Behavioral Risk Factor Survey of Chinese -- California, 1989

During the 1980s, Asians/Pacific Islanders were the fastest growing racial/ethnic group in both the United States and California (1). In Alameda County (which includes Oakland), California, persons of Chinese origin or ancestry are the largest subgroup (35.6%) among the more than 192,000 Asians (2). The prevalence of health risk factors for noninfectious health concerns (e.g., heart disease, cancer, and unintentional injuries) in Asian/Pacific Islander populations has not been well defined (3). To characterize risk factors for selected noninfectious diseases among persons of Chinese origin or ancestry in California, Asian Health Services (a private, nonprofit community health center) and the California Department of Health Services adapted CDC's Behavioral Risk Factor Surveillance System (BRFSS) for use in the Chinese community in Oakland. This report presents data from that survey conducted during June 1989-February 1990.

The standard BRFSS questionnaire was modified for cultural appropriateness, translated into Cantonese, backtranslated, and pretested. The 81 questions encompassed sociodemographics, acculturation, nutrition, exercise, tobacco use, alcohol consumption, hypertension, cholesterol, safety-belt use, cancer screening, and periodic examinations. A systematic sampling method targeted every second Chinese household within two census tracts with the highest concentrations of Chinese residents. Adult (aged greater than or equal to 18 years) respondents were randomly selected after enumeration of household members. Chinese community health workers fluent in Cantonese underwent intensive interviewer training; from June 1989 through February 1990, they conducted person-to-person interviews with 296 (82%) of the 359 eligible Chinese residents.

The chi-square test was used to compare associations involving education, income, English fluency, and health insurance status with specific health-care behaviors and knowledge.

The mean age of the respondents was 53.3 years (standard deviation: 19.8 years); 57% were women. Most (93%) of the respondents were born in Asian countries (including Hong Kong, the People's Republic of China, Taiwan, and Vietnam); respondents had lived in the United States a mean of 11.1 years. More than half (53%) lived in households with annual incomes of less than $10,000. Most (87%) spoke little or no English, and 52% had the equivalent of an eighth-grade education or less. More than one third (35%) of all respondents had no health insurance, and almost two thirds (65%) of those aged 45-64 years were uninsured.

Persons of Chinese descent born in the United States were more likely than Chinese born elsewhere to have annual incomes of more than $10,000 (56% (95% CI=50%-62%) versus 6% (95% CI=-5%-17%)). In addition, persons of Chinese descent born in the United States were more likely to have at least a ninth-grade education (55% (95% CI=49%-61%) versus 10% (95% CI=-3%-23%)). Chinese who were born elsewhere were less likely to be fluent in English (7% (95% CI=4%-9%)) than U.S.-born Chinese (90% (95% CI=77%-103%)).

The prevalence of several risk factors was higher for Chinese than for the total California population (Table 1). These included smoking among men, never having had a blood pressure measurement, hypertension, never having had breast and cervical cancer screening tests, and hypercholesteremia. In comparison, the prevalence for use of alcohol was lower among Chinese than among the total California population.

The likelihood of ever having had a mammogram among Chinese women who had an eighth-grade education or less (25%; 95% confidence interval (CI)=15%-35%) was lower than that among Chinese women who had a higher education level (50% (95% CI=32%-69%)) and was lower for Chinese women who did not speak English fluently (28% (95% CI=19%-37%) versus 100% (95% CI=100%-100%)). Chinese men who were uninsured were less likely to have had a periodic examination in the 2 years preceding the survey (40% (95% CI=26%-55%) versus 70% (95% CI=60%-80%)). Chinese aged greater than or equal to 40 years were less likely to have had their blood pressure measured if they were uninsured (83% (95% CI=69%-97%) versus 95% (95% CI=90%-100%)).

Respondents were less likely to correctly identify the association between sodium intake and hypertension if they were from low-income households (34% (95% CI=26%-42%) versus 46% (95% CI=37%-54%)) or if they were not fluent in English (37% (95% CI=31%-43%) versus 68% (95% CI=53%-83%)). Respondents were also less likely to correctly identify the association between cholesterol and heart disease if they lived in households with annual incomes less than $10,000 (30% (95% CI=22%-37%) versus 70% (95% CI=62%-78%)) or if they had an eighth-grade education or less (30% (95% CI=23%-37%) versus 68% (95% CI=60%-75%)). Self-reported hypercholesterolemia was more prevalent among Chinese than among the total population of California, regardless of education or income levels (Figure 1). Reported by: A Chen, MD, R Lew, MPH, V Thai, KL Ko, MS, L Okahara, S Hirota, S Chan, MD, WF Wong, MD, Asian Health Svcs, Oakland; G Saika, MS, Univ of California, San Francisco; LF Folkers, MPH, B Marquez, MPH, Health Promotion Section, California Dept of Health Svcs. Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report document that the health profiles of persons of Chinese origin or ancestry in California differ from those of the total population of California and are consistent with other surveys indicating that some risk factors are higher in certain subgroups of Asians/Pacific Islanders (4). For example, the 1987 National Health Interview Survey found that the prevalence of smoking was 20% for all male Asians/Pacific Islanders (L. Harlan, National Cancer Institute, National Institutes of Health, unpublished data, 1991); in comparison, the prevalence of smoking was 28% among Chinese men in this survey and 35% in a recent survey involving Vietnamese men (5).

Differences in the ethnicity of the interviewer and the respondent can influence responses to some sensitive questions (6); accordingly, this survey used a community-sensitive research approach (7) based on the theory of community participation (8) to recruit community residents as interviewers and to form a broad community health coalition to promote and guide data collection and use. In April 1990, the California Commission for Economic Development sponsored a public hearing that publicized the survey findings. Subsequently, Asian Health Services developed two health-promotion programs to address the high prevalence of smoking and hypertension.

This survey has at least three limitations. First, because the sample size was relatively small, and the geographic distribution of Chinese living in Oakland was highly focal, the findings may not be representative of Chinese living elsewhere. Second, all survey responses were self-reported but were not independently validated, and survey reliability was not assessed. Third, events in China during June 1989 (within the survey period) deterred some eligible residents in Oakland from participating in this survey. Consequently, the data-collection period was extended, increasing costs for the survey.

Differences reported in this survey underscore the need for tailored data collection approaches--such as characterizing ethnicity, nativity, income, insurance status, and language fluency -- to accurately determine the health status of Asians/Pacific Islanders and other racial/ethnic groups. Because the indicators of education and income are frequently associated with health risk, health knowledge, and access to care, identification of high-risk subgroups is critical in planning health-promotion and disease-prevention strategies that address the nation's year 2000 health objectives (9).

References

1. O'Hare W. A new look at Asian Americans. American Demographics 1990;12:26-31.

2. Bureau of the Census. 1990 U.S. population census. Summary tape file 1. Washington, DC: US Department of Commerce, Bureau of the Census, 1990.

3. Report of the Secretary's Task Force on Black and Minority Health. Volume I: executive summary. Washington, DC: US Department of Health and Human Services, 1987; DHHS publication no. 86-621-604.

4. Jenkins CNH, McPhee SJ, Bird JA, Bonilla NTH. Cancer risks and prevention behaviors among Vietnamese refugees. West J Med 1990;153:34-9.

5. CDC. Behavioral risk factor survey of Vietnamese -- California, 1991. MMWR 1992;41:69-72.

6. Weeks MF, Moore RP. Ethnicity-of-interviewer effects on ethnic respondents. Public Opinion Quarterly 1981;45:245-9.

7. Lew R, Chen A. Conducting a culturally-sensitive health survey in the Chinese community. In: Proceedings of the 1991 Public Health Conference on Records and Statistics. Washington, DC: US Department of Health and Human Services, Public Health Service, CDC, 1992; DHHS publication no. 92-1214.

8. Green LW. The theory of participation: a qualitative analysis of its expression in national and international health policies. In: Patton RD, Cissell WD, eds. Community organization: traditional principles and modern applications. Johnson City, Tennessee: Latchpin Press, 1990.

9. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. 91-50212.

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