Exploring the Impact of COVID-19 on AANHPI Patients

April 7, 2023 | VOLUME 1, ISSUE 1

The COVID-19 pandemic has touched every person and population in the last 3 years. But as clinicians have seen with many other pulmonary diseases, challenges like lack of access and communication barriers can amplify the effects of illness and further expand existing disparities. When a dramatic increase in racial bias is added to this mix, the resulting impact on patients can be devastating.

To learn more about the experience of patients from Asian American, Native Hawaiian, and Pacific Islander (AANHPI) communities during the COVID-19 pandemic—and how clinicians can improve care for this population—Elizabeth J. Stigler, PhD, Director, Diversity Equity, Inclusion, and Belonging at CHEST, spoke with David Li, Social Impact and Policy Officer at the Chinese American Service League (CASL).

Stigler: Tell us more about the mission and vision of CASL and the work it does with AANHPI individuals and communities.

Li: CASL is located in Chicago’s Chinatown neighborhood and is the largest AANHPI-serving nonprofit in the Midwest. For more than 40 years, CASL has provided a growing range of direct services and supports to individuals and families.

In 2021, we served more than 6,000 individual clients across our programs, including child and youth education, adult employment and financial empowerment, citizenship and legal support, as well as behavioral health and community engagement. Our clients come from all over Illinois and neighboring states to access our programs, like our HUD Housing Program, which is the only Chinese-language HUD-certified housing program in the state.

As the Social Impact and Policy Officer, my role is housed in our Center for Social Impact, which drives our data-informed practice and is where our social drivers of health (SDoH) survey instrument was developed. When we designed our SDoH 3 years ago, it was in response to a lack of disaggregated data about AANHPI individuals and also just a bigger lack of AANHPI representation at all. What started with a question to illuminate social conditions has now grown into a shared community data portal called Change InSight™.

Stigler: What does the existing data tell us about the specific impact COVID-19 has had on the health and well-being of AANHPI communities?

Li: Well, not much. Unfortunately, there is a serious lack of data about COVID-19 and AANHPI communities. The data that has been collected is mostly localized, so everyone is gathering different data, and not all data has the same traction. What makes this more complicated is the grouping of all AANHPI people under one monolithic identity of “Asian,” as you see in survey tools like the Chicago Health Atlas, for example. That broad “Asian” classification includes more than 50 countries where approximately 35 different languages are spoken, so lumping all of that cultural and historical diversity into one bucket paints a very dangerous and inaccurate picture of the health of AANHPI communities, and it can lead to false assumptions that “Asians are doing fine.”

Another challenge to successfully documenting and researching how COVID-19 impacts AANHPI communities is the lack of language accessibility. If the research studies and surveys being generated are not in your language, and the results that are published are not in your language, there is no incentive to participate.

Even before COVID-19, AANHPIs were underrepresented in federally funded clinical trials (JAMA Netw Open. 2019;2:e197432), so this pandemic has only intensified this issue. The research that does exist indicates that [in 2020] AANHPIs experienced the second highest increase in [annual] deaths following Latin Americans, and, still, there remains a serious lack of research (The Marshall Project. 2020).

Stigler: How have you seen COVID-19 showing up in the SDoH results?

Li: Something reflected in our SDoH but not exclusive to our clients is a severe decrease in feelings of safety as well as community and neighborhood belonging. Unfortunately, AANHPIs are facing a sort of “double pandemic” that is COVID-19 and the dramatic spike in anti-Asian hate and racism. Research conducted by The Asian American Foundation and Stanford shows that hate incidents across the country are up by more than 300% since 2021 (Leading Asian Americans to Unite for Change [LAAUNCH]. Index Report 2021). CASL’s SDoH shows a 20% decrease in feelings of community belonging among female participants from 2020 to 2021 (Chinese American Service League. 2021.). The fear that many AANHPI individuals feel makes navigating the health care system even more challenging.

Something else we know about CASL’s clients is that 90% of SDoH respondents [have] limited English proficiency (LEP), and this is not unique to CASL. Many AANHPI communities across the nation are similar. When compared with English-proficient individuals, people who deal with LEP are less likely to have consistent medical care or a primary care provider and more likely to have unmet medical care needs (J Immigr Minor Health. 2019;21:264-270).

Unfortunately, at present, the majority of low-literacy health strategies are focused on English- and Spanish-speaking communities and not AANHPI communities, which goes back to the monolithic category of “Asian” identity and the incorrect assumptions that are made due to a lack of disaggregated data.

Change InSight™, a collaboration of AANHPI leaders and agencies, seeks to break the mold by asking which communities are affected most by their social conditions. The SDoH data collected by these partners help establish opportunities where AANHPI-serving organizations can get connected with needed resources and representation. Change InSight™ helps inform why certain community groups [and] special and vulnerable populations experience COVID differently.

Stigler: What steps can health care providers take to support AANHPI communities recovering from COVID-19 and to provide better care for those individuals in general?

Li: Ask questions, and lead with empathy. Don’t make assumptions about what a patient knows or who they are. Before you even get to the patient interaction, make sure that the training you have received as a provider is culturally relevant and equitable so that you are prepared to understand the needs and experiences of a diverse group of people like AANHPIs.

Providing equitable care might require extra effort on your part to ensure that your patient has access to linguistically appropriate information that doesn’t rely on their child or spouse to be the translator. If you are not directly dealing with patients with limited English proficiency, then I encourage you to be an advocate for policy change. AANHPI priorities are poorly funded and under-researched at all levels, and it will take all of us to move the needle forward on health equity.

Advocacy opportunities

Clinicians in every area of medicine can advocate for better care for patients with limited English proficiency.

“A practical step for increasing language access—which subsequently feeds into the global language justice movement—is to recognize the difference between formally trained medical interpreters and individuals accompanying patients who speak a non-English language but have no medical context,” said Li. “This stems from a larger issue which is the lack of language diversity in medical education, insurance enrollment systems, and culturally relevant diagnoses.”

“For instance, mental illness is well-known among the AANHPI community as a stigmatizing topic, but what's missing is the bridge between culturally appropriate framing and symptom expression. Someone with limited English proficiency might have a hard time articulating what's understood as a 'panic attack' [and] describe it using terms that could be misinterpreted as a heart attack.”

Other opportunities recently highlighted by the Urban Institute include:

• Collaborating with community organizations, such as the Chinese American Service League, who have expertise in specific languages to develop more robust medical education for patients and families
• Advocating for increasing the availability and use of medical interpreters in your own institution
• Working to improve language accessibility in patient portals, telemedicine platforms, and electronic health records
• Incorporating education in medical training programs and fellowship programs, or other mentorship, on how to better inform patients of their rights to language services and use remote translation services more effectively.