Study’s Findings Challenge 'Model Minority Myth' (Episode 42)

August 27, 2018

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Darcy Grabenstein: Hello from SmartLinx! Solutions. Our guest today is XinQi Dong, director of Rutgers University’s Institute for Health, Health Care Policy, and Aging Research, or IFH. In addition to the institute directorship, he serves as the inaugural Henry Rutgers Professor of Population Health Sciences. He is the lead researcher of the Population Study of Chinese Elderly in Chicago, which examined the health and well-being of Chinese older adults and culminated in the publishing of 20 articles, which is the topic of today’s podcast. Most recently, XinQi was a professor of Medicine, Nursing, and Behavioral Sciences at the Rush University Medical Center and the associate director of the Rush Institute for Healthy Aging.

His research and advocacy have been recognized by many national and international organizations, including awards by the American Public Health Association, American Geriatric Society, Gerontological Society of America, and International Congress of Gerontology and Geriatrics. He was the first geriatrician to receive the National Physician Advocacy Merit Award by the Institute on Medicine as a Profession. This year, he was elected to the prestigious American Society of Clinical Investigation. He has served as a commissioner for the Commission on Law and Aging from the American Bar Association, and he chaired the workshop on elder abuse prevention for the Institute of Medicine’s Global Violence Prevention Forum. A native of China, he completed his geriatric fellowship at Yale University Medical Center.

Welcome back. Our last conversation in July focused on your new position at Rutgers. Good to have you as our guest again.

XinQi Dong: Thank you, Darcy, it’s great to be with you again.

DG: So let’s get started. Let’s start with some statistics. By 2030, it is estimated that 25 percent of the world’s aging population will be Chinese. Yet there appears to be a lack of health research regarding this segment of the population. Would you say that’s correct? And, if so, why?

XQD: It’s an important point. I think while there has been a growth of knowledge about Chinese health and aging issues in China, there has been relatively less research focusing on the changing social dynamics and how these phenomena impact wellbeing on their lives globally, especially in the United States. And I think that limited knowledge comes from multiple facets. It’s difficult to conduct research in this population, and the issue of aging health minority myth often doubles as a barrier to examine those issues in a more comprehensive way. It’s also difficult to access minority populations, especially Chinese population in the United States, because of linguistic and cultural barriers and lack of familiarity of many researchers to really truly understand the needs of this population.

DG: Thank you. So let’s start with the methodology of the studies. Could you set the stage for us?

XQD: Sure. The PINE study is a population-based cohort study in the greater Chicago area that we started about eight years ago, and really the goal is to provide quantifiable data on the health and needs of the population. We conduct in-depth home interviews of literally thousands of Chinese older adults and try to listen to their stories, trying to understand what makes their aging process successful and what makes them struggle on their day-to-day living, and to provide those data that we now have a more collective voice to understand the needs, so that action can be taken to meet those needs though research education advocacy, clinical care, and health policy.

DG: Thank you. In Confucianism, filial piety is the virtue and duty of respect, reverence, obedience, and care for one’s parents and elderly family members. What connection did the study reveal between filial piety and depression among seniors in the Chinese community?

XQD: Great question. It’s such a dominant cultural value in Chinese, as well as in many other Asian countries. We find filial piety is a fairly dynamic and complex construct in relation to mental health outcomes in that it is not just filial expectations and the filial receipts, but rather the differences between those areas. When I say filial expectation, that typically means what does the older adult expect their children to fulfil in those areas that you just mentioned. And filial receipts refers to what older adults are actually receiving in addition to their expectations. And discrepancy reflects the differences between what one expects with what one actually receives across each of those areas.

And we’re finding that while the filial piety expectation remains high, that may or may not be as high as they were ten, twenty, thirty years back, and their receipts is also something that’s very dynamic and that varies across different areas. While they may be high in certain areas of respect and obedience, there may be slightly less in care and financial support. And I think understanding those nuanced relationships with respect to depression are important, that there are findings that suggest that older adults may be modifying their filial expectations in the concern of not to be disappointed. And I think understanding those cultural roots, and the cultural determinants of health, especially with respect to depression and other mental health outcomes, are sometimes just as important if not more important than the social determinants of mental health outcomes.

DG: Thank you. So you mentioned depression. The study looked at the correlation between loneliness and depression. And the study has covered a lot of ground. So I’m going to give a little laundry list for our listeners, because I think it’s so interesting. The study has covered the association between social support and depression in community-dwelling older Chinese Americans, at social engagement, at acculturation and activity engagement, at support for migrant children and depression among older Chinese members of transnational families. They looked at the link between loneliness and personality, at the impact of sense of community, of neighborhood disorder and self-neglect, and even grandparent-grandchild relationships. And then more health-focused studies looked at musculoskeletal symptoms, at cancer screening and the association between cancer and the use of traditional Chinese medicine in U.S. Chinese older women. Can you share a few highlights, some high-level findings with us?

XQD: Sure. I think this group of studies really has a number of overarching themes. One is that it challenges our normative assumption about a model minority myth in Chinese populations. And many of the study findings that relate to significant results that may or may not be the case in other populations. And I think understanding unique contributions of those relationships are important.

Two, I think there are also some negative findings in our study that may not be the case in other populations. And I think sometimes we don’t want to assume that understanding the difference between health status across one population will apply to other populations. And I think some of our studies really highlight those significant but also non-significant findings as well.

The third is perhaps our attempt to understand much broader cultural determinants of health that really have not been well studied. How do we define culture? What you said about filial piety earlier really gets at a set of issues that most researchers have not been able to focus on, especially through the lens of large population-based cohort studies. I think, collectively, the set of articles really highlights not only a need to understand more issues to Chinese and broader Asian communities, but also a need for workforce, that we need to have broader workforce investigators interested in those issues. Some of the data that I highlight in the report, that even though Asian-Americans constitute 5 percent of the U.S. population, but yet when you look at the federal government funding, for example, is disproportionately lower. When you look, the Asian investigators are far less likely than other investigators to receive federal government funding. It highlights a broader picture of really coordinated efforts not only on how we need to generate analysis but also how we translate that knowledge into community, into practice, and into policy as well.

DG: Thank you. The studies offer insight on how healthcare professionals can provide support through the understanding of Asian cultural values such as filial piety, which we already talked about, collectivism, individualism, and a sense of harmony in families. Could you elaborate on this for our audience, many of whom work in long-term care? And wouldn’t you say that this holds true for any ethnic group?

XQD: Great question, Darcy. The issues of family value and cultural values are important to many cultures, they’re not isolated to Asian cultures specifically. And the thing really gets to the root of what do we expect intergenerational relationship across families. And even though those values may be unique to Asian cultures, but what is expectation of caregiving? What are the normative family values in respect to providing care to those who are the most vulnerable who can no longer care for themselves?

Many Asian families do not believe in long-term care and the placement of their family members. But yet at the same time, where do we draw the line where family are no longer either physically, emotionally, or financially able to care for their family members? And that’s where the boundaries may lie. And those are difficult questions, and I think as a long-term care provider, and having worked in nursing homes over my career, I certainly see that struggle and try to understand the sandwich population of family members who not only need to care for their own children but also care for older adults. Those are complex and difficult discussions. I think we’re just beginning to scratch the surface of that through the lens of this study in Asian families.

DG: Definitely. But it’s a great start. Among the research was the first population-based study investigating the stress and cognition relationships in U.S. Chinese older adults. What were the key takeaways, would you say?

XQD: Sure. Well, we think about mental health and stress uniquely that, you know, it’s important to distinguish and for other populations and community organizations and policymakers and clinicians to understand that stress and depression manifest in Chinese populations in a very different way than other populations. The symptoms are not often crying or feeling sad, they’re often very somatic in nature, such as feeling fatigued and tired and lack of sleep. Often that can be misunderstood as symptoms of other disease and illnesses, when in fact they’re relating to stress and mental health-related issues.

Same thing with cognition, that it’s important to understand there are different aspects of memory as well. It’s not just the global memory, but separated into what is episodic memory, what is executive function. And those different types of cognitions may have different sets of relationships with respect to mental health issues.

DG: Thank you. So today in society, I think there is a big interest in Chinese or Eastern medication. So how does that impact this demographic? Does it conflict with Western medical practices? How can the two coexist?

XQD: As with many families, especially Asian families, use of traditional complementary medicine is an important part of our culture for thousands of years. And there are great remedies that can be used to treat symptoms. And yet at the same time, I think it’s important for healthcare providers to ask not only what type of Western medicine our patient takes, but also what kind of complementary medicine and herbal medicine that people take. There are values in those treatment modalities. One, I think a healthcare professional needs to ask those questions, and patients need to share with their physicians what are those medications.

But two, it’s important for the patient as well as providers to understand the drug-drug interaction, drug-disease interaction of those medications, with respect to treating symptoms. And I think without that, often patients can be put in difficult situations, and not understanding how to treat their disease and conditions, in conjunction with what their physician may prescribe through a Western philosophy.

DG: Good points. Cultural beliefs also influence end-of-life priorities, such as the need for pain management, respect for dignity of the individual, and the importance of clinician and family involvement for Chinese-Americans. Your research indicates that a comprehensive end-of-life care plan for aging Asians should include cultural considerations as well as traditional family values in addition to physical, psychosocial, and spiritual needs. Could you give us some examples of how this would play out in an actual end-of-life scenario?

XQD: End-of-life discussions are difficult in all populations, but especially in cultures where it’s filled with stigma and disbelief. And I think in the case of Chinese-Americans, or Chinese in general, through my hat as a geriatrician when I often have those discussions with older adults or families, I would ask the question: What are the cultural issues that you want to consider with respect to end-of-life discussions? What are some of the myths or beliefs that you may have? What are some of the difficult discussions, not only from your perspective, but from your perceptions of how your children and spouse and other family members think about those issues? And how does the concept of filial piety, collectivism, individualism, and sense of harmony that we talked about earlier integrate into those discussions? And then keep an open mind.

And this is where sometimes, when you don’t have a native physician speaker discussing those topics, sometimes things get lost in translation. And that really speaks to the linguistic and culturally appropriate care, that patient-centric care that we all want to strive for in the current healthcare system, both nationally as well as internationally. But those, a lot more research needs to be conducted in those areas to see what actually works. In one experience for me, wearing the hat of the clinician was very different than larger research studies being conducted in this area.

DG: Were there any study results that surprised you? And why? And how would you say those results compare with similar research among the general aging population?

XQD: I think, as much as there are studies that did not surprise me too much, that highlighted the unique needs in our population, probably some of the negative findings in our study that did not seem to complement other majority populations are the health disparity populations. And I think that comes back to the earlier point that I stated, that one should not assume one set of findings in one minority population will apply to other populations. That’s probably really the biggest message that I think we need to consider, each population is unique. Even though the study covers specifically in Chinese population, one should also recognize that there is great diversity within Chinese populations as well. There are more than 50 minority groups, there are more than 20 million Muslims in China. And those studies may apply to majority populations, but may or may not apply to other racial ethnic populations, even within the Chinese context as well.

DG: So let’s switch gears. I have one more question, and this is regarding your role at Rutgers. Does Rutgers have any current or upcoming studies that might shed additional light on aging healthcare in society, and if so can you share some of the details with us?

XQD: Of course. And I think as the Institute for Health, our goal is population health, and we’re constantly studying important issues relevant to aging healthcare in society. As our studies are being pushed along, we will surely share those with you. But I can tell you that aging health equity is an important part of what I have done. We have many manuscripts are in preparation that really highlight some of the health consequences relating to aging in minority populations. And those studies coming along, I’ll be glad to share those with you.

DG: Thank you. We look forward to it. And thank you for sharing the findings of your study with our audience today. To all our listeners, thank you for taking the time to tune in. If you’d like to learn more about the Rutgers Institute, visit IHHCPAR.rutgers.edu. And if you’d like to learn more about SmartLinx Solutions and our fully integrated suite of workforce management solutions, visit us online at SmartLinxSolutions.com.

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