Identifying and Addressing the Culturally Specific Prenatal Health Needs and Concerns of Pregnant Chinese-American Immigrants

ABSTRACT

The United States, despite its relative wealth, ranks 28th among 37 industrialized nations in rates of infant mortality, and wide disparities in infant mortality persist across geographic regions and different racial/ethnic groups. Chinese Americans make up one of the fastest growing immigrant groups, and nearly one-half of Chinese households in the United States have no adults who speak English well. This burgeoning immigrant community, due to cultural, linguistic, educational, or financial barriers, lacks access to basic health care services and health education. Our collaboration – between a nonprofit focusing on prenatal health literacy and a community health center primarily serving Asian immigrants – sought to address this need by producing a Chinese-language version of Baby Basics, a prenatal health guide written at a 3rd and 5th grade level and targeting at-risk pregnant women. This valuable prenatal health tool offers an underserved population information, education, skills, support and resources to help to improve pregnancy outcomes and maternal health, as well as create more activated patients by increasing health literacy and helping them to become more capable navigators of the American health care system. The translation project provides a lens through which we can examine linguistic and cultural influences on health materials and explore the culture of pregnancy that Chinese immigrants bring to this country. Through this process, we have uncovered many lessons learned about how to collaborate with community based health providers, identify and honor cultural differences between groups, and appropriately meet the needs and priorities of a vulnerable population.

Summary

Background

The United States, despite its relative wealth, ranks 28th among 37 industrialized nations in rates of infant mortality. Wide disparities in infant mortality persist across geographic regions and different racial/ethnic groups. Perhaps not unrelated, over 50 million Americans read below the 5th grade level. Studies by UNICEF and UNESCO indicate a clear correlation between a mother's literacy level and birth outcomes. The majority of expecting parents served by such entitlement programs as Medicaid and Healthy Families do not have the reading, writing and English language skills to effectively understand or follow-through on prenatal health care information. A significant and growing percentage of these individuals are Asian American immigrants.

According to the 2000 U.S. Census, in 1999, the largest Asian ethnic group in New York City was Chinese, with a population increase of 61% from 1990. Fifty-two percent of Asian American mothers who gave birth in New York City were on Medicaid. Nearly one-half of Chinese households in the United States have no adults who speak English well. This burgeoning immigrant community, due to cultural, linguistic, educational, or financial barriers, lacks access to basic health care services and health education. Ironically, Asian Americans are often perceived as the “model minority”: the misconception that Asian populations have excellent health status, resulting from the lack of Asian American representation in research and the lack of available data on Asian health disparities. In fact, the Asian community faces a myriad of health, social and literacy concerns, including:

- Asian Americans are twice as likely to be poor as non-Hispanic whites.

- The illiteracy rate of Asian Americans is 5.3 times that of non-Hispanic whites.

- 14 percent of Asian Americans live below the poverty line, compared to 13 percent of the U.S. population.

- Every hour, an Asian American baby is born to a mother who had late or no prenatal care.

- Every 45 minutes, an Asian American baby is born at low birth weight

- Every hour, an Asian American baby is born to a teen mother

Prenatal care is, for many women, the entry point into our healthcare system. For some expectant women, the initial prenatal appointment is the first time she will, as an adult, visit a doctor. Pregnancy is not only a crucial health moment, but also a “teachable moment.” Pregnant women are eager to learn and are receptive to tools, strategies, and support that will help them do the best for their baby. Yet, women at-risk for poor pregnancy outcomes -- who need that information the most -- are the least likely to receive it. Pregnant women need appropriate information and materials, and the support needed to read and act upon these materials.

The Baby Basics Program

The cornerstone of the Baby Basics program is "Baby Basics: Your Month By Month Guide To A Healthy Pregnancy," a much-lauded, extensively researched, innovative prenatal guide/health literacy tool that is written to both a 3rd and 5th grade level. A publication of the What To Expect Foundation (WTEF), the book addresses the medical, social, economic, cultural, and linguistic concerns of pregnant women living at or below the poverty level.

Since the book's publication in 2002, close to 200,000 copies of Baby Basics have been provided to low-income pregnant women across the country. In 2006, WTEF received a grant from the United Hospital Fund and collaborated with the Charles B. Wang Community Health Center (CBWCHC) to create a culturally and linguistically rigorous Chinese translation of "Baby Basics," renamed "Xiao Bao Bao." CBWCHC is well known in New York City for its strong ties to the Chinese community. It is the preeminent and trusted provider of health services to the Chinese immigrant community, including the complete range of health care services, referrals, health education programs, social services, and assistance with insurance and entitlement programs. The health education team has the goal to improve the health literacy of the community, and CBWCHC saw this project as an exciting way to meet this goal and to more effectively reach a vital part of its population. "Xiao Bao Bao" -- much-needed and long-awaited -- has been met with great enthusiasm from healthcare leaders in Chinese American communities.

The book is the centerpiece of the Baby Basics program, which aims to: give providers the tools and strategies to integrate the latest research in health literacy and cultural competency into their daily practice; coordinate the message so that everyone (from the health center, to the WIC educator, to the home visitor) teaches from the same materials to provide a patient centered program; bring adult literacy/English as a Second Language's model of navigating systems, vocabulary and skill building to prenatal care in order to empower a pregnant woman to access, understand and act upon healthcare information and have a healthier pregnancy outcome. WTEF has piloted this work among multiple prenatal healthcare providers in New York and nationwide.

Translation Process

The project relied on a strong, communicative collaboration between WTEF and CBWCHC, which prioritized a translation process that paid careful attention to the cultural and linguistic differences – and similarities – between English-speaking Americans and Chinese-speaking immigrants to America.

In order to create a linguistically and culturally sound Chinese translation of Baby Basics, we undertook several activities, the first of which was to assess the cultural needs and concerns of the target population. How do the cultural needs and concerns of the underserved, pregnant Chinese women and men in New York City vary from those of the Hispanic and native English speaking audiences (as reflected in "Baby Basics" and "Hola Bebe," our Spanish translation)? Through focus groups, “gripe groups” and contributions from CBWCHC's Chinese staff, we collected necessary culturally sensitive health information, myths and first person narrative, as well as illustration and photography, to integrate into Baby Basics' existing medical content.

One signature feature of the Baby Basics books is the first person narrative section, which includes stories based on real people and real experiences. CBWCHC brought together groups of pregnant women and new mothers – all native Chinese speakers -- to talk, complain and laugh about their pregnancy concerns. These sessions were turned into stories by a talented writer who was able to capture the essence of their voices and maintain the flavor of Chinese language and culture. The stories reflect real problems and concerns faced by Chinese American immigrants. For example, many new immigrant mothers in New York City choose to send their newborns home to China to be raised by the grandparents, while the young mother stays in the U.S. and works full-time. One of the book's stories represents a woman who is grappling with the decision to send her baby home. In another story, a character muses about the kinds of food she is told she must eat by her Chinese elders, reflecting the fact, brought out in gripe groups, that many Chinese immigrant women observe numerous restrictions on diet and activity leading up to birth and following the baby's arrival.

Before completing the translation, we asked our advisory board for comments, edits, questions and feedback on the original English version of Baby Basics. The nationally-representative board included health providers and experts (leading OB-Gyns, Social Workers, Nurses, Home Visitors and mothers) who primarily serve Chinese American immigrants and/or were themselves of Chinese descent.

Once the key cultural information was gathered and edits were compiled, WTEF and CBWCHC began translating the English language book. The team relied on the skills and experience of CBWCHC's health education division, which produces culturally competent medical translations (the team has developed English-Chinese bilingual health education materials on more than 200 health care topics). Our Advisory Board, other CBWCHC staff, and representatives of the Chinese community reviewed the first manuscript and evaluated it for cultural and linguistic appropriateness.

Conclusion

"Xiao Bao Bao" is a new and valuable prenatal health/health literacy tool which offers an underserved population information, education, skills, support and resources to help to improve pregnancy outcomes and maternal health, as well as create more activated patients by increasing health literacy and helping them to become more capable navigators of the American health care system. The translation project also provides a lens through which we can examine the process of completing a linguistic and cultural translation of health materials into a new language. Through this process, we have identified a Chinese immigrant “culture of pregnancy” that will help all providers that serve this population understand how best to serve this new immigrant group. This program has also uncovered many lessons learned about how to collaborate with community based health providers, identify and honor cultural differences between groups, and appropriately meet the needs and priorities of a vulnerable population.