Using Culturally Competent Community-Based Participatory Research With Older Diabetic Chinese Americans

Abstract

The purpose of this article is to share culturally competent strategies and lessons learned from a study that used a community-based participatory research (CBPR) approach with older adult diabetic Chinese Americans. This approach was essential to gain insight into the health beliefs, attitudes, and practices of selected communities. The vulnerable population conceptual model (VPCM) provided a framework for the study. The CBPR, a collaborative research approach, and the VPCM provided the basis for the development of culturally competent research strategies. Strategies and lessons learned to be particularly effective for this CBPR study included (a) developing an in-depth understanding of the community ethnic culture; (b) developing mutual respect and trust with community members and study participants; (c) appreciating and praising community partners’ knowledge, expertise, and experiences; (d) developing a sense of ownership by incorporating their needs, ideas, suggestions, and opinions and empowering study participants to make decisions concerning the study approach and wording; (e) soliciting participant feedback and clarification of study results and involving them in disseminating the study findings to their community; and (f) having fun with them and encouraging them to have fun.

Keywords

community-based participatory research (CBPR)vulnerable population conceptual model (VPCM)culturally competent research older Chinese Americans type 2 diabetes mellitus

To understand, explain, and predict human responses and health care behaviors, nurse researchers are consistently seeking and choosing more comprehensive and collaborative engagement of research participants, particularly those who have limited diverse social interaction and environmental and health care resources. A combination of the vulnerable populations conceptual model (VPCM; Flaskerud & Winslow, 1998) and the community-based participatory research (CBPR) approach provided the foundation for conducting the study. The VPCM was employed in the project because it represents the population of this study, older diabetic Chinese American adults, who have limited resources and who experience increased morbidity and mortality from the disease (Washington & Wang-Letzkus, 2009). CBPR provided the orientation and guidance for working cooperatively with the participants and the communities represented in the day care centers. The researchers used the collaborative CBPR approach to engage these two Chinese adult day care centers in a qualitative study to better understand the self-care practices, health beliefs, and attitudes of older diabetic Chinese Americans. The CBPR process fully involved community participants in all aspects of the research in a genuinely respectful, trustful, and shared relationship (Wallerstein & Duran, 2006). An advisory board from each facility was formed to identify a community health need and to act as a liaison for the researchers. The boards from each center determined that diabetic management was a major concern for older adults (65 years and older) and wrote letters in support of the study.

This approach provided an inclusive strategy that was particularly useful for developing a culturally sensitive and competent nursing intervention for older diabetic Chinese American immigrants, with limited resources as described in the VPCM (Flaskerud & Winslow, 1998). The purpose of this article is to share the strategies and lessons learned during the process of conducting research involving older Chinese American adults (Washington & Wang-Letzkus, 2009). The intent of this article is not to disseminate the research findings but rather to reflect on the collaborative process that successfully involved a targeted community.

Background

The increase of diverse ethnic Asian populations in the United States presents numerous study opportunities for researchers (Suh, Kagan, & Strumpf, 2009). Chinese Americans are the largest group among the most rapidly growing Asian immigrant populations in the United States (U.S. Census Bureau, 2002). Chinese Americans, however, have been overlooked and are underrepresented in many research studies (Chen, 2001; Chesla & Chun, 2005). The challenges for researchers include not only overcoming different languages and other communication barriers but also being culturally sensitive and knowledgeable about the community being studied.

Chinese Americans, with a growth rate of 47.5% from 1990 to 2000, constitute 22.4% of Asian and 1.2% of the U.S. population. Los Angeles County has the largest concentration of Chinese American communities in the United States (Reyes, 2001). Eight out of 10 cities in the United States with the largest proportion of Chinese Americans are located in the San Gabriel Valley, several miles east of downtown Los Angeles in California. The diverse immigration history of this Chinese community ranges from early settlers during the 1850s to the most current arrivals. The majority were foreign born. Those who arrived before the mid-1900s as young adults were mostly unskilled laborers and more likely to keep themselves from the mainstream culture. Those who arrived within the past two decades are more educated and well-off. However, there are a large number who have a low economic status. Many of them came to join their adult children (Pang, Jordan-Marsh, Silverstein, & Cody, 2003). As the number of older Chinese Americans continues to grow, many Chinese-owned adult day care centers have been established to meet their needs. These adult day care centers are important places for social interactions among Chinese American elders during the day. Each local adult day care center has become a unique older Chinese American community with rich traditional cultural influences.

Vulnerable Populations Conceptual Model

Vulnerable populations are defined as social groups who have limited human capital, are of low social status, or lack health care access, and consequently they have higher risks for morbidity and premature mortality (Flaskerud & Winslow, 1998). The VPCM proposes that availability of social and environmental resources, exposure to risk factors, and health status and outcomes are interrelated. According to Flaskerud and Winslow, vulnerable populations often bear a disproportionate burden of the deleterious effects of diseases. Age, immigrant status, financial restraints, lack of English-language proficiency, limited access to public resources, physiological decline, and frequent chronic health problems classify Chinese American elders as a vulnerable population (Jang, Lee, & Woo, 1998).

The VPCM was used to identify important variables and concepts to guide the exploratory, three-phase study. Concepts such as cultural influence, attitudes, beliefs, resources, strengths, risks, and protective mechanisms were important to understand. Aldridge (2005) indicated that culture, age, and low socioeconomic status affect diet, exercise, and self-care choices. Older Chinese American adults may not be able or motivated to implement self-care diabetic management because of lack of income, health insurance, and health care services, along with language barriers, gender and age roles, and family role composition (Chun & Akutsu, 1999; Chun & Chesla, 2004). The study provided some insight into the attitudes, health beliefs, lifestyles, health practices, and self-diabetes management of older diabetic Chinese Americans. The findings from the study supported the use of the VPCM for cultural understanding and for facilitating culturally appropriate research strategies. The partnership facilitated a self-care management focus for an educative intervention. CBPR and the VPCM provided the philosophical and theoretical approaches that guided the study (Washington & Wang-Letzkus, 2009). A community advisory board identified diabetes mellitus as a problem of concern for the community. According to Washington & Wang-Letzkus (2009), the specific aims of the study were to (a) explore the self-care practices of Chinese American immigrants with type 2 diabetes; (b) identify risk factors related to lifestyle, attitudes, and health beliefs; and (c) disseminate findings by providing an educational intervention within each community.

Community-Based Participatory Research

CBPR is a research approach that establishes an equal partnership with vested ownership among community members, representatives from community-based organizations, health and social service agencies, and academia (Inouye, Arakaki, & Okiyama, 2007; Minkler, Vásquez, Tajik, & Petersen, 2008; Savage et al., 2006). In this partnership, the community identifies the area of interest and takes part in the research process by suggesting changes that would make the questions most relevant to other members at the center. Participants share their insights and participate in decision making and sustaining a goal-directed focus of enhancing knowledge and improving the health of community members (Israel et al., 2006). CBPR is particularly useful in lessening the barriers associated with conducting culturally sensitive research by valuing participants’ beliefs and health perspectives (Wallerstein & Duran, 2006). One’s cultural background, language capacity, acculturation, and socioeconomic status can influence health behaviors, willingness to seek health services, and readiness to participate in clinical trails and research studies (Chesla & Chun, 2005; Cristancho, Garces, Peters, & Mueller, 2008; Spolidoro & Demonteverde, 1998). CBPR provides a culturally sensitive framework for researchers, health care providers, and policymakers to better understand community problems, improve health, and reduce health disparities among vulnerable populations (Flaskerud & Winslow, 1998), such as older Chinese Americans. A CBPR approach recognizes the community as a partner in identifying health issues and research topics relevant to the community’s needs and mutual interests, developing culturally appropriate research questions, and sharing responsibilities and governance roles in the process of data collection, interpretation, and dissemination (Christopher, Watts, McCoimick, & Young, 2008; Williams, Bray, Shapiro-Mendoza, Reisz, & Peranteau, 2009).

Traditional community-based research is enhanced by establishing a genuine and respectful relationship with community partners, who learn each other’s culture while sharing benefits, findings, and knowledge (Trinh-Shevrin et al., 2007; Wallerstein & Duran, 2006; Williams et al., 2009). As active communities participate in the research process, community members act as a bridge between researchers and the community at large. The community identifies its needs as the researcher develops a culturally sensitive and acceptable research approach. Participation of community members in the research process promotes public awareness and engagement for improving and solving health issues (Foster & Stanek, 2007). The hallmark of CBPR is to fully involve community participants in all aspects of the research process. Participants are partners in a genuinely respectful, trustful, and shared relationship.

Although the many advantages of using CBPR are widely recognized, there are also common challenges. These challenges include the researcher’s cultural competence, lack of trust and respect among participating partners, breakdown of communication between researchers and participants, maintaining research excellence and ethics, and differences in priorities between the researchers and the community (Burhansstipanov, Christopher, & Schumacher, 2005; Findholt & Brogoitti, 2007; Savage et al., 2006; Wang & Matthews, 2009).

Culturally Competent Community-Based Participatory Research Strategies Applied

Culturally competent research requires a new research agenda, and it should include a fundamental change in how research is designed, conducted, and disseminated in collaboration with diverse racial and ethnic communities (Goode, Dunne, & Bronheim, 2006). Being culturally sensitive is the key for reaching out to these culturally deep-rooted Chinese communities. Some of the principles that were successfully used for this CBPR study include (a) identifying an accessible community and key persons within the community, (b) obtaining interest and support from the identified communities, (c) using the expertise of community advisors, (d) establishing a culturally sensitive caring partnership, and (e) establishing ownership by sharing research findings with the community.

Identify the Community and Key Persons

Of the many Chinese American adult day care centers in the San Gabriel Valley of Southern California, the researchers identified two centers in particular that were approved by the institutional review board to participate in their study. These two centers were selected because of the number of members and their age, communication ability, access to care, and economic status, as well as their accessibility to the researchers. Each center had more than 100 elder clients on a daily basis who were 65 to 85 years of age, mostly female, low income, able to communicate coherently, and able to attend the center’s programs. Although several dialects, including Taiwanese, Cantonese, Chaochouese, and Minnanese, were spoken among elders in the centers, everyone was able to communicate in Mandarin.

The center staff members include health care providers, nurses, physical therapists, social workers, and receptionists who are Chinese Americans. Depending on Medicare allowances and individual needs, each elder comes to the center on different days to attend different programs. While together in the center, these elders speak to each other in Chinese or Chinese dialects (primarily Mandarin, Taiwanese, and Cantonese), eat Chinese food, sing Chinese songs, play Chinese games, do Chinese exercises, watch Chinese TV programs, read Chinese newspapers, and learn Chinese arts.

Both centers are well-known and reputable among local Chinese communities. Knowing that both adult day care centers are privately owned and that the Chinese culture strongly respects ownership, the researchers realized that the owner of each center was the key person to gain access to the members. Establishing a relationship with the owners was a critical first step for ensuring the success of the study. The bilingual researcher first initiated a meeting with these two key persons at each day care center. This initial relationship was easier to establish since the bilingual researcher had a previous association with one of the center owners, who paved the way for the researcher to connect with the second owner. Both owners endorsed the research and wrote letters of support during the first meeting with them. With the owners’ permission, the researchers were able to access and meaningfully interact with day care center members.

Obtain Interest and Support

Disbelief and mistrust from a community of interest has been noted as one of the reasons that discourage ethnic minorities from participating in health research (Le Gris et al., 2000). Knowing that trust and support from the community are key elements of a successful CBPR approach, the bilingual researcher respectfully invited community members to become active members of the research team. The researcher explained the purpose of the study, the processes of participation, the benefits to be derived, and the importance of the collaborative process. The researcher was honest and open about expectations and intentions. Community members showed their interest and enthusiasm for the study after being convinced that the researcher was not simply using them to conduct a research study, but rather the researcher was aiming to conduct the study with and for them. Each facility consented to participate in the study based on a need and identified key persons suggested by staff to form a community advisory board (CAB). The CAB consisted of one staff and two senior clients from each center who were interested in participating in the project and volunteered to serve as board members.

Anticipating that older Chinese Americans have high respect for and expectations from academic institutions and scholars, the researchers diligently maintained a high standard of work ethic by following through with commitments, such as being on time for scheduled appointments, being organized, and using time efficiently. To further maintain interest and support from community members, the researchers actively listened to them, showing interest in their life stories, acknowledging their expertise, and accepting their suggestions and comments. Ultimately, the leadership role of CAB members facilitated overall community engagement and participation.

Use Community Advisors’ Expertise for CBPR Approach

The researchers regarded the CAB members as experts of their community. In return, CAB members provided the researchers with valuable insider knowledge about their community’s culture. The CAB members actively participated in all aspects of the study process, which included (a) assessment, planning, and dissemination of findings; (b) suggesting an incentive of a $30 Chinese supermarket gift certificate rather than the proposed $30 cash payment; (c) assisting with the development of a recruitment flyer, semistructured open-ended interview questions, and a self-reporting questionnaire and suggesting specific Chinese words for the informed consent to enhance the understanding of the study by participants (Lee, Kim, & Chen, 2010); (d) participating in the recruitment of study participants by distributing recruitment flyers and communicating research information to community members; (e) clarifying and validating the responses—for example, regarding certain exercises, foods, and herbs—obtained during individual and focus group meetings; and (f) planning and being instrumental in generating interest in the research project at the centers during the dissemination of research results. Overall, CAB members were trusted and valuable partners of the research team. Their involvement ensured that study outcomes would be meaningful to their center community and to elder Chinese communities at large.

Establish a Culturally Sensitive and Caring Partnership

Because the researchers were aware of barriers such as distrust, inadequate communication, and disregard of cultural beliefs, CBPR strategies were used to establish a culturally sensitive and caring partnership. The research team was open to the community’s identification of a problem that may not have been in the researchers’ area of expertise. If the problem focus was not in the researchers’ area of expertise, they were willing to spend time with community members to understand their problems and concerns. Both communities identified diabetic management as the focus for the study project during the initial meeting. This was particularly significant since both researchers are very proficient with applied and basic knowledge for diabetic management. Another key factor was the bilingual researcher’s extensive contacts within the Chinese community, including adult day care center organizations. Her Chinese ethnic background allowed her to relate well with the cultural background and experiences of the study population.

To further reduce cultural and language barriers that might prohibit community members from participating in the study, a culturally responsive study model (Ashing-Giwa, 2005) was used. In addition to the bilingual researcher, who speaks both Mandarin and Taiwanese, the researchers trained two senior nursing students who spoke Mandarin and Cantonese as research assistants. This was ideal since Chinese Americans value education and enjoy passing on their life story to younger generations. The students, therefore, easily established rapport with the day care members and facilitated their involvement and participation in the study. All instruments, both quantitative and qualitative, were translated into traditional Chinese characters. The individual and focus groups interviews were conducted in Mandarin by the bilingual researcher and research assistants.

In the Chinese culture, an older adult is seldom addressed by the first name or by the title of Mr. or Mrs. Instead, older adults are addressed by their last name, followed by a title such as “Ma Ma” (mother) and “Bo Bo” (father’s older brother), which represents their higher generational status. Given that Chinese people consider a title to be especially important, members of both centers always addressed the bilingual researcher using the title of “Professor.” This was the way they showed respect for the status, authority, and expertise of the researcher. In return, the researcher addressed community members as “Chen Ma Ma” or “Tung Bo Bo” to show respect for their older generation status and to bring the researcher/community member relationship to a more personal level and promote a sense of kinship with the elders. The research team was also flexible and patiently worked around program schedules of study participants. In doing so, the researchers demonstrated respect and consideration for the needs and priorities of community members.

Sharing of Research Findings

A CBPR approach to research is not complete without involving and sharing research findings with community participants. The CAB members actively participated in the plans for disseminating study findings. They recommended how best to present the study findings in order to generate the interest of older Chinese Americans. They decided the time and schedule for disseminating study findings. They modified activity schedules to allow all community center staff and members to attend the dissemination and education session.

The research team publicly recognized and individually thanked both centers for their participation in and contribution to the study. A PowerPoint presentation, written in traditional Chinese characters with large font and cartoons, was used to identify and explain themes, discuss findings, clarify misconceptions, and increase participant understanding and knowledge about diabetes. An interactive question/answer/discussion strategy was used to facilitate audience participation and to validate their comprehension and understanding of the information presented. Confidentiality of all participants was maintained during the sessions.

Since many older Chinese Americans like to buy lottery tickets, the research team used this method as an incentive for soliciting answers and questions from the audience during the dissemination of the study findings. The prize definitely generated audience interest and involvement as well as fun and excitement. Many of them thanked the researchers for the presentation. One participant approached the bilingual researcher and said, “I hope you will do more of this kind of study for us.” Another said, “We need more people like you to study something that will benefit us.”

As members of the research team, the CAB members helped in presenting the research results to the Center for Vulnerable Populations Research Summer Institute, hosted by the University of California, Los Angeles, in 2008. CAB members enthusiastically participated and expressed their appreciation for being invited to present.

Lessons Learned

The importance of the practitioner’s ability to understand and incorporate the needs and perspectives of culturally diverse communities is becoming more relevant as we recognize that health problems are influenced by many factors other than biological causes (Anderson, Calvillo, & Fongwa, 2007). The American Association of Colleges of Nursing (2003) responded to this trend by developing accreditation standards for the context of community-based education focusing on activities for community involvement and the use of partnerships and collaboration. The researchers, who are faculty in a large nursing program in Los Angeles County, became aware of the needs of the Chinese community while their students were learning the basics of community health care at different clinical sites. The researchers were able to identify and partner with two older Chinese American communities in a study to explore self-care practice, attitude, and health beliefs relevant to diabetic care.

The researchers learned that it is easier to approach and establish a partnership with a community based on an existing relationship or through a person (e.g., the owners) or persons (e.g., the CAB members) who have influential power in the community (Findholt & Brogoitti, 2007; Savage et al., 2006). To maintain the interest and support of community members, it was important for the researchers to match words with actions. The researchers also needed to treat each older adult with respect and care as if he or she were part of their own family.

The researchers learned that the CAB, consisting of three persons at each day care center who were actively involved with and had an influential effect in the community, was a vital element in employing a CBPR approach for this study. Because of the CAB members’ knowledge of the community and their guidance and suggestions, the researchers were able to modify the language used for recruitment flyers and semistructured interview questions, as well as develop a study approach that was culturally acceptable and respectful to community participants. As a result of the leadership role of the CAB members, community interest, awareness, and overall community participation were generated. Being treated as partners of the research project brought the CAB members and community members a sense of ownership and pride. One CAB member, following the summer institute presentation, told the researcher that she was very proud of being a part of the research team and that she had never dreamed of such involvement.

Many Chinese Americans perceive sickness or illness as bad and sad news. They consider diabetes to be a social stigma. The Chinese culture’s value of bao si bu bao yu (“Share happiness, not sadness”) prohibits many of them from speaking about the disease publicly. In addition, the language barrier and the Chinese qualities of being shy, being humble, and respecting authority and expertise can cause study participants to be hesitant and reluctant to verbalize their concerns. They are bu hao yee sue (“shy and embarrassed”) to express their ideas or opinions freely before a person with the title of “Professor” or “Doctor,” which has connotations of prestige and higher authority. The researchers learned that they needed to be culturally sensitive in working with this older population. The researchers’ colearning attitude and regard for the participants’ seniority and life experiences helped establish rapport and bridge cultural gaps. The use of two trained bilingual nursing students definitely helped achieve CBPR coalition goals and study results based on the desire of older Chinese adults to pass along personal wisdom to younger generations.

Based on several comments received from community members after the dissemination of the study findings, the CBPR approach used for this study was found to have successfully increased awareness of and interest in diabetes research among the participating members. This study suggests that vulnerable minority populations, such as older Chinese Americans, are interested and willing to participate in health studies and that they should be offered such opportunities.

Conclusions

It has been established that both the community and the researchers benefit from using the CBPR approach to conduct culturally sensitive research (Hartwig, Calleson, & Williams, 2006). This article offers an example of combining CBPR with the VPCM to conduct research addressing diabetes among older Chinese Americans and illustrates the importance of partnerships with communities where cultural beliefs and practices shared by community members provide the foundation for collaboration. Members of the community were included in meaningful ways and at all levels of the study. All participants, including the CAB members, research team, and community members, learned from each other. In so doing, the community increased their resources, with the potential for reducing their risks and thus improving their health status (Flaskerud & Winslow, 1998).

These culturally competent research strategies are appropriate for conducting a CBPR, regardless of the study topic and the ethnic population being addressed. When CBPR approaches to community involvement are in place, “the stage is set for additional partnerships between communities and Schools of Nursing to collaboratively design, implement, and integrate formal and informal cultural competence components in the nursing curricula” (Anderson et al., 2007, p. 21). When the community is involved, culturally competent health education, clinical practice, and research lead to improvements in all areas of health care and health disparities in vulnerable populations.

Footnotes

Acknowledgements

The authors thank Deborah Koniak-Griffin, RN, EdD, FAAN, Director, Center for Vulnerable Populations Research, School of Nursing, University of California, Los Angeles; the research assistants Sirong Li, RN, BSN and Jan Cheung, RN, BSN; and the staff and the Community Advisory Board of the two day centers, who participated in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded through the Center for Vulnerable Populations Research, School of Nursing, University of California, Los Angeles, National Institutes of Health/Nursing Institute for Nursing Research.

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