Health Care Choices for Low-Income Chinese Patients
The use of traditional Chinese medicine and Western medicine at an urban community health center.
By By Molly Mcnees, PhD, Claudia Lyon, DO, Walid Fouad Gellad, MD, Joseph Alban, LAC, and Christine Black-Langenau, DO
ABSTRACT: In the United States, Chinese immigrants continue to use traditional Chinese medicine along with Western medicine. Complex patterns of use depend on beliefs about the therapeutic qualities of each system and vary by demographic characteristics within immigrant populations. This study explores the use of traditional Chinese medicine and Western medicine among low-income Chinese patients in an urban community health center.
Although largely unrecognized prior to the 1970’s, traditional Chinese medicine (TCM) has been a part of Chinese immigrants’ healthcare for over a century.1 TCM represents a variation of Traditional East Asian Medicine (see appendix 1), which continues to be one of the most widely used medical practices in the entire world.2 The practice of TCM is diverse and can involve the prescription of medicinals and tonics, acupuncture, and manual therapies. Current research addresses TCM’s effectiveness for a broad range of conditions.2,3
Several studies have assessed the use of TCM among Asian immigrants in the United States. Recent use of a TCM modality through a Chinese medicine provider has been found to be around 45 percent.4,5,6,7 When home remedies and self-care with traditional Chinese treatments are considered, use is as high as 95 percent.6 The use of acupuncture and herbal medicines is more common among Asians than the general population.7,8,9 The use of TCM varies in Asian immigrant groups by country and region of origin, age, and economic status.10
When used, Asian immigrants commonly combine TCM with Western medicine (WM), using a variety of providers.5,6,10,11 While some reasons for choosing one medicine over the other are generally shared—WM is thought to treat symptoms, while Chinese medicine treats the root cause—specific usages vary. TCM is mentioned for disease prevention, pain relief, smoking cessation, and treatment of allergies, bronchitis, stroke, insomnia, and gastritis.6 In some cases, both types of medicine are used for acute illness, whereas TCM is sought for chronic conditions only after WM has not had the desired effect.5
TCM use among low-income Chinese immigrants has not been well studied. In one case study, 84 percent of elderly Chinese immigrants used some form of TCM, mostly home remedies which can be easily purchased in Chinatown pharmacies. A lack of economic means to visit the Chinese doctor (not covered by Medicare or Medicaid) and cultural assimilation have contributed to decreased use of TCM in the United States.11
Use of some form of complementary or alternative medicine (CAM) is common among many Americans, not just Asian Americans.14 However, a study of the use of herbal medications among a multiethnic population of primary care patients found that Asian patients were less likely than either whites or African-Americans to disclose their use to their physician.9 Distrust of WM providers who dismiss their traditional ways of viewing health and illness12 and the perception that use of TCM is not viewed as legitimate by physicians13 may be factors leading to non-disclosure. Current practice guidelines, which emphasize the gathering of information on patients’ use of CAM, are difficult to adhere to without open communication between patient and provider.14,15
This study continues the exploration of the pluralistic use of TCM and WM. The focus of this paper is twofold: 1) to examine the use of TCM and WM by low-income Cantonese-speaking patients, and 2) to explore patients’ willingness to discuss their usage of TCM with their physicians. Better knowledge of this population’s health care behaviors is valuable for achieving effective clinical interactions among similar patients.
Methods
A cross-sectional survey was conducted at a publicly funded community health center in New York City. Approval for the survey was obtained from the hospital’s institutional review board. The survey was conducted over an 11-week period in the summer of 2001. All adults of Chinese background who presented for a medical visit were approached. If the person spoke either English or Cantonese, he/she was asked to participate and informed consent was obtained.
A questionnaire was developed and translated/back-translated by native Cantonese speakers. Questions included reasons for using either WM or TCM, patterns of use in the United States and country of origin, characteristics of each type of medicine for specific health purposes, and communication with their family physician regarding use of TCM. Additionally, each participant was asked how they would seek care in response to three specific scenarios (acute care, chronic care, and care for mental health conditions). The questionnaire was administered in a face-to-face interview by bilingual/bicultural research assistants. Quantitative data were entered into a statistical software package and analyzed to determine the distribution of characteristics in the population. Qualitative data were coded and analyzed for recurring patterns and themes.
Results
Sample Population Characteristics
In total, 107 respondents participated in the study, yielding a 66 percent response rate. The population consisted of mainly working-age, married adults, with a preponderance of women noted. The most common occupations were restaurant employee, factory worker and homemaker. Only 7 percent were unemployed, although 60 percent were uninsured. Most (72 percent) did not have a high school education, and fully 48 percent had fewer than nine years of formal education. Although we did not ask about income, it would appear from occupation, insurance status, and educational achievement levels that many of these respondents had low incomes and would have difficulty affording health care. Over one-third said that they had not gone to a physician when needed, at some point, because they did not have insurance. Just over half rated their health status as fair to poor, yet few said they had missed work or failed to perform their usual duties in the past year due to illness.
All of the respondents were born abroad, mostly in the southern Chinese provinces of Guangdong and Fukian. They were more likely to come from a rural village than a city (56 percent vs. 44 percent) and to have immigrated as a younger adult (71 percent came to the United States between the ages of 18 and 40). Although 61 percent had been in the United States for more than five years, 72 percent spoke English poorly or not at all.
Use of TCM in the United States
While living in their home country, 44 percent of respondents reported using WM as their primary form of health care, 26 percent reported using predominately TCM and 24 percent reported equal use of the two systems. More than half of respondents used TCM less frequently in the United States, although about one-third had not changed their practice. Some characteristics distinguished TCM users in the sample (Table 1). A greater percent of women had consulted an herbalist or used herbs in the past year, while more men than women had used Chinese chiropractors. Those who rated their health as fair to poor used all types of TCM more than those in better health. Those who relied primarily on TCM in China were more likely to have consulted herbalists in this country. The use of traditional remedies for self-care was similar across the population.
Types of TCM Used in the United States
Consultation with a TCM practitioner in this country is fairly common (Table 2).4 In the study, 49 percent had sought help from an herbalist when sick. Another 26 percent said they had not had a reason to consult an herbalist, but would if needed. Of those who had been treated by an herbalist, 78 percent found this helpful, and most (74 percent) did not seek any other form of care. Three percent had used acupuncture and another 75 percent indicated they would if needed. Only 13 percent said they would never consult an acupuncturist and 16 percent would not use an herbalist. Nineteen percent had sought the care of a Chinese chiropractor and 9 percent had used traditional massage (tui na).
Chinese herbs, ointments, and other compounds that can be purchased in Chinatown pharmacies were used by over half of respondents. A much smaller proportion (3 percent) practiced qigong, a form of exercise designed to improve overall health and vitality. Manual therapies such as cupping and coining were used by 14 percent of respondents.
Factors in Choosing TCM
Forty-one percent stated that the choice of either Chinese or Western medicine depended on the situation or illness. Sixty-four percent believed that TCM takes longer to have an effect. TCM is thought to be good for common illnesses, but WM for more urgent or serious problems. Specific characteristics mentioned by respondents are shown in Table 3. Some reported that a drawback of TCM is that the herbs take too long to prepare and are bitter-tasting. Many believed that herbs will not harm the body, while WM has many side effects. More than half believed that WM is too strong for Chinese patients.
When asked what they would do if insurance covered TCM, 31 percent said they would use it more, but 52 percent reported they would not. Only two respondents said they had not gone to an herbalist because it was too expensive, and three people stated that they could not afford to use acupuncture. A large majority (89 percent) said if they could have insurance to pay for either TCM or WM, but not both, they would choose to have insurance to cover WM.
Dual Use of TCM and WM
Responses to case vignettes presented as part of the study (Table 3) tell us something about how individuals decide which medicine to use, together or in succession, provided by a professional or used in the home. In the case of an ill child, parents preferred to take the child to a physician, often even if they did not think the condition was serious, just to have the child checked out. If the child did not improve, they would seek out another physician or continue with the same doctor. Only a minority (6) would resort to a Chinese medicine practitioner, and only four individuals suggested using a traditional home remedy of herbal soup or congee, a broth made from rice.
One of the vignettes presented an individual with arthritis. In this case, the response pattern suggested preference for simultaneous use of both WM and TCM to achieve respective benefits of each modality. WM was thought to be beneficial to obtain an accurate diagnosis and to control pain. At the same time, respondents recommended acupuncture, tui na, qigong, and herbals for both pain relief and cure.
Respondents were presented with different sets of symptoms that could indicate mental illness. If the symptoms involved forgetfulness, fatigue or insomnia, most felt that some outside therapy was needed from a medical doctor, psychologist, or therapist. If someone was continuously sad and uninterested in daily life, then most thought that professional intervention was not needed. Rather, respondents said friends and family should council the person to talk with others, exercise more, try to think less, and engage in relaxing or social activities. In this circumstance, TCM was not thought to be an appropriate recourse.
Communication with Physicians about Traditional Beliefs and TCM Use
Overall, 87 percent reported that they had either used or would use TCM. Even though many patients used both systems, as illustrated in Table 4, less than half thought it was important for their physician to know they were consulting an herbalist or using Chinese herbs. However, if asked, 78 percent said they would tell their doctor if they were using herbal medications.
Reasons for informing their doctor about the usage of Chinese medicine included “I’m afraid the medicines [TCM and WM] might mix badly,” “She needs to understand my health,” and “If it helps me, he should know.” Reasons for not telling their physician about the use of TCM included “He wouldn’t understand,” “She might think you don’t believe in her,” “It’s just to keep healthy,” and “Western medicine is Western, Chinese is Chinese.”
Respondents were asked if they ever thought that prescription drugs were too strong for the Chinese body. Those who responded affirmatively were asked in a follow-up question what they would do if given a prescription by their physician that they felt was too strong for them. While 80 percent would just take the medicine as directed or discuss their concern with their physician, a significant number would decide on their own to adjust how they would take the medicine (Figure 1).
Discussion
The study examined the use of traditional Chinese medicine by a sample of patients who were seeking care at a community health center. Most of the respondents arrived in the United States with at least some prior experience using both systems of medicine. While the results showed a notable decrease in the use of TCM after arrival in the United States for most respondents, traditional remedies are not being abandoned altogether. It is possible that these patients find Western medicine, with which they are already familiar, more accessible in this country, leading to increased use. Also, lack of resources to seek TCM care may have limited its usage among the respondents. Previous studies found a higher rate of TCM usage among populations with higher socioeconomic status than the respondents.6,11 This may suggest that TCM is used less among the economically disadvantaged.
Decisions to use either WM, TCM, or both, were complex. Affordability appears to be a stronger concern when choosing WM. Similar to the findings of other studies, the respondents preferred TCM to treat chronic diseases and to improve health.6 Many still invoked traditional concepts when discussing the abilities of TCM such as “balancing hot and cold” and the treatment of “slow illnesses.” While many found that Western medicines are easier to take, the view remains strong that herbs won’t harm the body, but WM has many side effects. The attitude that Chinese herbs take too long to prepare, too long to work, and are bitter-tasting may suggest some assimilation to Western practices.
It would appear that these patients have developed a model for use of both systems, one in which they take responsibility for integrating this use, based on how they understand the characteristics, usefulness, and drawbacks of each. They often have an expectation that they, not their physician, will orchestrate this dual use. Their confidence in when and how to use TCM does not seem to extend to the care of children’s health, for which Western medicine may be preferred.
Many respondents are not entirely open about their TCM use with their physician. Nearly as many would inform their physician about consulting an herbalist (45 percent) as would not (44 percent). Importantly, this study has shown that physicians who ask can expect that most of their patients who are using TCM will answer truthfully. For a smaller number, however, this may not be the case. The comments from some of the respondents suggest that they do not believe that Western doctors have an understanding of Chinese beliefs about health and illness and are not informed about what they believe are physical differences between Chinese and Euro-American bodies. Lack of acknowledgment may be interpreted as disrespect for Chinese beliefs, resulting in a loss of trust and poor patient-provider communication. This may lead to non-adherence, which remains a risk for the respondents. This study found that while more than half would take medication if prescribed, up to 20 percent would either stop or change their dose without discussing this with their doctor.
Study Limitations
Limitations of this survey should be noted. The study was conducted in a community-based family practice center in an urban, low-income neighborhood. The population was predominately comprised of those with a low level of education, included few professionals, along with a high rate of uninsured patients. This gives a perspective of a specific population: health seekers in a community clinic from an inner-city Chinatown. The results may not be generalizable to those located outside immigrant neighborhoods. The survey was conducted in Cantonese with immigrants mainly from Southern China, therefore these results may not be applicable to overseas Chinese immigrants or those from other regions of China.
Conclusions
It does not appear that people are giving up the use of TCM, although they are using it less in the United States. Overall, there was a mixed use of TCM and WM. Current use of TCM therapies was moderately low, though the majority reported they would use TCM if needed. Those who used TCM herbalists were very satisfied and did not seek other forms of health care to treat the condition for which they were using TCM. Use of the two systems depended upon the nature of the disease, with TCM favored for chronic diseases and WM favored for acute diseases and prevention. While use of WM was high, almost half would not inform their physician about their use of TCM. However, if asked about their use of herbs and herbalists, most would tell their physician. Therefore, physicians should speak patiently and have an open mind when discussing the use of TCM and WM with their patients.
When approaching Chinese immigrant patients, primary care physicians should take into consideration the importance of having an open mind when discussing TCM therapies. It is important to have an open mind when discussing TCM therapies. Individuals in Chinese communities may tend to favor either WM or TCM for a wide variety of reasons. It is important to inquire specifically about use of TCM. Since the goal should be to establish open communication, it is very important to speak patiently and without judgment. A negative reaction by the physician may lead to the patient not revealing their TCM usage or concerns with recommendations and prescriptions. Patients should be offered thorough explanations of the physician’s concern for simultaneous use of TCM and WM, or use of TCM in lieu of WM.12 Education about TCM can also improve the physician’s understanding of such therapies, which can foster an open discussion about health care choices.
* The term ‘traditional East Asian medicine’ has recently been used as a more accurate and encompassing description of the medical traditions of East Asians, predominantly from China, Korea, and Japan. The styles share much of the same theory, treatment techniques, and medicinals, however the specific use varies from tradition to tradition.
Claudia Lyon, DO, is a 1988 graduate of the New York College of Osteopathic Medicine. She received her certificate in family medicine in 1991 and is currently the Chair and Program Director of a family medicine residency at Lutheran Medical Center in New York. Molly Mcnees, PhD, formerly family medicine faculty, Lutheran Medical Center, New York. WF Gellad, MD, Division of General Medicine, Brigham And Women’s Hospital, Boston. Joseph Alban, LAC, Graduate Program in Oriental Medicine, Touro College, New York. Christine Black-Langenau, DO, Associate Program Director, Family Medicine, Lutheran Medical Center, New York.
References