Health-seeking beliefs of cardiovascular patients: A qualitative study

Abstract

Objectives

The study aims were to (a) describe the experiences of Chinese Australians with heart disease following discharge from hospital for an acute cardiac event; (b) identify patterns and cultural differences of Chinese Australians following discharge from hospital; and (c) illustrate the illness/health seeking behaviors and health beliefs of Chinese Australians.

Design

Qualitative study.

Methods

Interview data were obtained from the following sources: (a) focus groups of Chinese community participants without heart disease; (b) interviews with patients recently discharged from hospital following an admission for an acute cardiac event; and (c) interviews with Chinese-born health professionals working in Australia. Qualitative thematic analysis was undertaken.

Results

Study themes generated from the data were: (1) linking traditional values and beliefs with Western medicine; (2) reverence for health professionals and family; and (3) juxtaposing traditional beliefs and self-management.

Conclusions

Considering the influence of cultural values in developing health care plans and clinical decision making is important.

Introduction

Cardiovascular disease (CVD) is a global health problem (Yusuf et al., 2001). Cultural backgrounds can influence perceptions of both illness and health. This is particularly the case in CVD where lifestyle is a large contributor to the etiology and progression of disease (Yusuf et al., 2001). Australia is the second most ethnically diverse nation in the world with a population comprising people from over 200 countries (Australian Institute of Health and Welfare, 2004a, Australian Institute of Health and Welfare, 2004b, Davidson et al., 2003a, Davidson et al., 2003b). One fifth of Australians are born overseas and many of these are from non-English speaking countries. Strict health requirements in Australia for immigration mean that the health of migrants is often superior to the Australian-born population. As the length of time living in Australia increases, the health advantage that migrants have over Australian-born people aligns with that of the general population (Young, 1992). This convergence may become more apparent in future decades as many migrants from the 1950s and 1960s become at a greater risk of ill health (Australian Institute of Health and Welfare, 2004a, Australian Institute of Health and Welfare, 2004b). Increasing rates of chronic conditions and the need for self-management means that health interventions need to be culturally sensitive and appropriate, providing services that are acceptable to people who are not from the dominant culture (Davidson et al., 2004).

These patterns of cultural diversity are not confined to Australia. Internationally, countries such as the United Kingdom, United States (US) and Canada have similar patterns of cultural and societal pluralism and a need to target and tailor health care that is relevant to migrant populations. Potentially people who are not from the dominant cultural group may be at a greater risk of poor health outcomes, particularly due to misunderstandings surrounding medication usage and not accessing health services (Bolton et al., 2002). There are diverse and complex reasons why migrants are less likely to use health services (Kliewer and Jones, 1997). Language and cultural factors commonly limit access to available health services (Hua et al., 2002). The association between low literacy and limited access suggests a need for improving knowledge of the health care system and accessible materials in migrant communities (Hua et al., 2002, Lipson and Steiger, 1996). Globally, it is important to consider that communities are rarely homogenous in their values, attitudes and beliefs (Chua and Yu, 2001). Chinese Australians also represent a range of cultural perspectives and as a consequence their cultural views are not always unified. However, culture commonly creates a backdrop against which an individual forges their own identity and is an important consideration in health care planning, delivery and evaluation.

Census data indicate that Chinese Australian migrants have lower levels of English proficiency compared with other groups (Rissel and Winchester, 1998). Although nearly two decades old, a National Health Survey found that there were challenges in accessing health care services and the use of doctors by ethnic Chinese was low with a tendency to access Traditional Chinese Medicine (TCM) instead (Young, 1992). In New South Wales, Australian people born in China are significantly more likely to report difficulties getting health care (Public Health Division, 2000) and are less likely to attend hospital emergency departments (Public Health Division, 2000) and consult general medical practitioners (Public Health Division, 2000). Similar problems exist in the United States (US), with Asian Americans not accessing health care services at the same rates as other groups (Ma, 2000). Chinese-Americans remain one of the least understood and most invisible and neglected minority groups in the US especially in the context of health service utilization (Ma, 2000). A study of barriers in the use of health services by Chinese Americans also found that cultural and socio-economic factors were strongly associated with access to and utilization of health services. In this study, language and communication difficulties were the major impediments to health services. Even though they had lived in the US for many years, 40% spoke Chinese only (these were elders and people with little education) (Ma, 2000, Shelley et al., 2004). Cultural factors influence health-seeking behaviors (Daly et al., 2002). Some of these factors include the individual's beliefs regarding health and illness, the role of family in health, attitudes to professional and traditional health interventions and their perceived severity, as well as susceptibility (Ma, 2000).

Although the Asian population has traditionally had a lower risk of coronary heart disease (CHD) compared with other Western nations, the increased Westernization of the Chinese culture has led to a concomitant increase in CHD (Holroyd, 2002). In Australia, rates of CHD tend to increase after their first 10 years of residence in Australia (Australian Institute of Health and Welfare, 2004a, Australian Institute of Health and Welfare, 2004b). Studies to date of CHD in Chinese patients, accessible in the English language literature, have examined responses to illness, such as anxiety, depression and coping methods rather than focusing on experiences and expectations surrounding the illness (Holroyd, 2002, Holroyd et al., 1998). Little is known about the illness and health seeking behaviors, health beliefs and knowledge of the Chinese migrant community in Australia, yet some data suggest that some aspects of the cultural tradition of Chinese migrants may impede their equity of access to health services.

As secondary prevention is a critical factor in improving health outcomes following an acute cardiac event it is important that individuals have appropriate expectations and available services are configured to meet their needs (World Health Organisation, 1993). Lui and Mackenzie (1999) studied the rehabilitation needs of Chinese stroke patients and suggested that the priorities, interpretations, and expressions of need are affected by Chinese upbringing and family values, particularly among the elderly population. A strong emphasis on collectivism is in contrast to Western populations, who focus more strongly on individual need (Bond, 1995). As a consequence, Chinese people may be less willing to express individual need unless encouraged to do so. Lui and Mackenzie (1999) also found that many Chinese elderly people are passive in expressing their health needs and this was related to their educational, social, and cultural background. The studies discussed above suggest that many Chinese patients may have unmet needs and in some instances traditional beliefs may be at odds with recommended treatment patterns. This research also highlights the need for more information on the experiences of people from diverse cultural perspectives. In spite of the rapid increase in migration described above, there is minimal Australian research investigating the health beliefs, behaviors and experiences of Chinese patients and community members. Data identifying their health beliefs, behaviors, and experiences concerning cardiovascular conditions will likely facilitate more equitable and culturally competent health care (Chen, 2001). When approaching investigation of any cultural group it is important to avoid stereotypical perspectives in both study design and interpretation of study data. However, health seeking behaviors and representations of health and illness are strongly influenced by social and cultural context (Gervais and Jovchelovitch, 1998). Understanding a range of cultural perspectives is crucial in effective health care planning and delivery. Following recognizing the need to tailor services to increasing numbers of Chinese patients, we considered that obtaining the perspective of care through the lens of health professionals, community members and patients may further inform culturally appropriate and competent care (Anderson et al., 2003).

The aims of this study were to:

• Describe the experiences of Chinese Australians with heart disease following a discharge from hospital for an acute cardiac event;

• Identify patterns and cultural differences of Chinese Australians following discharge from hospital;

• Illustrate the illness/health seeking behaviors and health beliefs of Chinese Australians.