TABLE 2.

Barriers and Opportunities to Improve Cardiovascular Health in South Asian Adults

Barriers	Comments
Racial and cultural discrimination^195,196	Racial/cultural discrimination experienced when seeking health care services may be related to poor self-rated health status and quality of life.^197,198
Existing cultural attitudes regarding health care	Fatalistic beliefs (all events are predetermined and therefore inevitable), cultural, and social norms influence self-management and illness beliefs.^199,200
Acculturation	In MASALA, 3 acculturation strategies were identified: separation (preference for South Asian culture over US culture), assimilation (preference for US culture over South Asian culture), and integration (similar level of preference for South Asian and US cultures). Length of stay in the US, English proficiency, and higher household income influenced assimilation or integration strategies.²⁰¹ Those in the integration and assimilation strategies had better cardiometabolic risk factors than those in the separation class.²⁰² Higher levels of acculturation influence health-seeking behaviors and higher self-reported health in a positive fashion.²⁰³
Socioeconomic status	Lack of health insurance and high out-of-pocket expense for appointments and prescriptions.²⁰⁴
Health literacy	Health literacy is closely associated with English proficiency and cultural health beliefs; limited literacy associated with a poor understanding of available health services, underutilization of available medical care, and lower levels of self-rated health status and diabetes care in SAs.^205,206
Geography - distance from healthcare center, extended wait times, child care responsibilities, and lack of access to transportation	Transportation is especially problematic for elders who cannot drive or/and speak English and those who live in multigenerational homes.²⁰⁷
Language^207,208	Effective healthcare use requires native language accessibility to explain symptoms, and understand diagnosis and treatment, for example. Children can help facilitate interpretation; however, this method is prone to incorrect or incomplete communication when children lack the appropriate medical terminology, lending itself to delay of care in the elderly.²⁰⁹ Lower rates of English proficiency are a predictor for higher traditional health practices.²¹⁰
Health care practices do not align with modern Western or allopathic medicine	South Asian patients question the need and efficacy of modern medication. In parallel with medical therapy use, they may use traditional remedies, perceived to be more efficacious and nontoxic. Family and friends can serve as important in decisions to use alternative medicines.⁴³
Opportunities	Comments
Culturally sensitive educational materials	Education material is written and translated into common languages native to South Asian countries. Educational material offers culturally specific information (eg, dietary recommendations that name foods common to a SA diet, or healthcare recommendations during religious obligations such as Ramadan fasting)^83,134.
Language/Health literacy	Patient experience is improved in practice settings that offer a language concordant with the patient’s ethnicity.²⁰⁸
Engagement of cultural/religious organizations and social networks.	Partnering with places of worship or community events to promote healthy lifestyle education, healthy eating habits, increased physical activity, and combat the effect of discrimination and racism.^148,211,212
Cultural competency	Systemic education on cultural behaviors and practices for all members of the healthcare team.²¹³
Disaggregation of health data	Disaggregation will help refine our understanding of health care disparities among South Asian subpopulations, considering broad genetic, cultural, and socioeconomic characteristics.³

MASALA = Mediators of Atherosclerosis in South Asians Living in America; SA = South Asians.