Social Science & Medicine 168 (2016) 93e100
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
First-generation Korean immigrants’ barriers to healthcare and their coping strategies in the US Sou Hyun Jang City University of New York (CUNY), Graduate Center, Department of Sociology, 365 Fifth Ave, New York, NY 10016, United States
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 January 2016 Received in revised form 29 August 2016 Accepted 7 September 2016 Available online 8 September 2016
This paper examines first-generation Korean immigrants' barriers to healthcare in the US and their strategies for coping with these issues by analyzing survey data from 507 Korean immigrants and indepth interviews with 120 Korean immigrants in the New York-New Jersey area. It reports that more than half of Korean immigrants have barriers to healthcare in the US, with the language barrier being the most frequent response, followed by having no health insurance. Korean immigrants are not passive, but rather active entities who display coping strategies for these barriers, such as seeing co-ethnic doctors in the US, seeking Hanbang (traditional Korean medicine) in the US, and taking medical tours to the home country. However, their coping strategies are far removed from formal US healthcare as their behaviors are still restricted to the informal healthcare within the ethnic community or home country. This study methodologically and theoretically contributes to the literature on immigrants’ healthcare behaviors by using a mixed-method approach and developing a specific framework for one particular immigrant group. © 2016 Elsevier Ltd. All rights reserved.
Keywords: United States Mixed-method approach Korean immigrants New York-New Jersey Korean community Barriers to healthcare utilization Co-ethnic doctors Hanbang Medical tourism
1. Introduction Since the 1980s, Asian Americans have been portrayed as a “model minority” by the media and scholars, particularly for their higher educational attainment than the general population in the United States (US) (Chen, 2010; Osajima, 2005; Poon et al., 2015; Suzuki, 1977). However, despite their image of having higher socioeconomic status, Asian Americans fall behind non-Hispanic whites in health fields, including health insurance rates and healthcare utilization rates (Brown et al., 2000; De Alba et al., 2005; Smith and Medalia, 2014; Stella et al., 2004). Moreover, when foreign-born Asians are analyzed separately from US-born Asians, they show even lower rates of health insurance and healthcare utilization than their US-born counterparts and non-Hispanic whites (Brown et al., 2000; Stella et al., 2004). Korean Americans are not an exception to this model minority myth, particularly in health fields. For example, they have lower health insurance rates (Anderson and Bulatao, 2004; Huang, 2013), which has a negative effect on their healthcare utilization in the US
E-mail address: [email protected]. http://dx.doi.org/10.1016/j.socscimed.2016.09.007 0277-9536/© 2016 Elsevier Ltd. All rights reserved.
(Derose et al., 2007, 2009; Jang et al., 2005; Ryu et al., 2001). According to the 2009e2011 American Community Survey (ACS) data, about 74% of foreign-born Koreans are insured while 89% of USborn non-Hispanic whites are insured. When compared to other Asian groups, Korean immigrants are still more likely to be uninsured than other Asian immigrant groups (Carrasquillo et al., 2000; Ryu et al., 2001). Analysis of the ACS data confirms that foreignborn Chinese (83%), foreign-born Indians (89%), and foreign-born Filipinos (89%) show higher insured rates than Korean immigrants. In addition to the uninsured status, Korean immigrants' language difficulty is a significant barrier to access to healthcare. For example, some studies have found a negative association between Korean immigrants’ poor English proficiency and their healthcare utilization in the US (De Gagne et al., 2014; Juon et al., 2000). Despite Korean immigrants' barriers to formal healthcare in the US, most earlier studies have focused on explaining the barriers themselves rather than examining how Koreans behave to cope with the barriers. Moreover, previous studies have used either quantitative data or qualitative data to examine Korean immigrants' healthcare behaviors in the US. Thus, using a mixed-method approach, this paper intends to bridge the gap in research on
94
S.H. Jang / Social Science & Medicine 168 (2016) 93e100
Korean immigrants' healthcare utilization and their coping strategies. Traditionally, the term coping strategy has been widely used in the field of psychology, to refer to an effort to solve problems and minimize stress (Lazarus and Folkman, 1984; Zeidner and Endler, 1996). However, in this paper, coping strategy will be construed as immigrants’ behavioral strategies to cope with their barriers to formal healthcare in the destination country, as in previous studies on minority health (Torsch and Ma, 2000; Portes et al., 2012). This paper has five main objectives. First, it examines Korean immigrants' barriers to formal healthcare in the US. Second, it identifies Korean immigrants' various strategies to cope with these barriers, and determines whether different types of coping strategies are associated with different barriers. Third, it investigates whether their coping strategies are inter-related. Fourth, it tests to see whether the previous model of immigrants' coping strategies with respect to healthcare (e.g. Portes et al., 2012) applies to Korean immigrants. Last, based on the findings, it develops a particular framework for Korean immigrants’ strategies to cope with healthcare barriers in the US. 2. Literature review Scholars have commonly pointed out three types of barriers to immigrants' healthcare utilization: structural, financial, and personal. First, structural barriers include limited chances to meet doctors who share the same culture, language, and race/ethnic background. An individual is more likely to choose a doctor of the individual's same race or ethnicity (Gray and Stoddard, 1997; LaVeist and Nuru-Jeter, 2002; Saha et al., 2000), and to feel higher satisfaction with the doctor-patient relationship if the doctor and patient share the same culture and language (LaVeist and Nuru-Jeter, 2002; Saha et al., 2000). However, most immigrants have fewer chances to meet doctors who share their language or culture than native-born white Americans due to the small number of immigrant doctors; this circumstance may lead to misunderstanding and frustration for them (Kraut, 1990; LaVeist et al., 2003; LaVeist and Nuru-Jeter, 2002; Takada et al., 1998). Structural barriers also include geographic proximity to hospitals, locations of hospitals, and access to public or private transportation to hospitals. In addition to these structural barriers, financial barriers to immigrants' healthcare include poverty, lack of financial resources, and lack of health insurance. Many scholars have found that immigrants' uninsured status plays a negative role in their access to healthcare (Derose et al., 2007, 2009; Jang et al., 2005; Yoo and Kim, 2008). Moreover, personal barriers, such as the level of acculturation (Abraido-Lanza et al., 2005; Arcia et al., 2001; Gorman et al., 2010; Salant and Lauderdale, 2003), perceived discrimination (Jang et al., 2005; Viruell-Fuentes, 2007; Yoo et al., 2009), limited language proficiency (Hu and Covell, 1986; Jang et al., 2005; Kim et al., 2011; Wu et al., 2009), and cultural differences (Jenkins et al., 1996; Kung, 2004; Wu et al., 2009) have been associated with lack of access to healthcare. In particular, previous studies have found that culture and language have a big impact in the provision of health care, such as the doctor-patient relationship (Ferguson and Candib, 2002; Flores, 2000; LaVeist and Nuru-Jeter, 2002) and the use of complementary and alternative medicine (Bodeker and Kronenberg, 2002; Hsiao et al., 2006; Kronenberg et al., 2006; Ma, 1999), especially among minority patients. For example, reviewing articles published from 1966 through 2000, Ferguson and Candib (2002) found that it is more difficult for minority patients to build rapport with doctors and to receive empathic responses from them
due to doctors' lack of cultural competence and minority patients’ limited English proficiency. Ma (1999) also found that Asian immigrants, including Chinese immigrants, tend to hesitate to openly discuss their cultural practices with Western doctors, making cultural competence one of their major barriers to healthcare. Consequently, Chinese immigrants look for co-ethnic doctors or use practitioners of traditional Chinese medicine. To cope with these structural, financial, and personal barriers to formal healthcare in the US, immigrants display several behavioral strategies. First, going to free clinics or community health centers has been used as a coping strategy, especially among undocumented or uninsured immigrants, because these clinics offer free (albeit limited) medical care without asking about patients’ legal status or insured status (Kamimura et al., 2013; Okie, 2007; Portes et al., 2012). Second, immigrants often seek co-ethnic doctors, especially when they have language barriers, cultural barriers, or limited knowledge of Western medicine (Choi, 2013; Wang, 2007; Wang et al., 2008; Zhang and Verhoef, 2002). Previous studies have pointed out that Asian Americans with limited English proficiency are more likely to see co-racial doctors (LaVeist and Nuru-Jeter, 2002), and Korean immigrants prefer Korean doctors, mostly due to the language barrier (Choi, 2013; De Gagne et al., 2014; Son, 2013). Using complementary and alternative medicine (CAM) is another coping behavior among immigrants. Although the use of this informal type of medical care is related to a group's own culture (Hsiao et al., 2006), immigrants who have barriers to formal healthcare are still more likely to use CAM (Akresh, 2009; Han, 2001; Hill et al., 2006; Kim and Chan, 2004; Portes et al., 2012; Pourat et al., 1999; Wu et al., 2007). Some Korean immigrants also utilize Hanbang, a non-Western form of Korean traditional medicine. Hanbang is known by various names, including CAM, traditional medicine, oriental medicine, and folk medicine. Han (2001, p. 146) defines it as traditional medicine that “originated in China and indigenized in Korea.” According to Hill et al. (2006), a significant proportion of Korean immigrants (23% of males and 29% of females) have used traditional remedies as a healthcare option in California. Korean immigrants' use of Hanbang is associated with barriers to formal healthcare, such as the language barrier, a low level of acculturation, and uninsured status (Han, 2001; Hill et al., 2006). The last distinctive coping strategy is returning to the home country to seek medical care. Scholars have found that some Mexican immigrants take medical tours to the home country due to the lack of health insurance in the US (Bastida et al., 2008; Bergmark et al., 2010; Brown, 2008). For Korean immigrants, cultural and language barriers, lack of health insurance or limited coverage, and having to take long domestic trips to see Korean doctors within the US have contributed to their decision to engage in medical tourism (Lee et al., 2010; Oh et al., 2014; Wang and Kwak, 2015). Considering different types of barriers, and especially responding behaviors, Portes et al. (2012) established a framework for immigrants' coping strategies. According to their categorization, four major coping behaviors are based on different types of barriers and situations. First, when immigrants have cultural-linguistic barriers, they tend to see co-ethnic healthcare professionals. Second, when immigrants are uninsured, they are likely to seek folk medicine or see unlicensed doctors. Third, if newcomers cannot access federal health programs, such as Medicaid and Medicare, they tend to go back to the home country for medical care or use free clinics. Last, undocumented immigrants tend to seek folk
S.H. Jang / Social Science & Medicine 168 (2016) 93e100
healers, go to free clinics, or receive drugs from the home country. Since no theory exists to explain how immigrants respond to their barriers to healthcare utilization, Portes and his associates’ approach will be used as the conceptual framework in this paper. Its applicability will be tested, and it will be compared to a particular framework for Korean immigrants. 3. Data and methods This study employed a mixed-method approach, with both quantitative and qualitative data. First, it analyzed the survey data of 507 Korean immigrants. The participantsdfirst-generation Korean immigrant adults 18 years and olderdwere recruited in the New York-New Jersey area from Korean ethnic churches, ethnic community centers, and ethnic events, such as the Korean Parade in Manhattan and the Korean Thanksgiving and Folklore Festival in Queens between fall 2013 and spring 2014. This paper used nonprobability sampling techniques because it was not feasible to secure a list of all Korean immigrants in the New York-New Jersey area. A quota sampling technique was used to select participants by gender, educational level, class of work, age, and religious background to match the demographic, socioeconomic, and religious characteristics of first-generation Korean immigrants (those who came to the US at age 13 or older). The survey questionnaire used in this study had approximately 40 items, asking about respondents' demographic and socioeconomic characteristics, immigration history, barriers to US healthcare utilization, health insurance status, and other health-related issues. The survey questionnaire also asked whether they had ever visited the home country for medical care. The survey was selfadministered and paper-based. On average, respondents took about 20 min to complete the survey, and no monetary reward was offered to the respondents. All answers from the survey data were coded and analyzed by the author using Stata 13. A chi-squared test was conducted to examine the association between firstgeneration Korean immigrants’ barriers to healthcare and their coping behaviors. Second, this paper analyzed the qualitative data from 120 indepth interviews. A small number of survey respondents was willing to respond to further open-ended questions immediately following the survey. However, the majority of survey participants refused to do so. Since it was hard to find a sufficient number of interviewees through the survey, a snowball sampling technique was used to recruit more informants. A small number of initial interviewees was recruited at Korean ethnic churches and Korean community centers in the New York-New Jersey area. Each in-depth interview took about 30 min to an hour to complete. All interviews were audio-recorded and transcribed in Word 2013. Every name appearing in this paper was a pseudonym. The qualitative data was analyzed manually instead of using a software program. Contents of in-depth interviews were categorized by assigning a number to important keywords, such as language barrier, health insurance, and co-ethnic doctor, then analyzed by keyword and the interviewee's sociodemographic characteristics. Third, the 2009e2011 ACS data were analyzed to compare the health insurance rates of Korean immigrants to that of other Asian immigrant groups and US-born non-Hispanic whites. Last, the business directory published by the Korea Daily in 2014 was used to examine the number of Korean medical and dental offices and Hanbang offices. This study conformed to ethical requirements for using human research subjects and was approved by the Institutional Review Board (IRB) of the City University of New York (CUNY). Before conducting the survey and in-depth interviews, an interviewer orally informed potential participants about the purpose and significance of the study and that their participation
95
carried minimal risk to them. Survey respondents and interviewees were also told that their participation was voluntary and they could withdraw from the study at any time. 4. Findings 4.1. Barriers to healthcare in the US More than half of survey respondents answered that they had at least one barrier to formal US healthcare. Fifteen percent of all survey respondents who had received medical care in the US reported that they encountered more than two barriers. The two most frequently cited combinations of barrier were the language barrier and having no insurance, followed by the language barrier and cultural differences. Table 1 shows that about one-third of the survey respondents experienced a language barrier in obtaining healthcare in the United States. Ten percent reported speaking English very well, and more than half said they spoke very little or no English. Thus, it is not surprising that more than one-third of the survey respondents reported that they experienced a language barrier when they received medical care in the US. In addition to the language barrier, survey respondents pointed out other barriers, such as immigrants' uninsured status, cultural differences, and perceived racial discrimination. A few survey respondents indicated additional obstacles, such as having difficulty in making appointments, long wait times, complicated referral processes, and poor medical equipment at doctors’ offices or other medical facilities. Analysis of the in-depth interviews revealed three types of language barriers in healthcare: (1) difficulty in understanding medical terminology in English, (2) difficulty in describing symptoms in English, and (3) difficulty in communicating with nonKorean doctors. The first two types have a linguistic aspect itself as a barrier. In contrast, the last type emphasizes an interpersonal aspect and is related to immigrants’ preference for co-ethnic doctors. Thus, this will be discussed in the next section. First, some interviewees reported that it was hard for them to understand difficult medical terminology in English. They were anxious about their inability to understand English medical terminology at hospitals, and their anxiety often led them to choose co-ethnic doctors. Second, for some Korean immigrants, the ability to describe their symptoms in English was limited. In their view, due to their limited English, they did not know enough English adjectives or other words to accurately describe their pain. For example, Min-Seok Kim, a middle-aged employee at a Korean community center, explained that he knew various adjectives to describe pain in Korean. Additionally, many Korean-language phrases or words used to describe certain kinds of pain or other symptoms simply do not have direct English translations. However, since he knew only one
Table 1 Types of Korean immigrants’ barriers to healthcare in the US. Barriers
N
%
No barriers Language barriers Having no insurance Cultural differences Other barriers Total
205 158 113 45 25 546
44.5 34.3 24.5 9.8 5.5 118.6
Source: Survey of 507 Korean immigrants in the New York-New Jersey area. Note: Respondents who had never received medical care in the US were excluded from this analysis (N ¼ 461). Since several respondents (N ¼ 73) gave multiple answers, the sum of the responses exceeds 100%. Survey question: “Please indicate below which describes any barriers or difficulties you have when you utilize healthcare in the U.S. (select one or more if applicable).”
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worddpaindto describe his discomfort in English, it was hard for him to elaborate on his pain to American doctors. Since Korean doctors understood his expressions or descriptions right away, he preferred to see Korean doctors or return to Korea for medical care. About a quarter of survey respondents answered that their uninsured status in the US was a major obstacle to their healthcare utilization. Since they had lived in Korea, which offers very affordable insurance for all people, many of them revealed their hesitance to pay for more expensive health insurance in the US. For example, a 40-year-old non-smoker who earns $30,000 a year will pay about $4,500 a year ($372 per month for 12 months ¼ $4,464) for the second lowest cost plan in New York state (Cox et al., 2015). In contrast, an employee in Korea who earns about $30,000 pays only about $1,800 annually for his/her health insurance, as the health-insurance contribution rate is only about 6% of his/her salary (Song, 2009). Korean immigrants’ having to pay large out-of-pocket amounts for medical care due to lack of health insurance and other barriers have contributed to their three major coping strategies: (1) seeing co-ethnic doctors, (2) practicing Hanbang, and (3) taking medical tours to the home country.
4.2. Great preference for co-ethnic doctors As mentioned earlier, immigrants generally prefer and seek coethnic physicians due to their shared language and culture and the immigrants' limited knowledge of Western medicine. Korean immigrant respondents also expressed their great preference for co-ethnic doctors in the US. According to the Korea Daily Business Directory published in 2014, more than 1,100 Korean medical offices are open in the New York-New Jersey area, which include Westernstyle medical offices and dental offices that fall within the formal healthcare system, as well as informal healthcare offices, such as Hanbang and chiropractic offices. Of these, about 500 were Western-style medical offices, comprising nearly half of all Korean medical offices in the New York-New Jersey area; 322 dental offices make up about 29% of all Korean medical offices, whereas 196 Hanbang offices account for about 17%. Chiropractic offices account for about 10% of New York-New Jersey Korean medical offices. Considering that about 250,000 Koreans live in the New York-New Jersey area, roughly one Korean medical office in this area is available for every 200 Koreans. These figures may explain Korean immigrants’ great preference for co-ethnic doctors and their heavy dependence on them. The analysis of survey and interview data also supported earlier findings. About two-thirds of all survey respondents preferred Korean doctors, whereas only 5% of them preferred non-Korean doctors. About a quarter of them showed no preference regarding the physician's ethnicity, and 6% of them answered that their preference depends on the type of medical care. In most cases, they preferred Korean doctors for dental care because they believed that Korean dentists were more dexterous than American dentists. Table 2 confirms the hypothesis of a significant relationship between barriers to utilizing US healthcare and preference for co-
Table 2 Preference for co-ethnic doctors by barriers to healthcare in the US. Preference for Co-ethnic doctor
Having barriers No barriers
Barriers
Total
No Yes Total
88 (42.7%) 118 (57.3%) 206 (100.0%)
92 (30.6%) 209 (69.4%) 301 (100.0%)
180 (35.5%) 327 (64.5%) 507 (100.0%)
Source: Survey of 507 Korean immigrants in the New York-New Jersey area. x2 (1, N ¼ 507) ¼ 7.889, p ¼
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
First-generation Korean immigrants’ barriers to healthcare and their coping strategies in the US Sou Hyun Jang City University of New York (CUNY), Graduate Center, Department of Sociology, 365 Fifth Ave, New York, NY 10016, United States
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 January 2016 Received in revised form 29 August 2016 Accepted 7 September 2016 Available online 8 September 2016
This paper examines first-generation Korean immigrants' barriers to healthcare in the US and their strategies for coping with these issues by analyzing survey data from 507 Korean immigrants and indepth interviews with 120 Korean immigrants in the New York-New Jersey area. It reports that more than half of Korean immigrants have barriers to healthcare in the US, with the language barrier being the most frequent response, followed by having no health insurance. Korean immigrants are not passive, but rather active entities who display coping strategies for these barriers, such as seeing co-ethnic doctors in the US, seeking Hanbang (traditional Korean medicine) in the US, and taking medical tours to the home country. However, their coping strategies are far removed from formal US healthcare as their behaviors are still restricted to the informal healthcare within the ethnic community or home country. This study methodologically and theoretically contributes to the literature on immigrants’ healthcare behaviors by using a mixed-method approach and developing a specific framework for one particular immigrant group. © 2016 Elsevier Ltd. All rights reserved.
Keywords: United States Mixed-method approach Korean immigrants New York-New Jersey Korean community Barriers to healthcare utilization Co-ethnic doctors Hanbang Medical tourism
1. Introduction Since the 1980s, Asian Americans have been portrayed as a “model minority” by the media and scholars, particularly for their higher educational attainment than the general population in the United States (US) (Chen, 2010; Osajima, 2005; Poon et al., 2015; Suzuki, 1977). However, despite their image of having higher socioeconomic status, Asian Americans fall behind non-Hispanic whites in health fields, including health insurance rates and healthcare utilization rates (Brown et al., 2000; De Alba et al., 2005; Smith and Medalia, 2014; Stella et al., 2004). Moreover, when foreign-born Asians are analyzed separately from US-born Asians, they show even lower rates of health insurance and healthcare utilization than their US-born counterparts and non-Hispanic whites (Brown et al., 2000; Stella et al., 2004). Korean Americans are not an exception to this model minority myth, particularly in health fields. For example, they have lower health insurance rates (Anderson and Bulatao, 2004; Huang, 2013), which has a negative effect on their healthcare utilization in the US
E-mail address: [email protected]. http://dx.doi.org/10.1016/j.socscimed.2016.09.007 0277-9536/© 2016 Elsevier Ltd. All rights reserved.
(Derose et al., 2007, 2009; Jang et al., 2005; Ryu et al., 2001). According to the 2009e2011 American Community Survey (ACS) data, about 74% of foreign-born Koreans are insured while 89% of USborn non-Hispanic whites are insured. When compared to other Asian groups, Korean immigrants are still more likely to be uninsured than other Asian immigrant groups (Carrasquillo et al., 2000; Ryu et al., 2001). Analysis of the ACS data confirms that foreignborn Chinese (83%), foreign-born Indians (89%), and foreign-born Filipinos (89%) show higher insured rates than Korean immigrants. In addition to the uninsured status, Korean immigrants' language difficulty is a significant barrier to access to healthcare. For example, some studies have found a negative association between Korean immigrants’ poor English proficiency and their healthcare utilization in the US (De Gagne et al., 2014; Juon et al., 2000). Despite Korean immigrants' barriers to formal healthcare in the US, most earlier studies have focused on explaining the barriers themselves rather than examining how Koreans behave to cope with the barriers. Moreover, previous studies have used either quantitative data or qualitative data to examine Korean immigrants' healthcare behaviors in the US. Thus, using a mixed-method approach, this paper intends to bridge the gap in research on
94
S.H. Jang / Social Science & Medicine 168 (2016) 93e100
Korean immigrants' healthcare utilization and their coping strategies. Traditionally, the term coping strategy has been widely used in the field of psychology, to refer to an effort to solve problems and minimize stress (Lazarus and Folkman, 1984; Zeidner and Endler, 1996). However, in this paper, coping strategy will be construed as immigrants’ behavioral strategies to cope with their barriers to formal healthcare in the destination country, as in previous studies on minority health (Torsch and Ma, 2000; Portes et al., 2012). This paper has five main objectives. First, it examines Korean immigrants' barriers to formal healthcare in the US. Second, it identifies Korean immigrants' various strategies to cope with these barriers, and determines whether different types of coping strategies are associated with different barriers. Third, it investigates whether their coping strategies are inter-related. Fourth, it tests to see whether the previous model of immigrants' coping strategies with respect to healthcare (e.g. Portes et al., 2012) applies to Korean immigrants. Last, based on the findings, it develops a particular framework for Korean immigrants’ strategies to cope with healthcare barriers in the US. 2. Literature review Scholars have commonly pointed out three types of barriers to immigrants' healthcare utilization: structural, financial, and personal. First, structural barriers include limited chances to meet doctors who share the same culture, language, and race/ethnic background. An individual is more likely to choose a doctor of the individual's same race or ethnicity (Gray and Stoddard, 1997; LaVeist and Nuru-Jeter, 2002; Saha et al., 2000), and to feel higher satisfaction with the doctor-patient relationship if the doctor and patient share the same culture and language (LaVeist and Nuru-Jeter, 2002; Saha et al., 2000). However, most immigrants have fewer chances to meet doctors who share their language or culture than native-born white Americans due to the small number of immigrant doctors; this circumstance may lead to misunderstanding and frustration for them (Kraut, 1990; LaVeist et al., 2003; LaVeist and Nuru-Jeter, 2002; Takada et al., 1998). Structural barriers also include geographic proximity to hospitals, locations of hospitals, and access to public or private transportation to hospitals. In addition to these structural barriers, financial barriers to immigrants' healthcare include poverty, lack of financial resources, and lack of health insurance. Many scholars have found that immigrants' uninsured status plays a negative role in their access to healthcare (Derose et al., 2007, 2009; Jang et al., 2005; Yoo and Kim, 2008). Moreover, personal barriers, such as the level of acculturation (Abraido-Lanza et al., 2005; Arcia et al., 2001; Gorman et al., 2010; Salant and Lauderdale, 2003), perceived discrimination (Jang et al., 2005; Viruell-Fuentes, 2007; Yoo et al., 2009), limited language proficiency (Hu and Covell, 1986; Jang et al., 2005; Kim et al., 2011; Wu et al., 2009), and cultural differences (Jenkins et al., 1996; Kung, 2004; Wu et al., 2009) have been associated with lack of access to healthcare. In particular, previous studies have found that culture and language have a big impact in the provision of health care, such as the doctor-patient relationship (Ferguson and Candib, 2002; Flores, 2000; LaVeist and Nuru-Jeter, 2002) and the use of complementary and alternative medicine (Bodeker and Kronenberg, 2002; Hsiao et al., 2006; Kronenberg et al., 2006; Ma, 1999), especially among minority patients. For example, reviewing articles published from 1966 through 2000, Ferguson and Candib (2002) found that it is more difficult for minority patients to build rapport with doctors and to receive empathic responses from them
due to doctors' lack of cultural competence and minority patients’ limited English proficiency. Ma (1999) also found that Asian immigrants, including Chinese immigrants, tend to hesitate to openly discuss their cultural practices with Western doctors, making cultural competence one of their major barriers to healthcare. Consequently, Chinese immigrants look for co-ethnic doctors or use practitioners of traditional Chinese medicine. To cope with these structural, financial, and personal barriers to formal healthcare in the US, immigrants display several behavioral strategies. First, going to free clinics or community health centers has been used as a coping strategy, especially among undocumented or uninsured immigrants, because these clinics offer free (albeit limited) medical care without asking about patients’ legal status or insured status (Kamimura et al., 2013; Okie, 2007; Portes et al., 2012). Second, immigrants often seek co-ethnic doctors, especially when they have language barriers, cultural barriers, or limited knowledge of Western medicine (Choi, 2013; Wang, 2007; Wang et al., 2008; Zhang and Verhoef, 2002). Previous studies have pointed out that Asian Americans with limited English proficiency are more likely to see co-racial doctors (LaVeist and Nuru-Jeter, 2002), and Korean immigrants prefer Korean doctors, mostly due to the language barrier (Choi, 2013; De Gagne et al., 2014; Son, 2013). Using complementary and alternative medicine (CAM) is another coping behavior among immigrants. Although the use of this informal type of medical care is related to a group's own culture (Hsiao et al., 2006), immigrants who have barriers to formal healthcare are still more likely to use CAM (Akresh, 2009; Han, 2001; Hill et al., 2006; Kim and Chan, 2004; Portes et al., 2012; Pourat et al., 1999; Wu et al., 2007). Some Korean immigrants also utilize Hanbang, a non-Western form of Korean traditional medicine. Hanbang is known by various names, including CAM, traditional medicine, oriental medicine, and folk medicine. Han (2001, p. 146) defines it as traditional medicine that “originated in China and indigenized in Korea.” According to Hill et al. (2006), a significant proportion of Korean immigrants (23% of males and 29% of females) have used traditional remedies as a healthcare option in California. Korean immigrants' use of Hanbang is associated with barriers to formal healthcare, such as the language barrier, a low level of acculturation, and uninsured status (Han, 2001; Hill et al., 2006). The last distinctive coping strategy is returning to the home country to seek medical care. Scholars have found that some Mexican immigrants take medical tours to the home country due to the lack of health insurance in the US (Bastida et al., 2008; Bergmark et al., 2010; Brown, 2008). For Korean immigrants, cultural and language barriers, lack of health insurance or limited coverage, and having to take long domestic trips to see Korean doctors within the US have contributed to their decision to engage in medical tourism (Lee et al., 2010; Oh et al., 2014; Wang and Kwak, 2015). Considering different types of barriers, and especially responding behaviors, Portes et al. (2012) established a framework for immigrants' coping strategies. According to their categorization, four major coping behaviors are based on different types of barriers and situations. First, when immigrants have cultural-linguistic barriers, they tend to see co-ethnic healthcare professionals. Second, when immigrants are uninsured, they are likely to seek folk medicine or see unlicensed doctors. Third, if newcomers cannot access federal health programs, such as Medicaid and Medicare, they tend to go back to the home country for medical care or use free clinics. Last, undocumented immigrants tend to seek folk
S.H. Jang / Social Science & Medicine 168 (2016) 93e100
healers, go to free clinics, or receive drugs from the home country. Since no theory exists to explain how immigrants respond to their barriers to healthcare utilization, Portes and his associates’ approach will be used as the conceptual framework in this paper. Its applicability will be tested, and it will be compared to a particular framework for Korean immigrants. 3. Data and methods This study employed a mixed-method approach, with both quantitative and qualitative data. First, it analyzed the survey data of 507 Korean immigrants. The participantsdfirst-generation Korean immigrant adults 18 years and olderdwere recruited in the New York-New Jersey area from Korean ethnic churches, ethnic community centers, and ethnic events, such as the Korean Parade in Manhattan and the Korean Thanksgiving and Folklore Festival in Queens between fall 2013 and spring 2014. This paper used nonprobability sampling techniques because it was not feasible to secure a list of all Korean immigrants in the New York-New Jersey area. A quota sampling technique was used to select participants by gender, educational level, class of work, age, and religious background to match the demographic, socioeconomic, and religious characteristics of first-generation Korean immigrants (those who came to the US at age 13 or older). The survey questionnaire used in this study had approximately 40 items, asking about respondents' demographic and socioeconomic characteristics, immigration history, barriers to US healthcare utilization, health insurance status, and other health-related issues. The survey questionnaire also asked whether they had ever visited the home country for medical care. The survey was selfadministered and paper-based. On average, respondents took about 20 min to complete the survey, and no monetary reward was offered to the respondents. All answers from the survey data were coded and analyzed by the author using Stata 13. A chi-squared test was conducted to examine the association between firstgeneration Korean immigrants’ barriers to healthcare and their coping behaviors. Second, this paper analyzed the qualitative data from 120 indepth interviews. A small number of survey respondents was willing to respond to further open-ended questions immediately following the survey. However, the majority of survey participants refused to do so. Since it was hard to find a sufficient number of interviewees through the survey, a snowball sampling technique was used to recruit more informants. A small number of initial interviewees was recruited at Korean ethnic churches and Korean community centers in the New York-New Jersey area. Each in-depth interview took about 30 min to an hour to complete. All interviews were audio-recorded and transcribed in Word 2013. Every name appearing in this paper was a pseudonym. The qualitative data was analyzed manually instead of using a software program. Contents of in-depth interviews were categorized by assigning a number to important keywords, such as language barrier, health insurance, and co-ethnic doctor, then analyzed by keyword and the interviewee's sociodemographic characteristics. Third, the 2009e2011 ACS data were analyzed to compare the health insurance rates of Korean immigrants to that of other Asian immigrant groups and US-born non-Hispanic whites. Last, the business directory published by the Korea Daily in 2014 was used to examine the number of Korean medical and dental offices and Hanbang offices. This study conformed to ethical requirements for using human research subjects and was approved by the Institutional Review Board (IRB) of the City University of New York (CUNY). Before conducting the survey and in-depth interviews, an interviewer orally informed potential participants about the purpose and significance of the study and that their participation
95
carried minimal risk to them. Survey respondents and interviewees were also told that their participation was voluntary and they could withdraw from the study at any time. 4. Findings 4.1. Barriers to healthcare in the US More than half of survey respondents answered that they had at least one barrier to formal US healthcare. Fifteen percent of all survey respondents who had received medical care in the US reported that they encountered more than two barriers. The two most frequently cited combinations of barrier were the language barrier and having no insurance, followed by the language barrier and cultural differences. Table 1 shows that about one-third of the survey respondents experienced a language barrier in obtaining healthcare in the United States. Ten percent reported speaking English very well, and more than half said they spoke very little or no English. Thus, it is not surprising that more than one-third of the survey respondents reported that they experienced a language barrier when they received medical care in the US. In addition to the language barrier, survey respondents pointed out other barriers, such as immigrants' uninsured status, cultural differences, and perceived racial discrimination. A few survey respondents indicated additional obstacles, such as having difficulty in making appointments, long wait times, complicated referral processes, and poor medical equipment at doctors’ offices or other medical facilities. Analysis of the in-depth interviews revealed three types of language barriers in healthcare: (1) difficulty in understanding medical terminology in English, (2) difficulty in describing symptoms in English, and (3) difficulty in communicating with nonKorean doctors. The first two types have a linguistic aspect itself as a barrier. In contrast, the last type emphasizes an interpersonal aspect and is related to immigrants’ preference for co-ethnic doctors. Thus, this will be discussed in the next section. First, some interviewees reported that it was hard for them to understand difficult medical terminology in English. They were anxious about their inability to understand English medical terminology at hospitals, and their anxiety often led them to choose co-ethnic doctors. Second, for some Korean immigrants, the ability to describe their symptoms in English was limited. In their view, due to their limited English, they did not know enough English adjectives or other words to accurately describe their pain. For example, Min-Seok Kim, a middle-aged employee at a Korean community center, explained that he knew various adjectives to describe pain in Korean. Additionally, many Korean-language phrases or words used to describe certain kinds of pain or other symptoms simply do not have direct English translations. However, since he knew only one
Table 1 Types of Korean immigrants’ barriers to healthcare in the US. Barriers
N
%
No barriers Language barriers Having no insurance Cultural differences Other barriers Total
205 158 113 45 25 546
44.5 34.3 24.5 9.8 5.5 118.6
Source: Survey of 507 Korean immigrants in the New York-New Jersey area. Note: Respondents who had never received medical care in the US were excluded from this analysis (N ¼ 461). Since several respondents (N ¼ 73) gave multiple answers, the sum of the responses exceeds 100%. Survey question: “Please indicate below which describes any barriers or difficulties you have when you utilize healthcare in the U.S. (select one or more if applicable).”
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S.H. Jang / Social Science & Medicine 168 (2016) 93e100
worddpaindto describe his discomfort in English, it was hard for him to elaborate on his pain to American doctors. Since Korean doctors understood his expressions or descriptions right away, he preferred to see Korean doctors or return to Korea for medical care. About a quarter of survey respondents answered that their uninsured status in the US was a major obstacle to their healthcare utilization. Since they had lived in Korea, which offers very affordable insurance for all people, many of them revealed their hesitance to pay for more expensive health insurance in the US. For example, a 40-year-old non-smoker who earns $30,000 a year will pay about $4,500 a year ($372 per month for 12 months ¼ $4,464) for the second lowest cost plan in New York state (Cox et al., 2015). In contrast, an employee in Korea who earns about $30,000 pays only about $1,800 annually for his/her health insurance, as the health-insurance contribution rate is only about 6% of his/her salary (Song, 2009). Korean immigrants’ having to pay large out-of-pocket amounts for medical care due to lack of health insurance and other barriers have contributed to their three major coping strategies: (1) seeing co-ethnic doctors, (2) practicing Hanbang, and (3) taking medical tours to the home country.
4.2. Great preference for co-ethnic doctors As mentioned earlier, immigrants generally prefer and seek coethnic physicians due to their shared language and culture and the immigrants' limited knowledge of Western medicine. Korean immigrant respondents also expressed their great preference for co-ethnic doctors in the US. According to the Korea Daily Business Directory published in 2014, more than 1,100 Korean medical offices are open in the New York-New Jersey area, which include Westernstyle medical offices and dental offices that fall within the formal healthcare system, as well as informal healthcare offices, such as Hanbang and chiropractic offices. Of these, about 500 were Western-style medical offices, comprising nearly half of all Korean medical offices in the New York-New Jersey area; 322 dental offices make up about 29% of all Korean medical offices, whereas 196 Hanbang offices account for about 17%. Chiropractic offices account for about 10% of New York-New Jersey Korean medical offices. Considering that about 250,000 Koreans live in the New York-New Jersey area, roughly one Korean medical office in this area is available for every 200 Koreans. These figures may explain Korean immigrants’ great preference for co-ethnic doctors and their heavy dependence on them. The analysis of survey and interview data also supported earlier findings. About two-thirds of all survey respondents preferred Korean doctors, whereas only 5% of them preferred non-Korean doctors. About a quarter of them showed no preference regarding the physician's ethnicity, and 6% of them answered that their preference depends on the type of medical care. In most cases, they preferred Korean doctors for dental care because they believed that Korean dentists were more dexterous than American dentists. Table 2 confirms the hypothesis of a significant relationship between barriers to utilizing US healthcare and preference for co-
Table 2 Preference for co-ethnic doctors by barriers to healthcare in the US. Preference for Co-ethnic doctor
Having barriers No barriers
Barriers
Total
No Yes Total
88 (42.7%) 118 (57.3%) 206 (100.0%)
92 (30.6%) 209 (69.4%) 301 (100.0%)
180 (35.5%) 327 (64.5%) 507 (100.0%)
Source: Survey of 507 Korean immigrants in the New York-New Jersey area. x2 (1, N ¼ 507) ¼ 7.889, p ¼
