How Can Chinese Immigrants in Western Countries Take Care of Their Cardiovascular Health?

July 1, 2022|Ling (Cristina) Zeng

Thank you to Cristine Zeng, PhD candidate, BN, MN, RN, Professor Lin Perry, and Dr Xiaoyue Xu for this article on cardiovascular health in Chinese immigrants.

Cardiovascular Health in Chinese Immigrants

Cardiovascular disease (CVD) is still the leading cause of death worldwide, attributing to more than 17.9 million deaths annually.1 CVD is also a significant issue among many immigrant groups.2 Compared to the host population, health disparities exist in the immigrant populations with higher CVD risk factors and prevalence, and poor CVD outcomes.3 Migration could expose immigrant populations to disadvantageous CVD profiles related to their changed living environment, and the mounting stress from adapting to a new culture and country.

Chinese immigrants are one of the world’s largest and fastest-growing ethnic populations.4 The most popular Western countries to which Chinese populations have migrated are the United States, Canada, Australia, New Zealand, and the United Kingdom.5 There is a long-standing myth that Chinese immigrants are healthy, due to the “healthy immigrant effect,” defined as “recent migrants are in better health than the non-migrant population in the host country”.6 However, some studies have shown that Chinese immigrants may have a suboptimal CVD profile. Some examples are:

  • Compared to the host population, Chinese immigrants had higher CVD risk factors related to diabetes, physical inactivity, and smoking.7,8 A study following participants for 2 to 20 years showed Chinese immigrants had higher short-term mortality after a diagnosis of CVD than white populations.9
  • Compared to people in mainland China, Chinese populations in Western Europe and North America had higher rates of hypertension, diabetes, obesity, and blood cholesterol level. In Western Europe, Chinese immigrants had poor risk factor management and increased prevalence of myocardial infarction.8 Results from a large study with 258,474 Chinese participants indicated that Chinese immigrants had lower rates of stroke, but their prevalence and mortality from coronary heart disease were higher than in individuals from mainland China.10
  • Results from a large Australian study in 2017 indicated that following migration to Western countries, the health status of Chinese immigrants worsened over time with the increasing risk of developing heart disease, obesity, and diabetes.11

Self-care Practices for Cardiovascular Health in Chinese Immigrants

According to research findings, for patients with CVD, the time spent with healthcare providers averages about 10 hours per year, indicating that patients undertake most of the care of their own disease outside of healthcare settings.12 For people with CVD risk factors, taking good care of the heart on a daily basis significantly reduces the risk of developing CVD. For people living with heart disease, good self-care helps to manage heart-related symptoms, and reduce hospitalizations.12 It is, therefore, important to understand and have knowledge of heart health, and how to implement self-care behaviors among individuals, including Chinese immigrants.

After moving to a new country, Chinese immigrants may change their traditional lifestyle as they adjust to Western culture; this may have an impact on their heart health. Furthermore, language and cultural barriers can hamper their access to mainstream health services in their new home country. Navigating the local healthcare system may be difficult since it is significantly different from the Chinese healthcare system. With these challenges, how can first-generation Chinese immigrants maintain heart health as they adapt to living in Western countries?

Dietary Adjustment

Following a diagnosis of coronary heart disease, some first-generation Chinese immigrants engaged in positive dietary changes such as reducing the consumption of salt, fat, carbohydrates, and sugar.13 Many Chinese patients preferred to eat homemade traditional Chinese meals, which were referred to as “little meat with a lot of vegetables.” Some Chinese patients controlled what they ate, eating until they feel 70 to 80 percent full, to maintain weight.14

Physical Activity

Chinese immigrants living with CVD reported actively performing exercise, including brisk walking, Tai Chi, and swimming on a regular basis.13

Taking Medication

Although traditional Chinese medicine is rooted in Chinese culture, many Chinese patients prioritized Western medication rather than traditional Chinese medicine for treating their heart disease.13,14 Because the Chinese immigrants thought heart disease was an acute condition, Western medications were taken as the first-line treatment for managing the heart symptoms. One survey study found that 77.2 % of Chinese immigrants took their medication for heart disease regularly.15 This high medication adherence was related to being able to afford the medication, remembering to take medication16, and understanding the need to take the medication.15

By comparison, most Chinese patients took some traditional Chinese medicine to manage other chronic diseases or to maintain their health. For example, they regularly drank herbal tea to clean the fat following greasy meals14, or used traditional Chinese medicine when experiencing cold or flu symptoms. Some patients took extra traditional Chinese medication if their heart symptoms were poorly managed with Western medication.17 Conversely, some Chinese patients gave up traditional Chinese medicines due to the side effects, and the high cost of medicines in host countries.13 Some individuals returned to China each year to see Chinese doctors, and to stock up on traditional Chinese medicines before returning to their new home.

Seeking Healthcare Resources

In terms of seeking healthcare services to treat heart disease, Chinese patients often chose doctors trained in host countries, but prefer those who are Chinese-speaking.13 Moreover, they actively engaged with medical care, making follow-up appointments with their physician, and consulting with multidisciplinary health professionals.

Regarding seeking health information, Chinese participants diligently and actively engaged in searching for the best health information and resources for their heart disease.14 For example, in the early stages of their heart disease diagnosis, these patients quickly started to seek information related to their treatment, rather than spending time struggling with their heart diagnosis and digesting related emotions.13 Many Chinese patients sought information about heart disease from friends or family who were in China, on Chinese websites, or via social media,14 and from health talks held by Chinese community centers. A study assessed the quality and cultural sensitivity of CVD-related health information targeting Chinese immigrants in western countries and indicated a significant lack of key information regarding heart rehabilitation in health education sources.17

In general, many first-generation Chinese immigrants with known heart disease actively took care of their heart health by adopting a healthy lifestyle and looking for health information and medical resources to best treat their heart conditions. Frequently, these patients took medications as prescribed, a health behavior that was associated with a strong belief in the benefit of Western medicine for treating heart disease. However, language and cultural barriers impede access by Chinese immigrants to mainstream health resources, so patients commonly sought heart information from Chinese websites or social media, and looked for Chinese-speaking doctors for their medical appointments.

How Cardiovascular Nurses can Promote Cardiovascular Health in Chinese Immigrants

For Nurse Researchers

The literature on the self-care practices and related cultural factors among Chinese first-generation immigrants living with CVD in Western countries is significantly limited.18 The existing studies mainly report aggregated data on CVD risk in primary prevention and lump together Chinese immigrants into a broad pan-Asian ethnicity. Moreover, most studies focusing on secondary CVD prevention fail to distinguish Chinese first-generation immigrants from second- or mixed-generations, whose self-care practices may vary significantly depending on the level of acculturation (how much they retain their home culture while receiving host culture regarding their behaviors and values). Given the large and growing size and aging of this population internationally, this indicates the need for further research in this area.

For Nurse Practitioners

It is important for clinical nurses to perform culturally competent practices for the immigrant population by improving their cultural sensitivity. The clinical nurse should avoid stereotyping of self-care practices of Chinese immigrant patients living with CVD. Specifically, by assessing the level of acculturation and heart health behaviors of Chinese immigrants, the clinical nurses could provide individualized health education programs to improve the implementation and adherence of evidence-based CVD self-care. For example, less acculturated patients who retain most of the Chinese culture can be targeted to focus more on the traditional healthy dietary patterns, while more acculturated patients who integrate well to the host culture are suggested to incorporate a healthy dietary regimen of the host country into their dietary practices.19

Culturally- and linguistically-sensitive health resources and education programs are urgently needed among the Chinese immigrant population living with CVD. Having insight into the culture-related self-care practices among Chinese immigrants living with CVD, the clinical nurses could maximize the acceptability of health education programs and improve their self-care practices for CVD via developing culturally appropriate resources and services for the Chinese immigrant population. 

References

  1. World Health Organization. (2021). Cardiovascular disease fact sheet. Accessed June 18, 2022.
  2. Agyemang, C., de-Graft Aikins, A., & Bhopal, R. (2012). Ethnicity and Cardiovascular Health Research: Pushing the boundaries by including comparison populations in the countries of origin. Ethnicity & Health, 17(6), 579-596. doi:10.1080/13557858.2012.730607.
  3. Agyemang, C., van den Born, BJ. Cardiovascular health and disease in migrant populations: a call to action. Nat Rev Cardiol 19, 1–2 (2022). doi:0.1038/s41569-021-00644-y.
  4. Koirala B, Turkson-Ocran RA, Baptiste D, et al. Heterogeneity of Cardiovascular Disease Risk Factors Among Asian Immigrants: Insights From the 2010 to 2018 National Health Interview Survey. J Am Heart Assoc. 2021;10(13):e020408. doi:10.1161/JAHA.120.020408
  5. Department of Economic and Social Affairs. (2019). International migrant stock 2019. 
  6. Ichou, Mathieu, and Matthew Wallace. The Healthy Immigrant Effect: The Role of Educational Selectivity in the Good Health of Migrants. Demographic Research, vol. 40, no. 4, Max-Planck-Gesellschaft zur Foerderung der Wissenschaften, 2019, pp. 61–94. doi: 10.4054/DemRes.2019.40.4
  7. Jin K, Neubeck L, Gullick J, Koo F, Ding D. Marked differences in cardiovascular risk profiles in middle-aged and older Chinese residents: Evidence from a large Australian cohort. Int J Cardiol. 2017;227:347-354. doi:10.1016/j.ijcard.2016.11.062
  8. Chiu M, Austin PC, Manuel DG, Tu JV. Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007. CMAJ. 2010;182(8):E301-E310. doi:10.1503/cmaj.091676
  9. Jin K, Ding D, Gullick J, Koo F, Neubeck L. A Chinese Immigrant Paradox? Low Coronary Heart Disease Incidence but Higher Short-Term Mortality in Western-Dwelling Chinese Immigrants: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2015;4(12):e002568. Published 2015 Dec 18. doi:10.1161/JAHA.115.002568
  10. Gong Z, Zhao D. Cardiovascular diseases and risk factors among Chinese immigrants. Intern Emerg Med. 2016;11(3):307-318. doi:10.1007/s11739-015-1305-6
  11. Jin K, Gullick J, Neubeck L, Koo F, Ding D. Acculturation is associated with higher prevalence of cardiovascular disease risk-factors among Chinese immigrants in Australia: Evidence from a large population-based cohort. Eur J Prev Cardiol. 2017;24(18):2000-2008. doi:10.1177/2047487317736828
  12. Riegel B, Moser DK, Buck HG, et al. Self-Care for the Prevention and Management of Cardiovascular Disease and Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association. J Am Heart Assoc. 2017;6(9):e006997. Published 2017 Aug 31. doi:10.1161/JAHA.117.006997
  13. King KM, LeBlanc P, Carr W, Quan H. Chinese immigrants’ management of their cardiovascular disease risk. West J Nurs Res. 2007;29(7):804-826. doi:10.1177/0193945906296431
  14. Jin K, Neubeck L, Koo F, Ding D, Gullick J. Understanding Prevention and Management of Coronary Heart Disease Among Chinese Immigrants and Their Family Carers: A Socioecological Approach. J Transcult Nurs. 2020;31(3):257-266. doi:10.1177/1043659619859059
  15. King-Shier K, Quan H, Mather C, Chong E, LeBlanc P, Khan N. Understanding ethno-cultural differences in cardiac medication adherence behavior: a Canadian study. Patient Prefer Adherence. 2018;12:1737-1747. Published 2018 Sep 7. doi:10.2147/PPA.S169167
  16. King-Shier KM, Singh S, Khan NA, et al. Ethno-Cultural Considerations in Cardiac Patients’ Medication Adherence. Clin Nurs Res. 2017;26(5):576-591. doi:10.1177/1054773816646078
  17. Li J, Lowres N, Jin K, Zhang L, Neubeck L, Gallagher R. Quality and Cultural Sensitivity of Linguistically Appropriate Cardiovascular Disease Information for Chinese Immigrants: A Review of Online Resources From Heart Foundations. J Cardiovasc Nurs. 2018;33(3):269-280. doi:10.1097/JCN.0000000000000457
  18. Zeng L, Perry L, Xu X. Self-care behaviours and related cultural factors among Chinese immigrants with cardiovascular disease in western countries: an integrative review [published online ahead of print, 2021 Nov 10]. J Clin Nurs. 2021;10.1111/jocn.16120. doi:10.1111/jocn.16120
  19. Deng F, Zhang A, Chan CB. Acculturation, Dietary Acceptability, and Diabetes Management among Chinese in North America. Front Endocrinol (Lausanne). 2013 Aug 27;4:108. doi: 10.3389/fendo.2013.00108. PMID: 23986745; PMCID: PMC3753561.
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