Abstract
Background:
Depression is a major public health concern among older adults and health care professionals play a vital role in screening and treatment. However, this process may be impeded by issues like lack of trust in physician (TIP). This study aims to examine the cross-sectional and longitudinal relationships between TIP and depressive symptoms among Chinese older adults in the Chicago area.
Methods:
Data were collected through the Population Study of Chinese Elderly (PINE), a longitudinal cohort study of Chinese older adults in the greater Chicago area. A total of 2,713 Chinese older adults completed both waves of data collection. TIP was measured through the Trust in Physician scale from Anderson and Dedrick (Anderson LA, Dedrick RF. Development of the Trust in Physician scale: a measure to assess interpersonal trust in patient-physician relationships. Psychol Rep. 1990;67(3 Pt 2):1091–1100. doi:10.2466/pr0.1990.67.3f.1091) (range: 11–55). Depressive symptoms were measured through Patient Health Questionnaire-9.
Results:
Every one point higher in TIP is associated with being 2% less likely to have any depressive symptoms (odds ratio [OR] 0.98, 0.97–0.99) in cross-sectional analysis. Longitudinally, every one-point increase in TIP score was associated with a 2% lower risk of depressive symptoms at Wave 2 (OR 0.98, 0.97–0.99). Improved TIP over 2 years was associated with 25% decreased risk of having any depressive symptoms at Wave 2 (OR 0.75, 0.63–0.89). Additionally, highest tertile of TIP change was associated with a 31% decreased risk of any depressive symptoms compared to lowest tertile (OR 0.68, 0.55–0.84).
Discussion:
Improved TIP over 2 years is associated with less risk of experiencing depressive symptoms. Future research should examine possible pathways and routes of intervention to improve mental health among older adults.
Keywords: Depression, Minority aging, Quality of care
Depression and depressive symptoms have been identified as growing public health concern for older adults in the United States (1) due to outcomes such as increased morbidity, mortality, and health care utilization (2). The estimated overall prevalence of depression among older adults ranges from 10% to 20% (1). The National Institutes of Health has identified clinical settings as important settings to treat and prevent adverse outcomes of depression (3); however, depression and depressive symptoms experienced by older adults often go unrecognized and/or untreated by health professionals (4,5). In addition, individuals may not seek treatment, in part due to poor relationships with physicians and other health professionals (6).
In particular, trust in physician (TIP) has been identified as an important component of providing healthcare to older adults (7–9) but there is limited research, which examines the relationship between TIP and mental health (10,11). Conceptually, researchers have posited that high levels of trust encourage exchange of information and feelings (12), which are necessary to recognize or treat psychological distress in healthcare settings. TIPs and trust in medical care has intrinsic importance due to its influences on attitudes and behaviors in patients, which are markedly psychological in nature (13). To our knowledge, existing research regarding TIP and depressive symptoms has garnered mixed conclusions (14–16). Thus, the relationship between TIP and psychological distress, like depressive symptoms, warrants further examination.
For older adults, the relationship between TIP and depressive symptoms may be particularly important, as TIP has been identified as an important construct to promote health and well-being (16–18). Since older adults are frequent consumers of health care (19), physicians may have a unique opportunity to screen for and treat depressive symptoms in this vulnerable population (20). In addition, older adults may be less likely to seek outside mental health services, making primary care settings vital for detection and treatment (5).
Research regarding the relationship between TIP and depressive symptoms among older adults is incomplete in a few ways. To our knowledge, there are no existing studies which examine TIP in relationship to depressive symptoms among older adults. A cross-sectional study of adults found depression to independently be associated with greater physician trust (21), which is not generalizable to other populations. Further, despite acknowledgement that TIP is a not a static construct and its improvement may also positively impact health status (13), there is limited data which examines TIP over time and in relationship to health outcomes. Most available data are cross-sectional and unable to examine how TIP may change (22) or are clinical interventions to improve TIP with a small sample size (23). Prospective, population-based studies may clarify if TIP affects health and how TIP changes without specific intervention.
There is a paucity of data about the U.S. Chinese older adult community, TIP, and depressive symptoms, despite constituting the largest ethnic subgroup of Asians in the U.S. Chinese older adults commonly endorse TIP (24) but little is known about the relationship between TIP and depressive symptoms in this population. A community-based, representative study of over 3,100 Chinese older adults found depressive symptoms were reported by 54.4% of the participants in the past 2 weeks (25). Understanding the longitudinal relationship between TIP and depressive symptoms in this population could provide researchers and clinicians with greater insight on how to provide psychological care for U.S. Chinese older adults.
This study aims to examine (i) the cross-sectional association between TIP and depressive symptoms, (ii) potential risk factors for depressive symptoms, and (iii) the association between change in TIP and Wave 2 depressive symptoms among Chinese older adults in the Chicago area.
Methods
Population and Settings
The Population Study of Chinese Elderly (PINE) is a population-based epidemiological study of U.S. Chinese older adults in the greater Chicago area. The purpose is to collect community-level data of U.S. Chinese older adults to examine key determinants of health and well-being. The project was initiated by a community-academic collaboration among Rush Institute for Healthy Aging, Northwestern University, and many community-based social service organizations throughout the greater Chicago area. Detailed descriptions of the first wave of PINE data collection are published elsewhere (26), which were collected from 2011 to 2013. The second wave of data collection for the PINE Study occurred from 2013 to 2015. Of 3,157 baseline participants, follow-up interviews were conducted with 2,713 individuals. The Institutional Review Boards of the Rush University Medical Center have approved the PINE study.
Measurements
Socio-demographic characteristics included age, sex, income, marital status, number of children, years in the United States and country of origin. Dichotomous variables were created for sex, marital status, and country of origin. TIP was measured by the Trust in Physician scale from Anderson and Dedrick (27). The 11 items assess an individual’s trust in his or her physician with respect to physician dependability, confidence in physician knowledge and skills, and confidentiality and reliability of information from the physician. Each question was evaluated on a 5-point Likert scale from strongly disagree to strongly agree. Four items were reverse coded. The TIP scale has shown validity and reliability in our population (24). A continuous aggregated score ranged from 11 to 55.
Depressive symptoms were assessed through the Patient Health Questionnaire (PHQ-9). Its nine items assess the depressive symptom criteria as outlined by the Diagnostic and Statistical Manual of Mental Disorders (28) in the past 2 weeks. Items were answered on a 4-point scale from 0 = not at all to 3 = nearly every day. Total score ranged from 0 to 27. PHQ-9 has shown validity and reliability in our population (29). Time was measured as the time between interviews (approximately 2 years).
Data Analysis
Change in TIP was determined by subtracting Baseline score from Wave 2 score. In our population, change in TIP ranged from −28 to 28. A dichotomous TIP was created to represent if TIP improved (1 to 28) or did not improve (−28 to 0). Tertiles of TIP change were calculated by splitting the sample into three equal groups labeled “worsened,” “maintained,” and “improved,” with ranges of −28 to −3, −2 to 3, and 4 to 28, respectively. We used descriptive chi-squared statistics to compare baseline demographic characteristics between groups with and without any depressive symptoms at Wave 2. The Analysis of variance procedure was used to calculate the change in TIP by groups of any and no depressive symptoms at Wave 2. Logistic regressions were run to determine the association between TIP and depressive symptoms. All covariates were taken from baseline. Model A controlled for time, age, female gender, and depressive symptoms. Model B added education and income. Model C added marital status and number of living children. Model D added years living in the United States and country of origin. Cross-sectional regression analysis followed similar models with the exception of controlling for time and depressive symptoms. Covariates were separated into models to determine if what, if any, covariates significantly changed the association between depressive symptoms and TIP. All statistical analyses used SAS, Version 9.2 (SAS Institute, Cary, NC).
Results
Longitudinal Sample Characteristics
Of the 2,713 participants who completed both waves, average age of the participants was 72.6 years, 58.4% were women, average years of education was 8.7 and 85.8% had an annual income of less than $10,000 at baseline. Roughly one third (32.8%) of the participants reported any depressive symptoms at Wave 2. Characteristics of the study participants by any depressive symptoms at Wave 2 are presented in Table 1. Out of the participants who had depressive symptoms, a greater proportion were women compared to men (36.8% vs 27.1%, p ≤ .001) and had an income of less than $5,000 compared to over $15,000 (34.1% vs 22.8%, p < .01) at baseline.
Table 1.
Baseline Socio-Demographic Characteristics by Wave 2 Depressive Symptoms
| Any/None Depressive Symptoms | ||
|---|---|---|
| Any (N = 886) | None (N = 1,817) | |
| Age, N (%) | ||
| 60–64 | 165 (27.82) | 428 (72.2) |
| 65–69 | 168 (30.6) | 383 (69.5) |
| 70–74 | 168 (31.5) | 365 (68.5) |
| 75–79 | 177 (36.8) | 304 (63.2) |
| 80+ | 208 (38.2) | 337 (61.8) |
| Sex, N (%) | ||
| Female | 581 (36.8) | 997 (63.2) |
| Male | 305 (27.1) | 820 (72.9) |
| Education, N (%) | ||
| 0 | 71 (42.3) | 97 (57.7) |
| 1–6 | 337 (32.4) | 702 (67.6) |
| 7–12 | 280 (30.2) | 648 (69.8) |
| 13–16 | 171 (35.2) | 315 (64.8) |
| 17+ | 24 (33.8) | 47 (66.2) |
| Income, N (%) | ||
| $0–$4,999 | 301 (34.1) | 583 (66.0) |
| $5,000–$9,999 | 480 (34.0) | 932 (66.0) |
| $10,000–$14,999 | 69 (27.0) | 187 (73.1) |
| $15,000 and over | 28 (22.8) | 95 (77.2) |
| Marital status | ||
| Married | 582 (30.3) | 1,336 (69.7) |
| Not married | 304 (38.7) | 481 (61.3) |
| Number of children, N (%) | ||
| 0 | 37 (31.0) | 65 (63.7) |
| 1–2 | 343 (31.8) | 735 (68.2) |
| 3 or more | 505 (33.3) | 1,014 (66.8) |
| Years in the United States, N (%) | ||
| 0–10 | 221 (31.0) | 492 (69.0) |
| 11–20 | 277 (32.0) | 588 (68.0) |
| 21–30 | 225 (33.7) | 442 (66.3) |
| 31 or more | 160 (35.8) | 287 (64.2) |
| Country of origin, N (%) | ||
| China | 822 (32.6) | 1,703 (67.5) |
| Not China | 64 (36.0) | 114 (64.0) |
Cross-Sectional Association Between TIP and Depressive Symptoms
At baseline, 54.4% of the participants reported any depressive symptoms. Table 2 presents the association between TIP and depressive symptoms (N = 3,157). Every one point higher in TIP (range: 11–55) is associated with being 2% less likely to have any depressive symptoms (OR 0.98, 0.97–0.99).
Table 2.
Cross-Sectional Association Between Baseline TIP and Depressive Symptoms
| Model A | Model B | Model C | Model D | |
|---|---|---|---|---|
| Age | 1.02 (1.01, 1.03)*** | 1.02 (1.01, 1.03) | 1.03 (1.02, 1.04)*** | 1.03 (1.02, 1.04)*** |
| Female | 1.57 (1.35, 1.81)*** | 1.58 (1.36, 1.84)*** | 1.57 (1.34, 1.84)*** | 1.57 (1.33, 1.84)*** |
| Education | 1.00 (0.99, 1.02) | 1.00 (0.98, 1.01) | 0.99 (0.98, 1.01) | |
| Income | 0.85 (0.80, 0.91)*** | 0.85 (0.80, 0.91)*** | 0.86 (0.80, 0.92)*** | |
| Married | 0.97 (0.80, 1.16) | 0.97 (0.80, 1.16) | ||
| Children | 0.93 (0.88, 0.98)* | 0.93 (0.88, 0.98)** | ||
| Years in United States | 0.99 (0.99, 1.00) | |||
| Born in China | 0.71 (0.53, 0.96)* | |||
| TIP | 0.98 (0.97, 0.99)*** | 0.98 (0.97, 0.99)*** | 0.98 (0.97, 0.99)*** | 0.98 (0.97, 0.99)*** |
Note: Outcome: Baseline Any Depressive Symptoms, OR (95% CI). TIP = trust in physician.
*p < .05. **p < .01. ***p < .001.
Change in TIP by Depressive Symptoms
Table 3 presents the differences of change in TIP by any depressive symptoms and no depressive symptoms at Wave 2. For those with any depressive symptoms, the average score of TIP decreased by 0.05, while those without depressive symptoms reported an increase in TIP of by 1.07. Further, those with improved TIP were less likely to report depressive symptoms at Wave 2 compared to those without improved TIP (30.1% vs 36.4%). Last, those with worsened TIP were more likely to report any depressive symptoms at Wave 2 compared to those with improved TIP (37.8% vs 29.7%). All group differences were significant at p less than .01.
Table 3.
Change in Trust in Physician by Wave 2 Depressive Symptoms
| Any/None Depressive Symptoms | ||
|---|---|---|
| Any (N = 886) | None (N = 1,817) | |
| Continuous change | ||
| Change in TIP, mean (SD) | −0.05 (76.3) | 1.07 (7.97) |
| Improved TIP | ||
| Yes, N (%) | 383 (30.1) | 891 (69.9) |
| No, N (%) | 474 (36.4) | 834 (63.6) |
| Tertiles of change | ||
| Improved (4 to 28), N (%) | 264 (29.7) | 626 (70.3) |
| Maintained (−2 to 3), N (%) | 271 (32.2) | 570 (67.8) |
| Worsened (−28 to −3), N (%) | 325 (37.8) | 529 (62.9) |
Note: TIP = trust in physician.
Association Between Change in TIP and Depressive Symptoms
Table 4 presents the associations between change in TIP and Wave 2 depressive symptoms. After controlling for the full model, female gender (OR 1.31, 1.08–1.59) and lower income at baseline (OR 0.90, 0.82–0.99) increased risk for depressive symptoms. Further, depressive symptoms at baseline increased risk for Wave 2 depressive symptoms (OR 1.18, 1.15–1.20). Every one-point increase in TIP score was associated with a 2% lower risk of depressive symptoms at Wave 2 (OR 0.98, 0.97–0.99). Further, improved TIP compared to maintained or worsened TIP was associated with 25% decreased risk of having any depressive symptoms at Wave 2 (OR 0.75, 0.63–0.89). Finally, improved TIP was associated with a 31% decreased risk compared to worsened TIP (OR 0.69, 0.55–0.84).
Table 4.
Association Between Change in TIP and Wave 2 Depressive Symptoms
| Model A | Model B | Model C | Model D | |
|---|---|---|---|---|
| Time | 0.88 (0.65, 1.18) | 0.90 (0.66, 1.22) | 0.90 (0.66, 1.21) | 0.87 (0.64, 1.18) |
| Age | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) |
| Female | 1.34 (1.12, 1.61)** | 1.35 (1.13, 1.63)** | 1.31 (1.08, 1.59)** | 1.31 (1.08, 1.59)** |
| Education | 1.01 (0.99, 1.02) | 1.00 (0.98, 1.02) | 1.00 (0.98, 1.02) | |
| Income | 0.93 (0.85, 1.02) | 0.93 (0.85, 1.01) | 0.90 (0.82, 0.99)* | |
| Married | 0.89 (0.72, 1.10) | 0.90 (0.72, 1.11) | ||
| Children | 0.98 (0.92, 1.05) | 0.98 (0.92, 1.05) | ||
| Years in United States | 1.01 (1.00, 1.01) | |||
| Born in China | 0.84 (0.59, 1.19) | |||
| Baseline continuous depressive symptoms | 1.18 (1.15, 1.21)*** | 1.18 (1.15, 1.20)*** | 1.18 (1.15, 1.20)*** | 1.18 (1.15, 1.20)*** |
| Continuous change in TIP | 0.98 (0.97, 0.99)*** | 0.98 (0.97, 0.99)*** | 0.98 (0.97, 0.99)*** | 0.98 (0.97, 0.99)*** |
| Time | 0.88 (0.65, 1.19) | 0.90 (0.67, 1.22) | 0.90 (0.67, 1.22) | 0.87 (0.64, 1.19) |
| Age | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) |
| Female | 1.34 (1.12, 1.61)** | 1.36 (1.13, 1.63)** | 1.32 (1.08, 1.60)** | 1.31 (1.08, 1.60)** |
| Education | 1.01 (0.99, 1.02) | 1.00 (0.99, 1.02) | 1.00 (0.98, 1.02) | |
| Income | 0.93 (0.85, 1.02) | 0.93 (0.85, 1.01) | 0.90 (0.82, 0.99)* | |
| Married | 0.89 (0.72, 1.10) | 0.90 (0.73, 1.12) | ||
| Children | 0.98 (0.92, 1.04) | 0.97 (0.91, 1.04) | ||
| Years in United States | 1.00 (1.00, 1.01) | |||
| Born in China | 0.83 (0.58, 1.18) | |||
| Baseline continuous depressive symptoms | 1.18 (1.15, 1.21)*** | 1.18 (1.15, 1.20)*** | 1.18 (1.15, 1.20) | 1.17 (1.15, 1.20)*** |
| Improved TIP | 0.75 (0.63, 0.89)** | 0.76 (0.64, 0.90)** | 0.75 (0.64, 0.90)** | 0.75 (0.63, 0.89)** |
| Time | 0.88 (0.65, 1.19) | 0.91 (0.67, 1.23) | 0.90 (0.67, 1.22) | 0.88 (0.65, 1.18) |
| Age | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) |
| Female | 1.35 (1.13, 1.61)** | 1.36 (1.13, 1.64)** | 1.31 (1.08, 1.60)** | 1.31 (1.08, 1.60)** |
| Education | 1.01 (0.99, 1.02) | 1.00 (0.98, 1.02) | 1.00 (0.98, 1.02) | |
| Income | 0.93 (0.85, 1.02) | 0.93 (0.85, 1.01) | 0.90 (0.82, 0.99)* | |
| Married | 0.89 (0.72, 1.10) | 0.90 (0.73, 1.12) | ||
| Children | 0.98 (0.92, 1.05) | 0.98 (0.91, 1.05) | ||
| Years in United States | 1.00 (1.00, 1.01) | |||
| Born in China | 0.83 (0.58, 1.18) | |||
| Baseline continuous depressive symptoms | 1.18 (1.15, 1.21)*** | 1.18 (1.15, 1.20)*** | 1.18 (1.15, 1.20)*** | 1.17 (1.15, 1.20)*** |
| Worsened TIP tertile (−28 to −3) | 1.00 (REF) | 1.00 (REF) | 1.00 (REF) | 1.00 (REF) |
| Maintained TIP tertile (−2 to 3) | 0.81 (0.66, 1.00) | 0.82 (0.67, 1.02) | 0.82 (0.66, 1.01) | 0.81 (0.66, 1.01) |
| Improved TIP tertile (4 to 28) | 0.68 (0.55, 0.84)*** | 0.69 (0.56, 0.86)*** | 0.69 (0.56, 0.86)*** | 0.68 (0.55, 0.84)*** |
Note: Outcome: Wave 2 Any Depressive Symptoms, OR (95% CI) p value.
*p < .05. **p < .01. ***p < .001.
Discussion
To our knowledge, this is the first examination of the relationship between TIP and depressive symptoms in the U.S. Chinese older adult population. Our study identified several risk factors for Wave 2 depressive symptoms: female gender, lower income, and previous depressive symptoms. We also found that higher TIP is associated with lower odds of experiencing any depressive symptoms in a cross-sectional analysis and improved TIP is a protective factor against later depressive symptoms, regardless of previous depressive symptoms.
Our study indicates that female gender, lower income, and depressive symptoms are risk factors for depressive symptoms among U.S. Chinese older adults, which is consistent with previous literature regarding risk factors of depression in older adults (5,30). However, among Chinese older adults, existing research has found that having fewer children is a risk factor for depression (31), which is contrary to our findings. It is likely that familial and social support are relevant constructs in relationship to depressive symptoms about U.S. Chinese older adults in the Chicago area (32) but this is perhaps not captured by the number of children. Future research should more closely examine the role of other potential risk factors for depressive symptoms, like social support and familial relationships.
Our study found an association between greater TIP and a lower likelihood of depressive symptoms among Chinese older adults. There are a few possible pathways that may elucidate our findings. First, increased TIP may lead to increased likelihood of disclosure of depressive symptoms, giving physicians an opportunity to treat depression or greater likelihood of compliance regarding treatment options. Previous research has indicated that trust in the clinical setting contributes to both disclosure of symptoms and compliance with physician orders (5,33). Fiscella and colleagues found that taking medication for depression was independently associated with greater physician trust in a cross-sectional sample (21), suggesting that TIP may be high if psychological distress is both recognized and treated. Given research that physicians often neglect to identify and treat depressive symptoms among older adults (5), our population likely is not screened or treated, which may either reflect or contribute to low TIP.
Further, TIP may be indicative of an individual’s interactions with their physician regarding other health factors, which may in turn influence depressive symptoms. Previous research has found lower patient satisfaction regarding cancer treatment to be associated with higher depressive symptoms (34). As TIP and patient satisfaction are both components of the patient–physician relationship, the association between TIP and depressive symptoms in our study may be influenced by treatment plans related to other health conditions. Older adults are likely to experience multiple medical comorbidities and receive complex medical care (17,35–40); their satisfaction in this medical care may secondarily decrease the likelihood of depressive symptoms. Future research should investigate how other medical conditions, their treatment satisfaction, and other patient–physician relationship components may impact the association between TIP and depressive symptoms.
In addition, we found that improved TIP over 2 years is associated with decreased risk of experiencing any depressive symptoms, regardless of previous depressive symptoms. Although current literature has provided some evidence regarding the importance of physician trust in relationship to desired health outcomes (23,41), our study is the first to our knowledge which can demonstrate the potential utility of improving TIP in reducing the risk of depressive symptoms. Similar to possible pathways outlined above, improving TIP may reduce the likelihood of depressive symptoms due overall better medical care. Researchers have emphasized the embedded natures of psychological, physiological, interpersonal, and cultural processes (42), which may be particularly relevant in explaining the relationship between TIP and depressive symptoms. Future research should work to disentangle these various components and elucidate clearer pathways between improving TIP and lowering risk of depressive symptoms in older adults.
Our findings should be interpreted with some limitations. First, this study is representative of U.S. Chinese older adults in the greater Chicago area, and our findings may not be applicable to other populations. Second, we did not collect data about physician characteristics, including whether there was continuity of care, which existing literature has indicated may greatly impact TIP (43). Third, TIP may interact or be impacted by a variety of other factors related to the physician–patient relationship, like institutional trust, provider choice, and type of insurance (5,13), which should be assessed in relationship to depressive symptoms through qualitative and longitudinal studies. Last, TIP may function differently among Chinese older adults due to demographic, linguistic, and cultural phenomena. Research has suggested that there are racial and ethnic differences in TIP (43), which may be disparately related to health outcomes.
Despite these limitations, our study provides the crucial first step in examining the effects of TIP on mental health outcomes and can provide future directions in research and clinical practice. With our findings in mind, future qualitative and longitudinal research should examine additional components which may influence TIP and/or depressive symptoms, that is, continuity of care, complexities of the patient’s health status, coverage of medical care, symptom disclosure, availability of psychological referrals, and medication use (5,13). Additionally, our study supports calls to improve depression care in nonpsychological and medical settings (44). Regarding minority and immigrant older adults in particular, there are few culturally and linguistically appropriate psychological services available (45); building trust in more common medical settings may be vital toward addressing depression in this population.
In sum, our study demonstrates the importance of TIP in understanding depressive symptoms among Chinese older adults. Not only is greater TIP associated with a lower chance of experiencing depressive symptoms, improving TIP over time may protect against future depressive symptoms. Future qualitative and longitudinal research should examine the possible pathways of this relationship, that is, other components of the physician–patient relationship, availability of mental health services, etc. Additionally, our study intimates the usefulness in building and improving TIP to better psychological wellbeing among older adults.
Funding
Dr. Dong has been supported by National Institute on Aging grant (R01 NR014846, R01 AG042318, R01 MD006173, R01 CA163830, P20 CA165592, R34 MH 100393A1 & R34 MH 100443A1), and Administration on Aging/ACL: 09EJIG0005-01-00.
Conflict of Interest
None.
Acknowledgment
We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong, Vivian Xu, and Yicklun Mo with Chinese American Service League (CASL), Dr. David Lee with Illinois College of Optometry, David Wu with Pui Tak Center, Dr. Hong Liu with Midwest Asian Health Association, Dr. Margaret Dolan with John H. Stroger Jr. Hospital, Mary Jane Welch with Rush University Medical Center, Florence Lei with CASL Pine Tree Council, Debbie Liu with Coalition for a Better Chinese American Community, Yvonne Lau with Loyola University, Karen Huang with Epoch Times, Craig Maki with Asian Human Services, Ji Hye Kim with Korean American Women in Need, and Radhika Sharma with Apna Ghar.
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