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Health disparities in Chinese Americans with hypertension: A review
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 3 1 8 e3 2 2
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Review
Health disparities in Chinese Americans with hypertension: A review Mei-Lan Chen, Jie Hu* School of Nursing, University of North Carolina at Greensboro, Greensboro, NC, USA
article info
abstract
Article history:
Hypertension is a leading risk factor for stroke and cardiovascular disease in the United
Received 13 January 2014
States. Chinese Americans have poorer control of high blood pressure than Caucasian
Received in revised form
Americans and are at higher risk for hypertension. This review presents and discusses the
18 July 2014
factors known to be associated with health disparities affecting Chinese Americans with
Accepted 22 July 2014
hypertension, including biological, genetic, sociocultural and environmental factors, as
Available online 11 August 2014
well as health behaviors, and health literacy. Culturally appropriate interventions are needed to decrease racial and ethnic health disparities.
Keywords:
Copyright © 2014, Chinese Nursing Association. Production and hosting by Elsevier
Chinese Americans
(Singapore) Pte Ltd. All rights reserved.
Health disparities Hypertension
1.
Introduction
Hypertension is a significant cause of morbidity and mortality, and a leading risk factor for stroke and cardiovascular disease. Overall, one in three adults in the United States has hypertension, corresponding to an estimated 67 million people [1]. In 2008, 43.9% of male deaths and 56.1% of female deaths in the US were related to hypertension [2,3], which is considered as the primary cause leading to an average of 1000 American deaths each day in 2009 [4]. Nearly seven out of every ten heart attack victims and chronic heart failure patients have high blood pressure [4]. Poor control of high blood pressure remains a critical issue for Americans, as less than half have their high blood pressure under control [5,6]. A consequence of this high prevalence is an estimated annual healthcare cost of $47.5 billion. [7]
Health disparity refers to the differences in health outcomes within a population according to ethnic/racial, demographic, social, cultural, geographical, and environmental attributes [8]. This is exemplified by the fact that racial and ethnic minority groups in the US have the highest rates of morbidity and mortality due to high blood pressure [9,10]. Chinese Americans are one of the fastest growing minority groups and the largest Asian American subgroup in the US, of those who are 66e92 years old and have hypertension, less than half have their blood pressure under control [11]. Although the prevalence of hypertension in Chinese Americans between the ages of 45 and 85 is similar to Caucasians (39 vs. 38%), a larger proportion of medicated Chinese Americans have uncontrolled hypertension (33 vs. 24% of Caucasians) [12]. The aim of this review was to examine the contributing factors to and propose intervention strategies
* Corresponding author. E-mail address: [email protected] (J. Hu). Peer review under responsibility of Chinese Nursing Association. http://dx.doi.org/10.1016/j.ijnss.2014.07.002 2352-0132/Copyright © 2014, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. All rights reserved.
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 3 1 8 e3 2 2
for minimizing health disparities in Chinese Americans with hypertension.
2. Factors associated with health disparities in Chinese Americans with hypertension 2.1.
Genetic/biological factors
Research has shown that compared with Caucasians, Chinese have a higher percentage of body fat for a given body mass index (BMI) [13]. Furthermore, BMI is a larger contributor to hypertension in Chinese than in Caucasian and African Americans [13], which indicates that BMI may play an important biological role in health disparities among Chinese Americans. Family history is also related to health disparities in Chinese Americans with hypertension, as a higher paternal BMI is associated with higher blood pressure in Chinese American children [14]. Moreover, 43.2% of Chinese Americans have a family history of hypertension compared with 38.8% of Caucasians. [14] Aging is another disparate contributor to hypertension, with Chinese Americans aged 45e74 years having the lowest incidence of hypertension in the US, but the highest incidence among those aged 75e84 years, when compared with Caucasian, African, and Hispanic Americans [15]. Gender differences have also been implicated in hypertension, as women are more likely than men to develop high blood pressure after 65 years of age, but less likely when younger than 45 years [4]. However, Li and Froelicher found that among Chinese immigrants, the percentage of high blood pressure was 52% for men and 50% for women. [16] Differences in race and ethnicity may also affect responses to antihypertensive medications. Older Chinese adults taking angiotensin-converting enzyme inhibitors are more likely to have a dry cough than Caucasians, and twice as sensitive to the effects of amlodipine [17]. Evidence suggests that the adverse effects of pharmacologic antihypertensive therapy can influence medication adherence among older Chinese Americans [18]. This may in turn contribute to health disparities in uncontrolled hypertension among Chinese Americans.
2.2.
Sociocultural factors
Social and cultural barriers are major factors associated with health disparities in the prevention and control of hypertension [19]. Li and Froelicher found that Chinese Americans who were married had better high blood pressure control than those who lived alone or were widowed [16]. In addition, discrimination, lower educational level, and unemployment are sources of chronic stress that can facilitate the development of hypertension. Thus, social equality, social support, and family resources are crucial for Chinese Americans to reduce health disparities. Health insurance coverage plays an important role in reducing health disparities, though it does not ensure access to equivalent healthcare resources. For example, Ahn et al. found that despite the fact that nearly 85% of Chinese Americans have health insurance coverage, including Medicaid
319
(19%) and Medicare (15%), almost a quarter self-report their health status as poor [20]. Also, the rates for Pap smears and mammograms among Chinese American women are significantly lower than for American women as a whole [20]. Culture also plays an important role in health disparities through its influences on health beliefs, habits, and practices [21]. Chinese cultural heritage is a major factor contributing to poor hypertension medication adherence [18]. For example, Chinese immigrants perceived less benefits of antihypertensive medication, and are more likely to use Chinese herbs or visit traditional Chinese doctors for treatment of hypertension [16,22]. In addition, the majority of Chinese American elders are foreign born [23], and are more likely to live with their family, relatives, or a caregiver. This may relate to the fact that approximately 30% of Chinese Americans report experiencing cultural barriers to understanding hypertension and antihypertensive drugs [20]. Finally, the family-style sharing of meals also makes it difficult to adhere to a low-salt diet.
2.3.
Environmental factors
Several environmental factors, including residential location, hazards and pollutants, have been implicated in racial and ethnic health disparities in hypertension [9,24,25]. For example, older Chinese Americans who live in urban areas have more healthcare resources than those who live in rural areas [19]. In one of the few studies exploring environmental effects, Lau et al. found that many hypertensive Chinese immigrants in San Francisco were living in small and singleroom residences around Chinatown communities [19]. Minority neighborhoods were found to be more likely to have fewer pharmacies and fewer grocery stores with healthy foods [24]. Some of the low income and disadvantaged communities that racial and ethnic minorities tend to live in can impact healthcare and health status [9]. These minority communities face greater exposure to environmental toxins, such as industrial pollution, second-hand smoke, chemical poisoning, and pesticides [24], which may contribute to health disparities in morbidity and mortality. Finally, such hardships promote a state of chronic stress that can exacerbate health problems [26]. Thus, research should not only focus on racial differences in exposure to chronic stress, but also study racial differences in responses to chronic stress.
2.4.
Health behaviors
A low-salt diet and regular exercise are two methods widely used to control high blood pressure [2]. Research has found that Chinese Americans are more likely to have a diet high in salt, such as monosodium glutamate, soy sauce, and salty flavorings [19]. The family priorities in Chinese culture make it difficult for children to follow a standard low-salt diet. Hence, health education for family and family caregivers is crucial for older Chinese Americans. One of the goals of Healthy People 2020 is to promote at least 30 minutes of physical activity most days of the week among Americans [5]. Key factors to promoting physical activity include encouragement from family and friends, enjoyment of the activity and confidence in its benefits,
320
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 3 1 8 e3 2 2
whereas lack of time, poor weather conditions, safety issues, and economic difficulties are barriers [27]. However, Chinese Americans are influenced by cultural health beliefs, such as the belief that moderate or vigorous physical activity is inappropriate for older people [22]. As a result, Asians in the US engage in less physical activity than the general population [14]. Although many Chinese Americans perform Qigong exercise, only 31% engage in regular physical activity (at least five days per week for 30 minutes or more) [27]. Hence, traditional Chinese cultural beliefs about exercise should be addressed to increase levels of physical activity for Chinese Americans.
2.5.
Health literacy
The term “health literacy” refers to the ability to obtain, process, interpret, and apply health information to make appropriate health decisions [28]. Health literacy includes reading, writing, listening, critical thinking, information-seeking, communication, and decision-making [29]. Simons-Morton et al. reported a low health literacy among older adults and individuals with chronic diseases [29]. This corresponds to a lack of knowledge about diseases and disability that can lead to the inability to take medications properly. Most Chinese Americans are foreign born [23], and the process of adaptation and acculturation along with overcoming language barriers and financial difficulties can lead to chronic stress [30]. Chinese Americans who speak only Chinese or have limited English are three times more likely to have improper medication practices than those who are without an English language barrier [31]. Seventy-five per cent of Chinese Americans have limited English proficiency [16], which is a key barrier to healthcare access. Racial and ethnic minorities are less likely to have a healthcare provider with the appropriate linguistic skills and cultural competence [9,32,33]. Although nearly 80% of Chinese Americans report having seen their healthcare providers for a regular check-up in the past year, only 22% report being able to communicate with them in English, and almost 34% report needing an interpreter [20]. Some insurance plans may provide interpreters, but it is difficult to discuss sensitive health issues through interpreters. Li and Froelicher found that the majority of Chinese Americans tend to go to medical clinics where the healthcare providers can speak Chinese [16].
3.
Intervention strategies
It is imperative that interventions are culturally tailored for Chinese Americans with hypertension, and use traditional Chinese exercises and family-based and community-based strategies, Chinese educational pamphlets, and Chinesespeaking nurses and exercise trainers. Chinese culture is a community-bound culture that greatly values harmonious family relationships [23]. Moreover, many health problems stem from culture and family. Hence, health education and promotion interventions need to focus on the family, family caregivers, and the community. In addition, cultural considerations may help older Chinese immigrants better self-
monitor their blood pressure, as they tend to over-report their performance of this [11].
3.1.
Hypertensive education
To reduce health disparities, education can be used to raise health awareness of the perceived severity, susceptibility, and threat of hypertension, and increase the desire to manage the disease. Educational strategies and activities should incorporate a variety of Chinese teaching aids and include group discussions on the threat of hypertension to health, selfmonitoring skills, adverse side effects of medications, and a low-salt diet plan. Most important, education should include the family, church, and community, and take the cultural backgrounds of Chinese Americans, such as cultural beliefs about hypertension and treatment, into consideration.
3.2.
Promoting exercise
As one of the key methods for controlling blood pressure, promoting good exercise habits can be an effective intervention for managing hypertension. Often, this involves increasing motivation to initiate and engage in physical activities. Promoting self-efficacy, or one's ability to overcome barriers, can enhance an individual's capacity to conquer difficulties to perform regular exercise [29,34]. Strategies and activities to achieve this include discussing benefits and barriers to regular exercise, as well as providing incentives and encouragement [34,35]. Feedback has also been shown as an effective strategy for promoting exercise adherence [35,36]. Based on the Health Belief Model, a greater perception of achieved benefits is associated with a greater likelihood of health behaviors [29]. The goal of coaching is to help patients experience the benefits of exercise for long-term exercise adherence. Strategies and activities include discussing and identifying proper goals, forms, tempo, skills and plans for exercise. Training and supervision will ensure that correct exercise form and skills are performed to maximize the benefits achieved. For long-term adherence, however, homebased exercise programs, which tend to be more comfortable, convenient, and flexible, have been shown to be more effective than fitness center-based programs [35,36].
4. Implications for nursing practice and research This review suggests that it is important for nurses to be cognisant of factors associated with health disparities and provide culturally competent care to Chinese Americans with hypertension. Healthcare providers should therefore be aware of genetic/biological, sociocultural, environmental, and behavioral factors such as age, gender, BMI, therapeutic responses to medications, use of traditional Chinese medicine, English language proficiency, health beliefs, and cultural practices. Many Chinese Americans distrust Western medications and believe they are not safe and may have long-term adverse effects on their health status [11]. Nurses can thus play an important role in identifying these cultural barriers and improving medication adherence.
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 3 1 8 e3 2 2
5.
Discussion and conclusion [8]
Racial/ethnic differences in genetic, social and cultural influences, health behaviors and lifestyle can affect the detection, treatment, and control of hypertension. Despite efforts to eliminate them in the US, health disparities in hypertension persist among Chinese Americans. Culturally appropriate interventions, including addressing the need for linguistically and culturally competent healthcare providers, are important for reducing these health disparities. However, evidencebased interventions to eliminate disparities in healthcare for minority groups are still underdeveloped [9,24,32,37]. Sociocultural factors and health literacy must be considered when tailoring interventions, particularly for Chinese Americans, which involves reducing barriers, such as language difficulties, cultural variation, lack of available and accessible preventive services, and addressing perceptions about healthcare. Chinese culture focuses on traditional values of family and community. Educational interventions that target the family/ social support system are important for improving clinical outcomes for Chinese Americans with hypertension. Further, nurse-led community-based health education programs and use of Chinese pamphlets at a low literacy level are strongly recommended. Future research should develop and test culturally tailored interventions to reduce health disparities for this population.
Conflict of interest statement
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
None of the authors have any financial and personal relationships with other people or organizations that could inappropriately influence their work. [18]
references [19] [1] Centers for Disease Control and Prevention. Vital signs: awareness and treatment of uncontrolled hypertension among adults-United States, 2003e2010. MMWR 2012;61(35):703e9. [2] American Heart Association. High blood pressure. Statistical fact sheet: 2012 Update. Available at: http://circ.ahajournals. org/content/125/1/e2.full. ~ o AM, Kung H-C. [3] Kochanek KD, Xu J, Murphy SL, Minin Deaths: final data for 2009. National Vital Statistics Reports 2011;60(3):7e13. [4] Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statisticsd2013 update: a report from the American Heart Association. Circulation 2013;127:e6e245. [5] Centers for Disease Control and Prevention. Healthy people 2020. Available at: http://www.cdc.gov/nchs/healthy_people/ hp2020.htm. [6] Yoon SS, Ostchega Y, Louis T. Recent trends in the prevalence of high blood pressure and its treatment and control, 1999e2008. National Center for Health Statistics Data Brief; 2010. p. 48. Available at: http://www.cdc.gov/nchs. [7] Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular
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[27] Taylor VM, Cripe SM, Acorda E, The C, Coronado G, Do H, et al. Development of an ESL curriculum to educate Chinese immigrants about physical activity. J Immigr Minority Health 2008;10:379e87. [28] Mancuso JM. Assessment and measurement of health literacy: an integrative review of the literature. Nurs Health Sci 2009;11:77e89. [29] Simons-Morton B, McLeroy KR, Wendel ML. Behavior theory in health promotion practice and research. Burlington, MA: Jones and Bartlett Learning; 2012. [30] Wu B, Chi I, Plassman BL, Guo M. Depressive symptoms and health problems among Chinese immigrant elders in the US and Chinese elders in China. Aging & Ment Health 2010;14(6):695e704. [31] Zhan L, Chen J. Medication practices among Chinese American older adults: a study of cultural influences. J Gerontol Nurs 2004;30:24e33. s DE, Schneider KL, Graves A, Rosman B. [32] Maxwell J, Corte Massachusetts' health care reform increased access to care
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/journals/internationaljournal-of-nursing-sciences/2352-0132
Review
Health disparities in Chinese Americans with hypertension: A review Mei-Lan Chen, Jie Hu* School of Nursing, University of North Carolina at Greensboro, Greensboro, NC, USA
article info
abstract
Article history:
Hypertension is a leading risk factor for stroke and cardiovascular disease in the United
Received 13 January 2014
States. Chinese Americans have poorer control of high blood pressure than Caucasian
Received in revised form
Americans and are at higher risk for hypertension. This review presents and discusses the
18 July 2014
factors known to be associated with health disparities affecting Chinese Americans with
Accepted 22 July 2014
hypertension, including biological, genetic, sociocultural and environmental factors, as
Available online 11 August 2014
well as health behaviors, and health literacy. Culturally appropriate interventions are needed to decrease racial and ethnic health disparities.
Keywords:
Copyright © 2014, Chinese Nursing Association. Production and hosting by Elsevier
Chinese Americans
(Singapore) Pte Ltd. All rights reserved.
Health disparities Hypertension
1.
Introduction
Hypertension is a significant cause of morbidity and mortality, and a leading risk factor for stroke and cardiovascular disease. Overall, one in three adults in the United States has hypertension, corresponding to an estimated 67 million people [1]. In 2008, 43.9% of male deaths and 56.1% of female deaths in the US were related to hypertension [2,3], which is considered as the primary cause leading to an average of 1000 American deaths each day in 2009 [4]. Nearly seven out of every ten heart attack victims and chronic heart failure patients have high blood pressure [4]. Poor control of high blood pressure remains a critical issue for Americans, as less than half have their high blood pressure under control [5,6]. A consequence of this high prevalence is an estimated annual healthcare cost of $47.5 billion. [7]
Health disparity refers to the differences in health outcomes within a population according to ethnic/racial, demographic, social, cultural, geographical, and environmental attributes [8]. This is exemplified by the fact that racial and ethnic minority groups in the US have the highest rates of morbidity and mortality due to high blood pressure [9,10]. Chinese Americans are one of the fastest growing minority groups and the largest Asian American subgroup in the US, of those who are 66e92 years old and have hypertension, less than half have their blood pressure under control [11]. Although the prevalence of hypertension in Chinese Americans between the ages of 45 and 85 is similar to Caucasians (39 vs. 38%), a larger proportion of medicated Chinese Americans have uncontrolled hypertension (33 vs. 24% of Caucasians) [12]. The aim of this review was to examine the contributing factors to and propose intervention strategies
* Corresponding author. E-mail address: [email protected] (J. Hu). Peer review under responsibility of Chinese Nursing Association. http://dx.doi.org/10.1016/j.ijnss.2014.07.002 2352-0132/Copyright © 2014, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. All rights reserved.
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 3 1 8 e3 2 2
for minimizing health disparities in Chinese Americans with hypertension.
2. Factors associated with health disparities in Chinese Americans with hypertension 2.1.
Genetic/biological factors
Research has shown that compared with Caucasians, Chinese have a higher percentage of body fat for a given body mass index (BMI) [13]. Furthermore, BMI is a larger contributor to hypertension in Chinese than in Caucasian and African Americans [13], which indicates that BMI may play an important biological role in health disparities among Chinese Americans. Family history is also related to health disparities in Chinese Americans with hypertension, as a higher paternal BMI is associated with higher blood pressure in Chinese American children [14]. Moreover, 43.2% of Chinese Americans have a family history of hypertension compared with 38.8% of Caucasians. [14] Aging is another disparate contributor to hypertension, with Chinese Americans aged 45e74 years having the lowest incidence of hypertension in the US, but the highest incidence among those aged 75e84 years, when compared with Caucasian, African, and Hispanic Americans [15]. Gender differences have also been implicated in hypertension, as women are more likely than men to develop high blood pressure after 65 years of age, but less likely when younger than 45 years [4]. However, Li and Froelicher found that among Chinese immigrants, the percentage of high blood pressure was 52% for men and 50% for women. [16] Differences in race and ethnicity may also affect responses to antihypertensive medications. Older Chinese adults taking angiotensin-converting enzyme inhibitors are more likely to have a dry cough than Caucasians, and twice as sensitive to the effects of amlodipine [17]. Evidence suggests that the adverse effects of pharmacologic antihypertensive therapy can influence medication adherence among older Chinese Americans [18]. This may in turn contribute to health disparities in uncontrolled hypertension among Chinese Americans.
2.2.
Sociocultural factors
Social and cultural barriers are major factors associated with health disparities in the prevention and control of hypertension [19]. Li and Froelicher found that Chinese Americans who were married had better high blood pressure control than those who lived alone or were widowed [16]. In addition, discrimination, lower educational level, and unemployment are sources of chronic stress that can facilitate the development of hypertension. Thus, social equality, social support, and family resources are crucial for Chinese Americans to reduce health disparities. Health insurance coverage plays an important role in reducing health disparities, though it does not ensure access to equivalent healthcare resources. For example, Ahn et al. found that despite the fact that nearly 85% of Chinese Americans have health insurance coverage, including Medicaid
319
(19%) and Medicare (15%), almost a quarter self-report their health status as poor [20]. Also, the rates for Pap smears and mammograms among Chinese American women are significantly lower than for American women as a whole [20]. Culture also plays an important role in health disparities through its influences on health beliefs, habits, and practices [21]. Chinese cultural heritage is a major factor contributing to poor hypertension medication adherence [18]. For example, Chinese immigrants perceived less benefits of antihypertensive medication, and are more likely to use Chinese herbs or visit traditional Chinese doctors for treatment of hypertension [16,22]. In addition, the majority of Chinese American elders are foreign born [23], and are more likely to live with their family, relatives, or a caregiver. This may relate to the fact that approximately 30% of Chinese Americans report experiencing cultural barriers to understanding hypertension and antihypertensive drugs [20]. Finally, the family-style sharing of meals also makes it difficult to adhere to a low-salt diet.
2.3.
Environmental factors
Several environmental factors, including residential location, hazards and pollutants, have been implicated in racial and ethnic health disparities in hypertension [9,24,25]. For example, older Chinese Americans who live in urban areas have more healthcare resources than those who live in rural areas [19]. In one of the few studies exploring environmental effects, Lau et al. found that many hypertensive Chinese immigrants in San Francisco were living in small and singleroom residences around Chinatown communities [19]. Minority neighborhoods were found to be more likely to have fewer pharmacies and fewer grocery stores with healthy foods [24]. Some of the low income and disadvantaged communities that racial and ethnic minorities tend to live in can impact healthcare and health status [9]. These minority communities face greater exposure to environmental toxins, such as industrial pollution, second-hand smoke, chemical poisoning, and pesticides [24], which may contribute to health disparities in morbidity and mortality. Finally, such hardships promote a state of chronic stress that can exacerbate health problems [26]. Thus, research should not only focus on racial differences in exposure to chronic stress, but also study racial differences in responses to chronic stress.
2.4.
Health behaviors
A low-salt diet and regular exercise are two methods widely used to control high blood pressure [2]. Research has found that Chinese Americans are more likely to have a diet high in salt, such as monosodium glutamate, soy sauce, and salty flavorings [19]. The family priorities in Chinese culture make it difficult for children to follow a standard low-salt diet. Hence, health education for family and family caregivers is crucial for older Chinese Americans. One of the goals of Healthy People 2020 is to promote at least 30 minutes of physical activity most days of the week among Americans [5]. Key factors to promoting physical activity include encouragement from family and friends, enjoyment of the activity and confidence in its benefits,
320
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 3 1 8 e3 2 2
whereas lack of time, poor weather conditions, safety issues, and economic difficulties are barriers [27]. However, Chinese Americans are influenced by cultural health beliefs, such as the belief that moderate or vigorous physical activity is inappropriate for older people [22]. As a result, Asians in the US engage in less physical activity than the general population [14]. Although many Chinese Americans perform Qigong exercise, only 31% engage in regular physical activity (at least five days per week for 30 minutes or more) [27]. Hence, traditional Chinese cultural beliefs about exercise should be addressed to increase levels of physical activity for Chinese Americans.
2.5.
Health literacy
The term “health literacy” refers to the ability to obtain, process, interpret, and apply health information to make appropriate health decisions [28]. Health literacy includes reading, writing, listening, critical thinking, information-seeking, communication, and decision-making [29]. Simons-Morton et al. reported a low health literacy among older adults and individuals with chronic diseases [29]. This corresponds to a lack of knowledge about diseases and disability that can lead to the inability to take medications properly. Most Chinese Americans are foreign born [23], and the process of adaptation and acculturation along with overcoming language barriers and financial difficulties can lead to chronic stress [30]. Chinese Americans who speak only Chinese or have limited English are three times more likely to have improper medication practices than those who are without an English language barrier [31]. Seventy-five per cent of Chinese Americans have limited English proficiency [16], which is a key barrier to healthcare access. Racial and ethnic minorities are less likely to have a healthcare provider with the appropriate linguistic skills and cultural competence [9,32,33]. Although nearly 80% of Chinese Americans report having seen their healthcare providers for a regular check-up in the past year, only 22% report being able to communicate with them in English, and almost 34% report needing an interpreter [20]. Some insurance plans may provide interpreters, but it is difficult to discuss sensitive health issues through interpreters. Li and Froelicher found that the majority of Chinese Americans tend to go to medical clinics where the healthcare providers can speak Chinese [16].
3.
Intervention strategies
It is imperative that interventions are culturally tailored for Chinese Americans with hypertension, and use traditional Chinese exercises and family-based and community-based strategies, Chinese educational pamphlets, and Chinesespeaking nurses and exercise trainers. Chinese culture is a community-bound culture that greatly values harmonious family relationships [23]. Moreover, many health problems stem from culture and family. Hence, health education and promotion interventions need to focus on the family, family caregivers, and the community. In addition, cultural considerations may help older Chinese immigrants better self-
monitor their blood pressure, as they tend to over-report their performance of this [11].
3.1.
Hypertensive education
To reduce health disparities, education can be used to raise health awareness of the perceived severity, susceptibility, and threat of hypertension, and increase the desire to manage the disease. Educational strategies and activities should incorporate a variety of Chinese teaching aids and include group discussions on the threat of hypertension to health, selfmonitoring skills, adverse side effects of medications, and a low-salt diet plan. Most important, education should include the family, church, and community, and take the cultural backgrounds of Chinese Americans, such as cultural beliefs about hypertension and treatment, into consideration.
3.2.
Promoting exercise
As one of the key methods for controlling blood pressure, promoting good exercise habits can be an effective intervention for managing hypertension. Often, this involves increasing motivation to initiate and engage in physical activities. Promoting self-efficacy, or one's ability to overcome barriers, can enhance an individual's capacity to conquer difficulties to perform regular exercise [29,34]. Strategies and activities to achieve this include discussing benefits and barriers to regular exercise, as well as providing incentives and encouragement [34,35]. Feedback has also been shown as an effective strategy for promoting exercise adherence [35,36]. Based on the Health Belief Model, a greater perception of achieved benefits is associated with a greater likelihood of health behaviors [29]. The goal of coaching is to help patients experience the benefits of exercise for long-term exercise adherence. Strategies and activities include discussing and identifying proper goals, forms, tempo, skills and plans for exercise. Training and supervision will ensure that correct exercise form and skills are performed to maximize the benefits achieved. For long-term adherence, however, homebased exercise programs, which tend to be more comfortable, convenient, and flexible, have been shown to be more effective than fitness center-based programs [35,36].
4. Implications for nursing practice and research This review suggests that it is important for nurses to be cognisant of factors associated with health disparities and provide culturally competent care to Chinese Americans with hypertension. Healthcare providers should therefore be aware of genetic/biological, sociocultural, environmental, and behavioral factors such as age, gender, BMI, therapeutic responses to medications, use of traditional Chinese medicine, English language proficiency, health beliefs, and cultural practices. Many Chinese Americans distrust Western medications and believe they are not safe and may have long-term adverse effects on their health status [11]. Nurses can thus play an important role in identifying these cultural barriers and improving medication adherence.
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5.
Discussion and conclusion [8]
Racial/ethnic differences in genetic, social and cultural influences, health behaviors and lifestyle can affect the detection, treatment, and control of hypertension. Despite efforts to eliminate them in the US, health disparities in hypertension persist among Chinese Americans. Culturally appropriate interventions, including addressing the need for linguistically and culturally competent healthcare providers, are important for reducing these health disparities. However, evidencebased interventions to eliminate disparities in healthcare for minority groups are still underdeveloped [9,24,32,37]. Sociocultural factors and health literacy must be considered when tailoring interventions, particularly for Chinese Americans, which involves reducing barriers, such as language difficulties, cultural variation, lack of available and accessible preventive services, and addressing perceptions about healthcare. Chinese culture focuses on traditional values of family and community. Educational interventions that target the family/ social support system are important for improving clinical outcomes for Chinese Americans with hypertension. Further, nurse-led community-based health education programs and use of Chinese pamphlets at a low literacy level are strongly recommended. Future research should develop and test culturally tailored interventions to reduce health disparities for this population.
Conflict of interest statement
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None of the authors have any financial and personal relationships with other people or organizations that could inappropriately influence their work. [18]
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