Journal of Community Health

, Volume 41, Issue 4, pp 741–752 | Cite as

Healthcare Communication Barriers and Self-Rated Health in Older Chinese American Immigrants

  • Janice Y. TsohEmail author
  • Tetine Sentell
  • Ginny Gildengorin
  • Gem M. Le
  • Elaine Chan
  • Lei-Chun Fung
  • Rena J. Pasick
  • Susan Stewart
  • Ching Wong
  • Kent Woo
  • Adam Burke
  • Jun Wang
  • Stephen J. McPhee
  • Tung T. Nguyen
Original Paper


Older Chinese immigrants are a growing population in the United States who experience multiple healthcare communication barriers such as limited English proficiency and low health literacy. Each of these obstacles has been associated with poor health outcomes but less is known about their effects in combination. This study examined the association between healthcare communication barriers and self-rated health among older Chinese immigrants. Cross-sectional survey data were obtained from 705 Chinese American immigrants ages 50–75 living in San Francisco, California. Communication barriers examined included spoken English proficiency, medical interpreter needs, and health literacy in written health information. The study sample (81 % females, mean age = 62) included 67 % who spoke English poorly or not at all, 34 % who reported needing a medical interpreter, and 37 % who reported “often” or “always” needing assistance to read health information. Two-thirds reported poor self-rated health; many reported having access to racial-concordant (74 %) and language-concordant (86 %) healthcare services. Both poor spoken English proficiency and low health literacy were associated with poor self-rated health, independent of other significant correlates (unemployment, chronic health conditions, and having a primary doctor who was ethnic Chinese). Results revealed that spoken English proficiency and print health literacy are independent communication barriers that are directly associated with health status among elderly Chinese American immigrants. Access to racial- or language-concordant health care services did not appear to resolve these barriers. These findings underscore the importance of addressing both spoken and written healthcare communication needs among older Chinese American immigrants.


Communication barriers Health literacy Limited English proficiency Health status Immigrant health 



The authors wish to express their gratitude to Corina Liew, Christina Nip, Ying Wang, and Hy Lam; the Sức Khỏe Là Vàng!—UCSF Vietnamese Community Health Promotion Project; and the Asian American Network for Cancer Awareness, Research and Training-San Francisco (SF-ANNCART) for their valuable contributions in data collection and study implementation.


This research was supported by the National Cancer Institute (5R01CA138778, PI: Nguyen, T). Additional support was provided by the National Cancer Institute’s Center to Reduce Cancer Health Disparities through Grant 1U54153499 to the Asian American Network for Cancer Awareness, Research, and Training. The content is solely the responsibility of the authors and does not reflect the official views of the funders.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Standard

The Institutional Review Boards of the University of California San Francisco and San Francisco State University approved all study procedures.


  1. 1.
    Agency for Healthcare Research and Quality. (2010). Chapter 4: Defining Language Need and Categories for Collection. In Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement (Publication # 10-0058-EF ed.). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from
  2. 2.
    Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1–10.CrossRefPubMedGoogle Scholar
  3. 3.
    Baker, D. W. (2006). The meaning and the measure of health literacy. Journal of General Internal Medicine, 21(8), 878–883. doi: 10.1111/j.1525-1497.2006.00540.x.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Derose, K. P., Gresenz, C. R., & Ringel, J. S. (2011). Understanding disparities in health care access—and reducing them—through a focus on public health. Health Affairs (Millwood), 30(10), 1844–1851. doi: 10.1377/hlthaff.2011.0644.CrossRefGoogle Scholar
  5. 5.
    Green, A. R., Ngo-Metzger, Q., Legedza, A. T., Massagli, M. P., Phillips, R. S., & Iezzoni, L. I. (2005). Interpreter services, language concordance, and health care quality. Experiences of Asian Americans with limited English proficiency. Journal of General Internal Medicine, 20(11), 1050–1056. doi: 10.1111/j.1525-1497.2005.0223.x.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Ho, S. C. (1991). Health and social predictors of mortality in an elderly Chinese cohort. American Journal of Epidemiology, 133(9), 907–921.PubMedGoogle Scholar
  7. 7.
    Hoeffel, E. M., Rastogi, S., Kim, M. O., & Shahid, H. (2012). The Asian Population: 2010. In U.S. Department of Commerce (Ed.) 2010 Census briefs. Retrieved from
  8. 8.
    Hosmer, D. W., & Lemeshow, S. (1989). Applied logistic regression. New York: Wiley.Google Scholar
  9. 9.
    Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38(1), 21–37.CrossRefPubMedGoogle Scholar
  10. 10.
    Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, DC: National Academics Press.Google Scholar
  11. 11.
    Jacobs, R. J., Lou, J. Q., Ownby, R. L., & Caballero, J. (2014). A systematic review of eHealth interventions to improve health literacy. Health Informatics Jounal [Epub ahead of print]. doi: 10.1177/1460458214534092.Google Scholar
  12. 12.
    Jylha, M. (2009). What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Social Science and Medicine, 69(3), 307–316. doi: 10.1016/j.socscimed.2009.05.013.CrossRefPubMedGoogle Scholar
  13. 13.
    Kim, G., Worley, C. B., Allen, R. S., Vinson, L., Crowther, M. R., Parmelee, P., & Chiriboga, D. A. (2011). Vulnerability of older Latino and Asian immigrants with limited English proficiency. Journal of the American Geriatrics Society, 59(7), 1246–1252. doi: 10.1111/j.1532-5415.2011.03483.x.CrossRefPubMedGoogle Scholar
  14. 14.
    Kimbro, R. T., Gorman, B. K., & Schachter, A. (2012). Acculturation and self-rated health among Latino and Asian immigrants to the United States. Social Problems, 59(3), 341–363.CrossRefGoogle Scholar
  15. 15.
    Krochalk, P. C., Li, Y., & Chi, I. (2008). Widowhood and self-rated health among Chinese elders: The effect of economic condition. Australas Journal Ageing, 27(1), 26–32. doi: 10.1111/j.1741-6612.2007.00269.x.CrossRefGoogle Scholar
  16. 16.
    Lee, H. Y., Rhee, T. G., Kim, N. K., & Ahluwalia, J. S. (2015). Health literacy as a social determinant of health in Asian American immigrants: findings from a population-based survey in California. Journal of General Internal Medicine, 30(8), 1118–1124. doi: 10.1007/s11606-015-3217-6.CrossRefPubMedGoogle Scholar
  17. 17.
    Leung, A. Y., Bo, A., Hsiao, H. Y., Wang, S. S., & Chi, I. (2014). Health literacy issues in the care of Chinese American immigrants with diabetes: A qualitative study. BMJ Open, 4(11), e005294. doi: 10.1136/bmjopen-2014-005294.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Leung, K. K., Tang, L. Y., & Lue, B. H. (1997). Self-rated health and mortality in Chinese institutional elderly persons. Journal of Clinical Epidemiology, 50(10), 1107–1116.CrossRefPubMedGoogle Scholar
  19. 19.
    Liao, Y., Bang, D., Cosgrove, S., Dulin, R., Harris, Z., Taylor, A., et al. (2011). Surveillance of health status in minority communities—Racial and Ethnic Approaches to Community Health Across the U.S. (REACH U.S.) Risk Factor Survey, United States, 2009. MMWR Surveillance Summaries, 60(6), 1–44.Google Scholar
  20. 20.
    Lor, M., Xiong, P., Schwei, R. J., Bowers, B. J., & Jacobs, E. A. (2015). Limited English proficient Hmong- and Spanish-speaking patients’ perceptions of the quality of interpreter services. International Journal of Nursing Studies [Epub ahead of print]. doi: 10.1016/j.ijnurstu.2015.03.019.PubMedGoogle Scholar
  21. 21.
    Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The single item literacy screener: Evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7, 21. doi: 10.1186/1471-2296-7-21.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Nguyen, B. H., McPhee, S. J., Stewart, S. L., & Doan, H. T. (2008). Colorectal cancer screening in Vietnamese Americans. Journal of Cancer Education, 23(1), 37–45. doi: 10.1080/08858190701849395.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Nguyen, B. H., Stewart, S. L., Nguyen, T. T., Bui-Tong, N., & McPhee, S. J. (2015). Effectiveness of lay health worker outreach in reducing disparities in colorectal cancer screening in Vietnamese Americans. American Journal of Public Health, 105(10), 2083–2089. doi: 10.2105/AJPH.2015.302713.CrossRefPubMedGoogle Scholar
  24. 24.
    Nguyen, T. T., Love, M. B., Liang, C., Fung, L. C., Nguyen, T., Wong, C., et al. (2010). A pilot study of lay health worker outreach and colorectal cancer screening among Chinese Americans. Journal of Cancer Education, 25(3), 405–412. doi: 10.1007/s13187-010-0064-3.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Pew Social & Demographic Trends. (2012). The rise of Asian Americans. Retrieved from
  26. 26.
    Ponce, N. A., Hays, R. D., & Cunningham, W. E. (2006). Linguistic disparities in health care access and health status among older adults. Journal of General Internal Medicine, 21(7), 786–791. doi: 10.1111/j.1525-1497.2006.00491.x.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Powers, B. J., Trinh, J. V., & Bosworth, H. B. (2010). Can this patient read and understand written health information? JAMA, 304(1), 76–84. doi: 10.1001/jama.2010.896.CrossRefPubMedGoogle Scholar
  28. 28.
    Remler, D. K., Teresi, J. A., Weinstock, R. S., Ramirez, M., Eimicke, J. P., Silver, S., & Shea, S. (2011). Health care utilization and self-care behaviors of Medicare beneficiaries with diabetes: Comparison of national and ethnically diverse underserved populations. Population Health Management, 14(1), 11–20. doi: 10.1089/pop.2010.0003.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Sentell, T., & Braun, K. L. (2012). Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California. Journal Health Communication, 17(Suppl 3), 82–99. doi: 10.1080/10810730.2012.712621.CrossRefPubMedGoogle Scholar
  30. 30.
    Sentell, T. L., Tsoh, J. Y., Davis, T., Davis, J., & Braun, K. L. (2015). Low health literacy and cancer screening among Chinese Americans in California: A cross-sectional analysis. BMJ Open, 5(1), e006104. doi: 10.1136/bmjopen-2014-006104.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Simon, M. A., Li, Y., & Dong, X. (2014). Levels of health literacy in a community-dwelling population of Chinese older adults. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 69(Suppl 2), S54–S60. doi: 10.1093/gerona/glu179.CrossRefGoogle Scholar
  32. 32.
    Teh, J. K., Tey, N. P., & Ng, S. T. (2014). Ethnic and gender differentials in non-communicable diseases and self-rated health in Malaysia. PLoS ONE, 9(3), e91328. doi: 10.1371/journal.pone.0091328.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Todorova, I. L., Tucker, K. L., Jimenez, M. P., Lincoln, A. K., Arevalo, S., & Falcon, L. M. (2013). Determinants of self-rated health and the role of acculturation: Implications for health inequalities. Ethnicity and Health, 18(6), 563–585. doi: 10.1080/13557858.2013.771147.CrossRefPubMedGoogle Scholar
  34. 34.
    U.S. Bureau of the Census. (2014). 20112013 3-year American community survey. Retrieved from
  35. 35.
    U.S. Bureau of the Census. (2015). Annual estimates of the resident population by Sex, race alone or in combination, and Hispanic origin for the United States, States, and counties: April 1, 2010 to July 1, 2014. Retrieved from
  36. 36.
    Viswanathan, M., Kraschnewski, J. L., Nishikawa, B., Morgan, L. C., Honeycutt, A. A., Thieda, P., et al. (2010). Outcomes and costs of community health worker interventions: A systematic review. Medical Care, 48(9), 792–808. doi: 10.1097/MLR.0b013e3181e35b51.CrossRefPubMedGoogle Scholar
  37. 37.
    Viswanathan, M., Kraschnewski, J., Nishikawa, B., Morgan, L. C., Thieda, P., Honeycutt, A., Lohr, K. N., & Jonas, D. (2009). Outcomes of community health worker interventions. Evid Rep Technol Assess (Full Rep)(181), 1–144, A141-142, B141-114, passim.Google Scholar
  38. 38.
    Zack, M. M. (2013). Health-related quality of life—United States, 2006 and 2010. MMWR Surveillance Summaries, 62(Suppl 3), 105–111.Google Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Janice Y. Tsoh
    • 1
    • 2
    Email author
  • Tetine Sentell
    • 3
  • Ginny Gildengorin
    • 4
  • Gem M. Le
    • 2
    • 4
  • Elaine Chan
    • 1
  • Lei-Chun Fung
    • 6
  • Rena J. Pasick
    • 2
    • 7
  • Susan Stewart
    • 8
  • Ching Wong
    • 4
  • Kent Woo
    • 5
  • Adam Burke
    • 2
    • 9
  • Jun Wang
    • 2
    • 10
  • Stephen J. McPhee
    • 4
  • Tung T. Nguyen
    • 2
    • 4
  1. 1.Department of PsychiatryUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Asian American Research Center for Health (ARCH)San FranciscoUSA
  3. 3.Office of Public Health StudiesUniversity of Hawaii at ManoaHonoluluUSA
  4. 4.Department of Medicine, Division of General Internal MedicineUniversity of CaliforniaSan FranciscoUSA
  5. 5.NICOS Chinese Health CoalitionSan FranciscoUSA
  6. 6.Health Education DepartmentChinatown Public Health CenterSan FranciscoUSA
  7. 7.University of California, San Francisco, Helen Diller Family Comprehensive Cancer CenterSan FranciscoUSA
  8. 8.Division of BiostatisticsUniversity of CaliforniaDavisUSA
  9. 9.Health Education/Holistic Health StudiesSan Francisco State UniversitySan FranciscoUSA
  10. 10.Academy of Chinese Culture and Health SciencesOaklandUSA

Personalised recommendations