Taking Action to Improve Asian American Health

In my experience as a health equity researcher, it has become evident that the terms health disparities and Asian American do not go hand-in-hand in popular thought. I am routinely met with skepticism when describing low-income Asian American communities or the poor health status, health care use, or health outcomes for these communities. My work, however, is guided by data. Specifically, Asian Americans

• •Have the highest poverty rate of all racial/ethnic minority groups in New York City,¹
• •Constitute 15% of the New York City population yet were awarded 1.4% of New York City–based agency contracts to social services providers in the past 13 years,² and
• •Are the most understudied racial/ethnic group in the peer-reviewed literature (6% of US population; 0.01% of MEDLINE articles).³

Furthermore, research including Asian American participants is critically underfunded by the National Institutes of Health (less than 0.17% of the total National Institutes of Health budget).⁴ To put it bluntly, Asian Americans are simply not a part of the collective consciousness of public health researchers and practitioners either as a community of color or as a population that experiences health disparities.

Aggregated data from national and local data sources across the diverse umbrella term “Asian American” indicate that Asian Americans appear to have better socioeconomic, behavioral, and health outcomes than do other racial/ethnic groups. For example, overall education and income levels are higher in Asian Americans compared with the overall US population.⁵ Wealthy, successful, and highly educated Asian Americans are highly visible in society, from Andrew Yang to the Crazy Rich Asians franchise. But two major facts are masked by aggregated data: (1) the glaring bimodal income distribution among Asian Americans⁶ and (2) the stark sociopolitical, ethnic, economic, and linguistic disparities across Asian subgroups.⁵ As a result of the prominent visibility of the Asian Americans at the highest end of the socioeconomic distribution, Asian Americans across the remaining portion of the socioeconomic distribution are ignored.

In this issue of AJPH, Adia et al. (p. 520) present evidence describing (1) the health disparities that Asian Americans experience in comparison with non-Hispanic Whites and (2) how aggregation of Asian American subgroups (e.g., Chinese, Vietnamese, Filipino) masks important health disparities within the Asian American community. They used the 2011–2017 California Health Interview Survey—a survey that has made great strides to ensure representation across Asian American subgroups—and found that overall, Asian American adults were more likely to be overweight or obese and to self-report diabetes. Overall, Asian Americans were less likely to report disability or delayed access to and uptake of medications and health care compared with White adults. However, after disaggregating the data by Asian subgroup, specific health disparities were identified, including fair or poor health among Vietnamese Americans, overweight or obesity in Chinese and Japanese Americans, and greater reporting of no usual source of care among Korean Americans. Additionally, Filipino Americans reported experiencing the most health disparities compared with Whites, including fair or poor overall health; being overweight or obese; and having high blood pressure, diabetes, or asthma despite having generally similar access to health care.

Several lessons may be drawn from their approach, outlined in the following section and in Table 1.

TABLE 1—

Actionable Recommendations for the Public Health Community to Improve Asian American Health

Recommendations	Unique Salience to Asian American Health Research	Action Steps
Making meaningful use of already collected data	Data on Asian Americans are sparse.	Conduct secondary data analysis being inclusive of Asian Americans of existing, administrative data sets.
		Include data by subgroups, when possible.
Digging deeper—who is represented in the Asian American sample?	The Asian American category includes different people in different studies with regard to geography, Asian subgroup, and socioeconomic status.	Provide context on Asian American sample in Methods sections.
		Describe specific Asian subgroups and socioeconomic status, guided even by quick search of the Internet.
Partnering with local communities	Community-partnered research has been shown to be a successful model to enhance trust, participation, and cultural resonance.	Meet or volunteer with community-based organizations serving Asian American communities to understand local health needs and build trusted relationships.
Some data are better than no data	A lack of data leads to invisibility.	Present data on Asian Americans.
		If data are not available, cite reasons and discuss or contextualize what implication this may have (e.g., Asian Americans were excluded from the analysis because of inadequate sample size, but increasing diabetes prevalence in this group has been observed by others).

MEANINGFUL USE OF ALREADY COLLECTED DATA

Researchers in the public health community have increasingly focused on the promise of big data, such as electronic health records, large health insurance databases, or data from social media. This is particularly salient for research for Asian American communities—among whom data are sparse. Secondary analyses of existing, administratively collected data such as those presented by Adia et al. are also an efficient way to gain a preliminary understanding of the diverse Asian American populations, which can then lead to future primary data collection and research efforts that focus on specific groups who are likely to experience greater health disparities.

WHO IS REPRESENTED IN THE SAMPLE?

Generalizability is highly relevant for research on Asian American communities. As noted as a limitation by Adia et al., the results of their analysis are not generalizable to Asian American communities in places other than California. For research among Asian Americans, this statement has historical and modern-day relevance. The term Asian Americans, as used across studies in different geographic settings, typically includes different combinations of Asian subgroups because of varying migration histories, geography, income and health literacy, or research methods. For example, an Asian American sample from Texas may be predominantly South Asian, but an Asian American sample from Minnesota might be 100% Hmong. This pertains to both community-based studies and nationally representative samples. For instance, the National Health Interview Survey has oversampled Asian Americans annually since 2006, but it is conducted in English and Spanish only. One third of Asian Americans have limited English proficiency, and these individuals are also more likely to have poorer socioeconomic profiles and health outcomes.⁵ This is not meant to suggest that analyzing data from the National Health Interview Survey or other, similar data sets is not useful but rather that researchers must acknowledge that findings for Asian Americans are more likely to be generalizable to Asian Americans of higher income and educational status and, hence, have better health outcomes.⁷

Researchers conducting such analyses need to contextualize these findings responsibly by understanding and explaining who along the socioeconomic spectrum is represented when interpreting results. Failing to do so makes it difficult to make appropriate comparisons across studies and, worse, perpetuates myths of a healthy immigrant advantage.

PARTNERING WITH LOCAL COMMUNITIES

The work of Adia et al. also exemplifies another important theme relevant to understanding the health of the diverse Asian American subgroups: partnership with local Asian American communities and community organizations. The authors report on Asian American groups that are of plurality in California: Chinese, Vietnamese, Koreans, Japanese, and Filipinos. Notably missing are South Asian Americans. Their findings highlight opportunities for direct community-partnered work (e.g., connecting Korean Americans to a usual source of care) and for future investigation (e.g., health needs assessment of South Asian California groups). In both instances, recognizing the central role of faith- and community-based organizations as a trusted part of the fabric of the Asian American experience is critical for successful implementation and long-term sustainability.

Connections with such community partners can also offer insight into pressing health concerns, subgroup-specific expertise on cultural norms and language support, and shared staffing with an academic partner through a community health worker approach. Note, however, that engaging with community partners is just one element of a broader set of initiatives that can improve the health and well-being of Asian Americans across ethnic groups. Additional efforts include diversification of the social services workforce and support for pipeline opportunities to encourage researchers interested in studying Asian American health disparities.

SOME DATA ARE BETTER THAN NO DATA

Often, as was the case for Adia et al., researchers are faced with a conundrum: advocating for data disaggregated by ethnic group within the Asian American category yet having to use and report on aggregated data nonetheless. The reality is, presenting some data on the health status of Asian Americans is more helpful toward the broader dialogue than not presenting any data at all—particularly if the data are carefully interpreted and contextualized as described earlier. In the peer-reviewed, public health literature, data on the health status of Asian Americans often are not available; available but excluded because of small sample size; or, worse, available but excluded for no specific reason. A lack of data perpetuates the most harmful inequality for Asian Americans: invisibility as a community of color, as a health disparity population, and as a population deserving of equal consideration in health research, funding, and policymaking.

The lack of visibility and lack of recognition that health and health care disparities exist for Asian Americans are difficult challenges to overcome, but through small, actionable steps and a renewed mindset of inclusivity, we as a public health community can work together toward improved health for Asian Americans. Achieving health equity—an agenda of national and public health importance—may be most readily achieved through incremental and specific steps of this archetype for all racial/ethnic groups.