A Trauma-Informed Approach to Health Services Research: The Significance of Birthplace, Historical Events, and Resilience in Asian Minority Aging Research

Asian American older adults comprise the fastest growing racial/ethnic group in the United States, which is expected to more than double in size from 2010 to 2050. Most health outcomes research aggregates data on Asian Americans, masking differences in health and health risks among Asian ethnicities. The main goal of this project is to develop the methods and research resources (data and human) to support future R01 projects that will disaggregate Asian American subgroups and utilize a trauma-informed approach to health services research that considers birthplace, immigration history, and associated historical events.

Preliminary Evaluation of Community-Based Educational Outreach to Increase Intention to Screen for Colorectal Cancer among South Asians in California.

South Asians are the second largest Asian subgroup and one of fastest growing minority populations in the United States. Despite being perceived as a “model minority”, this population suffers disproportionately from a number of preventable health outcomes including metabolic and cardiovascular conditions, as well as site-specific cancers. In addition to a bimodal distribution of socioeconomic indicators, many factors contributing to South Asian health disparities originate from socio-cultural norms and behavior. One disparity of concern, especially among elderly foreign-born South Asians in the U.S., is the increasing incidence of colorectal cancer (CRC). One potential reason for this pattern is suboptimal rates of screening in this population. For example, population-level data in California have shown that rates of CRC screening have remained stagnant among South Asians in the state and one of the lowest among Asian American subgroups, far short of target rates found in Healthy People 2020. Such patterns seem to persist even among South Asians who have access to care. Thus, understanding and addressing salient determinants of CRC screening behavior are paramount to development of effective culturally sensitive interventions. This is particularly noteworthy given that most literature characterizing South Asian disparities in cancer and screening focus on Asian Indians, thus neglecting unique or overlapping facilitators and barriers found among other ethnic groups, such as Bangladeshis and Pakistanis. Moreover, a South Asian community notably absent in investigations of health disparities in the U.S. are those whose presence in the U.S. is through an intermediate destination of migration. For instance, in California, there is a considerable population of Indo-Fijians whose socio-demographic profile and immigration history are distinct from other South Asians in the state, underscoring the role of educational and economic factors not found among other more advantaged South Asian communities. A common factor found among South Asians in the native subcontinent and across the Diaspora is trauma related to colonization, including the effects of redefined nationalities, forced relocation, religious conflicts, indentured servitude, and caste hierarchies. There remains little investigation of how such cultural traumas may persevere through migration, and ultimately affect beliefs and behaviors related to disparities found in this population. Comprehension of such historical antecedents –as well as resultant resiliencies –may provide a more nuanced characterization of the social determinants of health driving inequities in health among South Asians in the U.S., particularly in later stages of the life course.

Help-seeking among U.S. Chinese Older Adults with Elder Mistreatment.

Elder mistreatment (EM) is a common, costly and fatal condition and there has been inadequate attention at the national level. EM refers to an intentional single, repeat action, or lack of action that causes harm or risk of harm to an older adult. EM has several subtypes, including physical, psychological, and sexual mistreatment, and financial exploitation. EM not only causes physical disability and psychological distress but also increases the risk of morbidity and mortality. Previous studies showed that only 4%–14% of EM victims reported their abusive experiences to law enforcement, legal/justice, or adult protective services. The majority of older adult victims remain hidden from authorities and endure mistreatment.1Formal support services can assist reduce the risk and magnitude of revictimization. Often times, older adults seek help from informal supporters (e.g., family, friends, neighbors). Only few research is available to understand factors related to EM victim help-seeking. Information of whether EM victims seek informal help will facilitate formal service is limited. Chinese Americans form the largest ethnic group among the Asian-American population in the United States. We are not aware of any study that has examined informal and/or formal help-seeking (intentions and actual action) among U.S. Chinese older adults with EM. Filling these gaps could have significant implications for future targeted prevention and intervention strategies, as well as inform practice and policy. Andersen’s Behavioral Model of Health Services Use (BMHSU) has been adapted and utilized extensively in many studies investigating the use of health services for diverse racial and ethnic populations. Anderson’s BMHSU model has been used to understand service use among older adults with EM. This model proposes that the use of formal services is predicted by a person’s predisposing characteristics, enabling resources, and level of need. Predisposing characteristics include socio-demographic factors that limit or enhance access to services. The enabling resources include personal, social, and community resources that enable or impede from service utilization. The presence of supportive relationship in a person’s social network is a key enabling resource to facilitate the utilization of formal services. The need factors include the nature and magnitude of the presenting problem or clinical need. Given that Chinese cultural values could deeply influence mistreated older adults on help-seeking, we tailored the BMHSU by adding the cultural factor domain to address this issue for this specific vulnerable populations. This proposed study aims to conduct secondary data analyses of the representative data of the Population Study of Chinese Elderly (PINE) in the United States to identify factors that impede or facilitate help-seeking. Guided by the Anderson’s BMHSU model, our central hypotheses that greater predisposing characteristics, cultural factors, enabling resources, and need predict higher levels of service utilization; and informal help-seeking can facilitate formal help-seeking. Using data from the Time 1 and Time 2 wave of the PINE, this study addressed three specific aims:1) Explore the patterns of informal and formal help-seeking (intentions and actual action) among older adults with EM.

The NOVA dietary framework and its association with cardiometabolic risk, cognition, and mortality among Asian and other ethnic/minority older US adults.

Very little is known about the diets of Asian Americans – including children, adults and older adults - but analyses of national data are revealing previously undocumented dietary disparities for the Asian American population. Compared to peers of other racial/ethnic groups, Asian American adults have higher sodium and refined grain intakes and are less likely to consume the recommended amount of sodium per day (≤2300 mg/day). Asian Americans are at high risk of cancer, cardiovascular disease, diabetes, and Alzheimer’s disease and related dementias– conditions which may be mitigated by improved dietary behaviors. However broad stereotypes both societally and among researchers that this community suffers from few health disparities and a lack of reliable and systematically collected data among Asian Americans have contributed to limited knowledge of diet in Asian American children, adults and older adults. In addition to the limited availability of data pertaining to Asian American diet, there is also a glaring lack of cultural adaptation with respect to preventative dietary approaches for Asian Americans. For example, the Mediterranean diet emphasizes fruit, vegetable, whole grain, and fish consumption, but as its name suggests, it is based off of typical dietary patterns common in the Mediterranean region. There is an urgent need for evidence-based diets or dietary patterns complemented with preservation of healthy aspects of traditional Asian diets to prevent diet-related death and disability. Diets classified according to the NOVA framework are one such example of a diet pattern that can be applied cross-culturally. The NOVA framework emphasizes the consumption of minimally processed foods over highly processed foods rather than specific nutrients. The NOVA framework has been linked to less chronic conditions, has a simple to follow message, is easy to measure, and is flexible—it can easily be adapted to any cuisine. Yet its relationships to health endpoints have not yet been assessed for racial/ethnic minorities, or specifically among older adults. Within this context, the overall goal of this proposal is to fill the critical gap in our understanding of the associations between diets classified according to the NOVA framework with key cardiometabolic risk factors (i.e., blood pressure, fasting glucose, total cholesterol, body mass index), cognition, and mortality within older and racial/ethnic minority populations. To do so, we will utilize data from multiple waves of the NHANES survey (1999 – 2016)– which includes an oversampling of Asian Americans (from 2011-2016)—and when applicable, link these data to the National Death Index for mortality information, updated through 2015. Analyses will be representative of older US adults age 50+ and stratified by race/ethnic group, with an emphasis on Asian Americans, and when possible, Asian-American subgroups.

Prevalence, Risk Factors, and Economic Burden of Alzheimer's Disease and Related Dementias among Older Multi-Ethnic Asian Americans.

In 2019, 5.8 million Americans are living with Alzheimer's disease and related dementias (ADRD) and the number is projected to increase to 13.8 million by 2050. Compared to non-Hispanic whites, non-Hispanic blacks and Hispanics are more likely to have ADRD. Common risk factors of ADRD include age, family history, and apolipoprotein E (APOE) gene. These risk factors play different roles in different racial/ethnic groups. African Americans are more likely to have APOE4 and have a higher risk of ADRD. Total costs of health care, long-term care, and hospice for individuals with ADRD are estimated at $290 billion in 2019 and are projected to reach to $1.1 trillion in 2050. Among individuals with ADRD, non-Hispanic blacks and Hispanics have higher total costs. It is well documented in the literature that racial/ethnic disparities exist in the prevalence, risk factors, and economic burden of ADRD. However, little is known about Asian Americans.

Intergenerational reminiscence approach in improving emotional well-being: A pilot study with older Asian Americans in early-stage dementia using virtual reality.

Immigration, aging, and dementia often results in triple jeopardy for Asian Americans. Immigration is a life-changing event that is often accompanied by elevated stress and adversity. Aging adds an additional layer of adversity to immigration. Triple jeopardy occurs when they further experience adverse event such as dementia. This co-occurrence of triple jeopardy poses trauma to Asian American older adults. Which calls for a pressing need to understand how to best restore and preserve the resilience for them. After dementia diagnosis, people often experience anxiety, negative effects on self-esteem, preoccupation with the diagnosis, hyper-vigilance and precipitating a crisis. Asian Americans also report feelings of shame and weakness after a dementia diagnosis; however, they seek fewer formal services for support compared to Whites, leading to negative emotional and mental health outcomes. Despite vulnerabilities among this population, Asian Americans often attract less research attention in part due to the “Model Minority” myth. Despite their overall better physical health, older Asian immigrants have worse mental health outcomes than their White counterparts. People who are emotionally well (i.e., satisfaction with life, positive affect, purpose or meaningful life), a quality of resilience, are able to bounce back faster from difficulties. While there are some studies that specifically looked at the emotional well-being among adults and adolescents, few studies examined emotional well-being among older adults. Prevention or intervention to improve the emotional well-being among aging populations had called special attention because of its strong correlation with health. Reminiscence and life review have been identified as potentially effective intervention strategies for helping depression and emotional well-being for older adults. Literature also asserts the positive impact of the intergenerational approach in achieving positive mental health and emotional well-being of older adults. Intergenerational solidarity between grandparents and grandchildren has been emphasized in Asian families and is beneficial for the health of persons with dementia. When reminiscence and life review strategies are combined with the intergenerational approach, the mental health benefits for older adults are even clearer and more significant. This approach may also help grandchildren gain more historical and cultural understanding of grandparents’ lived experiences, positively change their views of aging, and increase their bonding with grandparents. Using technology to help enhance the well-being of older adults is a growing research and practice trend. One recent technological advancement is audiovisual virtual reality (VR), which creates a three-dimensional, computer-generated environment to provide an immersive and interactive personal experience. As an emerging technology that allows older adults to socialize across geographic boundaries, it has been well accepted by older adults using a head-mounted display paired with a smartphone. Studies have also shown the potential for social VR as a powerful reminiscence tool to challenge ageing stereotypes and promote the well-being of older adults. This pilot study is the first one to develop and test how social VR could help older Asian Americans improve their emotional well-being to cope with the stress and adversity of having been diagnosed with dementia. It is hypothesized that the resiliencies of family through grandchildren, reminiscence, and technology together will help older adults develop better emotional well-being, which will help them undergo difficulties in the journey of dementia and have better mental health outcomes in the end.

Dining with Diabetes: Precise and Personalized Behavioral Nutrition Intervention for Asian American older adults.

Diabetes mellitus is a chronic disease suffered by more than a quarter of the US population older than age 65, and requires continuous monitoring and management of blood glucose, medication, diet, and exercise. Asian Americans (AAs) represent 6% (17.3 million) of the US population and are expected to grow to 34.4 million by 2060. Similarly, the number of older AAs (≥ 65 years old) will double to 15% by 2050. Despite having lower BMI than Whites, AAs have 60% higher risk of diabetes, with 9% of AAs affected. For the older AAs, there are higher prevalence rates, worse diabetes control, and higher rates of complications. The complex interplay between biological, behavioral, environmental, and social factors contribute to health inequalities in type 2 diabetes (T2D) self-management among older AAs. Furthermore, lifestyle factors such as inappropriate diet and lack of physical activity led to increasing rates of obesity, a major risk factor for T2D. In addition, limited health literacy and access to programs using digital health devices are likely contributors to present and future health disparity gaps in underrepresented ethnic groups including older AAs. Despite the large body of evidence concerning the effects of dietary interventions on glycemic control, studies often suffer from systematic measurement errors, unclear response to the dietary interventions, and the use of dietary assessment tools that have no cultural sensitivity. To address these challenges, recent clinical findings have suggested new perspectives for the prevention and treatment of chronic diseases – T2D, obesity –through a personalized nutrition approach combining metabolomics and digital health technologies in translational science. However, the field of personalized nutrition is in its early infancy, and several current available programs applicable to diabetes have significantly limited clinical use. The dietary patterns of each person are very complex due to the interplay between biological, behavioral, environmental, and social factors. Furthermore, current personalized nutrition approaches are not tailored to individuals’ health literacy levels, cultures, or personal traits. Therefore, personalized behavioral nutrition for diabetes self-management in a given population must be tailored to that population’s characteristics if they are to generate sufficient interest and engagement to translate into effective nutrition behaviors. Therefore, we propose a randomized, controlled trial to investigate the effect of Personalized Behavioral Nutrition (PBN) intervention to improve glycemic control among older AAs with T2D focusing on Chinese, Korean, and South Asian. We hypothesize that the PBN group will show significant improvements in hemoglobin A1C (HbA1C), diet patterns, weight, and metabolites profiles compared with the American Diabetes Association (ADA)-based diet group.

SHARE (Share History, Activity, Resilience, and Experience) project among Asian American older adult caregivers of individuals with Alzheimer’s disease and related dementias.

Little attention has been given to the effectiveness of interventions designed to improve the well-being of family caregivers in Asian American communities. Journey of Caregiving (JOC) is the only known Vietnamese-language caregiving curriculum developed by bilingual social workers at the Family Caregiver Resource Center (FCRC) in Orange County for Vietnamese American (VA) caregivers. The FCRC is the only nonprofit in the region that provides ongoing bilingual and bicultural case management and supportive services (e.g., support groups, workshops, consultations) to ethnically diverse caregivers, including 700-800 VA caregivers and their families annually. The primary clientele at the FCRC are adult and older adult caregivers providing care to a family member (spouse and parents) affected by chronic physical, mental health or memory problems. The current design of the JOC is a series of three classes (90 minutes per weekly class) developed in response to a need among older VA caregivers at the FCRC for a language-specific, brief psychosocial intervention tailored to their caregiving experiences. The social workers at the FCRC utilized resources and their expertise to create the content of the JOC, divided into the following three segments aimed to increase the caregivers’ well-being and resiliency: 1) caregivers’ knowledge about caregiving and resources; 2) caregivers’ communication with the care recipient and family members; 3) coping strategies with a focus on self-care and stress management. The FCRC has delivered JOC in a series of classes to over 20 VA caregivers (ages ranging from 50s to 70s) in the past year, yet it has not been evaluated for acceptability and feasibility or for translation accuracy, nor has feedback been requested from the VA caregivers regarding the JOC’s cultural and linguistic appropriateness for this population. Therefore, the overall goal of this proposed study is to conduct this needed evaluation and to refine this novel intervention to enhance its cultural and acceptability for VA caregivers age 55 and older. Further, focus groups will be conducted with Cambodian and Thai caregivers to assess for the feasibility and acceptability of the intervention with these subgroups. This is a critical and important step first step toward a larger research to adapt the JOC intervention for older adult caregivers in Southeast Asian communities.