studies of Chinese Americans and Korean Americans. Using appropriate dialects is particularly important in the studies of Chinese Americans; for example, in the New York metropolitan area, there is a new wave of immigrants residing in lower Manhattan and Brooklyn who mainly speak Fuzhounese, whereas the earlier group of immigrants who live in Long Island and Queens speak mainly Cantonese and Mandarin. A similar phenomenon was found in the San Francisco Bay Area. People who live in Chinatown (particularly elderly adults) are mainly Cantonese speakers, whereas those who live in the San Francisco Peninsula Bay area are mainly Mandarin or Taiwanese speakers. In addition to differences in the spoken language, new immigrants, particularly the younger generation from Mainland China, can only read simplified Chinese characters. In contrast, those who came from Taiwan, Hong Kong, Manchu, or Singapore are most likely able to read traditional Chinese characters. Thus, when targeting subgroups of Chinese immigrants for study, it is necessary to use the appropriate language and characters to maximize respondent rates (Chen & Bakken, 2004).

To have the instruments ready in the target group’s various languages and dialects as well as in English is very helpful because different generations of Asian Americans prefer using different languages or dialects. For example, in S. Y. Lee and Rankin’s study (2004), only 29 (most of whom were second generation) out of a total of 195 bilingual Chinese American adult participants preferred English, if given an option. In E. Kim’s (2001) study of 106 Korean American families (105 mothers, 98 fathers, 106 adolescents) only 21% of mothers and 40% of fathers reported that they spoke English “fairly well or very well.” In contrast, 95% of Korean adolescents indicated that their English fluency as “fairly well or very well.” Accordingly, all the first-generation mothers and fathers filled out the instruments in Korean, whereas most adolescents filled out the instrument in English.

Using the study participants’ primary language often requires an interpreter. Although several strategies have been suggested for translating the written instrument, there are limited recommendations regarding oral interpretation issues. It is very important to keep in mind that an interpreter may not necessarily accurately interpret the statements during a conversation. This can lead to real misunderstanding: for example, in S. Y. Lee’s (2004) study of Chinese parents with an infant in the intensive care unit, one mother thought her son’s jaundice resulted from both heart and liver problems because the physician interpreted bilirubin as cholesterol. In Mandarin, bilirubin sounds like tan-hung-su and cholesterol sounds like tan-ku-chun. The mother had no opportunity to clarify her concern until she was interviewed by Lee. The mother said,

Two doctors came to my room, one spoke Chinese but with some accent, they told me not to worry about my baby’s problem, it (supposedly indicated jaundice but was pronounced as cholesterol during conversation) is a common problem for newborns because the liver function is not fully developed yet. I know that cholesterol is related to heart problem, and I asked the doctor several times to make sure that my son did in fact have high cholesterol and what would cause that. The doctor just kept telling me that it is a common condition, and told me not to worry. How is that possible for me not to worry? My son is only a few days old and he has problems both in his liver and heart … Although I would like to ask more questions, but I really don’t know how to ask.

This mother suffered unnecessary worry because of inadequate interpretation and the physician’s lack of awareness that an error had been made. This could have been prevented by using a culturally trained interpreter or by asking the mother to repeat what she had understood from the interpreter.

Acculturation as an Important Measurement Variable for Validation of Research Results

According to acculturation theory, acculturation occurs in many different ways: unidimensionally, bidimensionally, and multidimensionally. In unidimensional acculturation, the acculturation process is considered as a linear progression toward Americanization, resulting in the disappearance of the original ethnic group’s distinctive values in the individual (Gordon, 1964). In the bidimensional acculturation, both the heritage culture (e.g., a Korean orientation) and the mainstream culture (e.g., an American orientation) coexist (Berry, 1997; Cuellar, Arnold, & Maldonado, 1995). In the multidimensional acculturation, the acculturation is defined as immigrants’ selecting components of both the heritage and the mainstream cultures (Berry, 1997). For example, Korean Americans may balance both Korean and American cultures (i.e., “Integration”), exclusively follow either Korean (i.e., “Separation”) or American culture (i.e., “Assimilation”), or follow neither culture (i.e., “Marginalization”; Berry, 1997). Using these unidimensional, bidimensional, multidimensional, and typological acculturation concepts, E. Kim (2001) found that higher levels of acculturation was related to low levels of depression in Korean American parents. Those who were categorized as the belonging to the “Integration” group had the lowest depression mean score followed by the “Assimilation,” “Marginalization,” and “Separation groups,” each of which were found to have significantly increasing levels of depression (E. Kim, 2001).

E. Kim et al. (2006) found that among Koreans maternal acculturation plays a moderating role in parenting behavior and children’s psychological developmental outcomes. Adolescents’ psychological maladjustment was found to be positively related to low levels of maternal warmth associated with mothers’ rejecting of American culture. Similarly, low levels of maternal warmth was found to be related to children’s low social competence and mothers’ lower adoption of American culture (E. Kim, Han, & McCubbin, 2007). Higher acculturation levels were also related to Korean American mothers’ adoption of “appropriate” (by U.S. standards) discipline (e.g., ignoring, timeouts). After completion of a parenting program, mothers in the high-acculturation group were significantly more likely to increase their use of appropriate discipline than were mothers in the low-acculturation group (E. Kim et al., 2008).

In a study of the Chinese American population by S. Y. Lee et al. (2005), the study participants’ ethnic identity (retention on original ethnical value system) was identified as an important variable that affected these parents’ stress perceptions and stress responses while their infants were hospitalized in intensive care units. Asian family values were found to significantly contribute to variance in parental stress for those less acculturated parents, because they fear losing their offspring, particularly sons, thus resulting in no one to carry on the family name. In contrast, Chen’s study of breast cancer awareness in Chinese American population in the New York area did not identify a significant relationship between levels of acculturation and breast cancer risk awareness. Instead, the difference was marked by the number of years of education, marital status, and household income, all of which significantly predicted breast cancer risk awareness (Chen, 2009; Chen & Bakken, 2004). We would argue that the seeming unimportance of acculturation levels with breast cancer awareness may be related to the acculturation scale chosen by the researchers. The acculturation tool used in this study focuses on assimilation (e.g., language use and preference in different circumstances) rather than ethnic identity. We might expect a more valid finding by including both assimilation and ethnic identity as categories with which to examine levels of acculturation, because the relationship between the two components is not necessarily a linear one. There are a host of scales that represent different approaches to measuring acculturation. The criteria for the selection of an acculturation measurement should include the following qualities: (a) cultural appropriateness for the Asian population and (b) capacity for examining wide domains, particularly the ethnic identity component of acculturation.

Strategies for Recruiting and Retaining Participants

There are a number of factors, in addition to the language barriers, that have been identified as typically inhibiting ethnic minorities from participating in research. These factors include misunderstanding the value of research, mistrusting the researcher, and having other priorities in their lives, such as fear of exposure of their status as an illegal immigrant (Demi & Warren, 1995; M. J. Kim, Cho, Cheon-Klessig, Gerace, & Camilleri, 2002; Mann, Hoke, & Williams, 2005; Marin & Marin, 1991). The key strategies for recruiting and retaining ethnic minorities in research studies include helping participants comprehend the meaning of the study, emphasizing confidentiality, and providing necessary assistance after study completion. Following these principles, S. Y. Lee et al. (2005) conducted a study in the San Francisco area to explore Chinese American parents’ stress perceptions while their infants were in an intensive care unit. Lee provided the potential study participants with questionnaires in both Chinese and in English. In addition to honoring participants’ preferences with respect to interview language, Lee spent time listening to participants’ concerns and provided resources for them to use after they completed the study. As a result, the study had a 9% refusal rate and 100% retention of participants.

E. Kim et al.’s (2008) pilot study had an 88% retention rate over a 12-week intervention program. Parents stated that the following strategies used by the research team motivated them to participate in the study: the fact that the class was offered at the same time and at the same place as their children’s Korean language school, that sincere encouragement was provided by the principal investigator, that no registration fee was required to participate, and that free child care and free Korean lessons were given to children who were not enrolled in the language school. In addition, the following retention strategies used by the research team also helped participants continue their attendance: telephone calls to remind participants of class schedules during the week, weekly buddy calling systems, provision of snacks at meetings, and incentives (e.g., stickers for coming to class on time and doing homework, door prize books for children, and subject payment).

It is usually easier to recruit participants for a cross-sectional study than for a longitudinal study. This is particularly true for Asians, which may be related to their orientation toward the present rather than the long term with respect to study goals (Chin, 2005; Im, 2005). When Chen conducted her study related to breast cancer knowledge and behavior in the New York Metropolitan area, she asked participants to fill out questionnaires on site (Chen, 2009; Chen & Bakken, 2004). The return rate was 70%, with a total of 177 women completing the questionnaire. Lee combined translated questionnaires with a face-to-face interview strategy, which resulted in a respondent rate of 91% (S. Y. Lee, 2004). If a cross-sectional study is not an appropriate strategy for the particular research question, using a community advocate such as church leader or ethnic group leader may help retain Asian study participants. The community advocate can facilitate the development of a trust relationship between the researcher and study participants. This method was used in Lee’s study to recruit and then follow-up on her survey study in three Chinese communities. The response rate was 78% for a 2-week interval repeated measure study (S. Y. Lee & Rankin, 2004).

Conclusion

Current methods of research are challenged by the presence of multiple cultures in a single country (Constantine & Gloria, 1999). Minority populations with different cultural backgrounds and language problems face barriers that can prevent them from participating in research. One result is that the health issues of members of ethnic minority groups are neither adequately nor accurately studied. This may make it difficult to provide culturally sensitive health care services for them and may increase their vulnerability when dealing with complex health issues. Comprehension of each Asian subgroup’s cultural background is the essential foundation for validating data analysis and interpretation. The identification of a participant’s acculturation level, both with respect to ethnic identity and assimilation, is an important variable in promoting the understanding of Asian Americans’ perceptions of health-related issues. Adopting a translated instrument for the study participants and using a data collector who speaks the same language may increase the study retention rates. Showing respect for participants, providing help, and establishing ongoing relationships between the researcher and study participants also contributes to a high participation rate in our studies. Before data analysis, it is necessary to establish the equivalence between the original and translated questionnaires to increase internal validity and prevent bias. A multidisciplinary research group, including team members of the targeted ethnic group, may also be beneficial in analyzing data objectively. Furthermore, incorporation of qualitative research methods may help amplify the relationships among variables beyond that was predetermined by quantitative methods.

Health care providers need to fully understand the importance of differences between cultures and consider cross-cultural relationships in their assessment and treatment of ethnic minority clients and their family members. Cultural competence is the foundation for health care providers in providing competent service to ethnic minorities. Culturally competent service includes a set of congruent behaviors, attitudes, and policies that work effectively in cross-cultural situations within a system or institution (Lu, 1996; OMH, 2008). To achieve this competency requires the assessment of cultural differences, the expansion of cultural knowledge, and a commitment to adapt services to meet culturally unique needs (Mattson, 2000; Purnell & Paulanka, 2008). Thus, cultural diversity issues in patient care need to be included in every nursing school’s curriculum as well as in continuing education for health care providers. In addition, intercultural communication skills need to be emphasized in the nursing curriculum to avoid ethnocentrism and ensure effective communication with ethnic minorities.

Clinical research suggests that the utilization of appropriate language is an important communication tool between health care providers and their bicultural clients (Perez-Foster, 1996). Language differences can exacerbate tensions between individuals in the same language community as well as in different language communities within a single country; they can also create intercultural problems that affect individuals from different countries. Only interpreters who have been culturally trained in the client’s culture should be used when the client has language barriers. This is because interpreters are not only responsible for interpreting the spoken words but also for interpreting the client’s cultural values and beliefs. Cultural interpretation programs should therefore be facilitated in the hospital setting, so as to help patients and family members to cope with their medical problems.