US National Health Data on Asian Americans and Pacific Islanders: A Research Agenda for the 1990s

Elena S. H. Yu, PhD, MPH, and William T. Liii PhD

Introduction Officially counted at just 7.3 million in 1990, Asian Americans and Pacific Islanders (or Asian/Pacific Islanders) are the fastest growing ethnic minorities in America.1,2 By and large, published papers on the health status, morbidity, and mortality pattems of the Asian/Pacific Islander populations have relied on the following three major sources of data: (1) investigatorinitiated epidemiologic surveys or casecontrol studies of specific diseases3- 6; (2) records maintained by private organizations, such as treatment-based data from large prepaid health plans (e.g., the Kaiser Permanente health plan)17-19; and (3) programmatic data collected by federal govemnment agencies, such as the Surveillance, Epidemiology, and End Results program maintained by the National Cancer Institute,W,211 surveys and vital statistics managed by the National Center for Health Statistics (NCHS),22-30 and studies sponsored by the Agency for Health Care Policy Research, the Alcohol, Drug Abuse, and Mental Health Administration, and other organizations. Of these, data compiled by the federal govemment agencies remain the most publicly accessible source and have the greatest potential of providing a national profile on the health of minorities. Unfortunately, current "race" coding practices in several of these data collection systems have not produced, and will not produce, meaningful data on the health of Asian Americans and Pacific Islanders-unless changes are instituted. To illustrate, the Agency for Health Care Policy Research conducts the National Medical Expenditure Survey. Data from the 1987 survey and its predecessor, the 1977 National Medical Care Expenditure Survey, provide useful information on health insurance of "minorities" in the United

States.31 However, because the Agency for Health Care Policy Research race coding identifies only "Black," "Hispanic," "White," and "other race," there are no data from either of the national expenditure surveys on health insurance of the Asian/Pacific Islander populations. In contrast, NCHS is somewhat better in providing a modicum of information on Asian/Pacific Islanders as a broad category, but changes in race-coding practices would still be necessary if we are to obtain useful data on the health of the fastest growing group of Americans. This paper has two objectives. First, we wish to document the weaknesses in the federal data collection systems in providing meaningful information on the health of Asian/Pacific Islanders. Attention is focused specifically on NCHS because it is the richest source of health and epidemiologic data on the US population. Second, we wish to make a few recommendations on ways to improve the quality of information that is being collected in NCHS's ongoing vital statistics and sample survey programs. Insofar as the sampling procedures and race-coding practices used by other federal agencies (such as the Agency for Health Care Policy Research, the Alcohol, Drug Abuse, and Mental Health Administration, and the Health Care Financing Administration) Elena S. H. Yu is with the Division of Epidemiology and Biostatistics, Graduate School of Public Health, San Diego State University. William T. Liu is with the Departments of Sociology, University of Illinois at Chicago and California State University at San Marcos. Requests for reprints should be sent to Elena S. H. Yu, PhD, MPH, Division of Epidemiology and Biostatistics, Graduate School of Public Health, San Diego State University, San Diego, CA 92182. This paper was submitted to the Journal February 4, 1991, and accepted with revisions January 7, 1992.

American Journal of Public Health 1645

are similar to those of NCHS, the weaknesses and recommendations noted here will also apply to these other governmental bodies. In what follows, we will briefly recapitulate the mission of NCHS, identify useful data sources within its programs, pinpoint the limitations of its racecoding practices, discussways to improve the denominator data, and outline a research agenda for the 1990s.

T7e Mision of NCHS NCHS, established in 1960, collects, analyzes, and disseminates national health statistics; conducts research in survey and statistical methodology; coordinates the efforts of various federal agencies in health statistics to the maximum extent feasible; cooperates in international health statistics activities; and serves as a focal point of health data.32 NCHS's multivariegated and highly integrated research programs are probably the most sophisticated taxpayer-supported national health data collection systems in the world. They provide the best estimates of the health characteristics of Americans, some based on self-reports and others inferred from objective biological measures. Two major types of data collection programs are maintained, namely, population-based surveys and record-based surveys.33 Population-based survey programs include the National Health Interview Survey,34 the National Health and Nutrition Examination Survey (NHANES),35 the NHANES I Epidemiologic Followup Study,36'37 and the National Survey of Family Growth.38 Record-based programs include the Vital Statistics Cooperative Program,39 the National Maternal and Infant Health Survey,40 the National Mortality Followback Survey,41 the National Death Index,42 and the Linked Bithnfant Death Records.43 In anticipation of future needs for health care statistics, four of the center's recordbased surveys will be merged by 1993 and expanded into one integrated survey of health care providers called the National Health Care Survey. These four surveys are the National Hospital Discharge Survey,"445 the National Ambulatory Medical Care Survey,46 the National Nursing Home Survey,47 and the National Master Facility Inventory.48 Through these complex data collection systems,49 NCHS supplies the Congress with useful annual statistics and publishes, among other documents, a periodic report on the health of the nation. Heath United States 199050 is one of its showcase publications. 1646 Amencan Joumal of Public Health

Changig Race-Cog Pade Over the last three decades, in reto growing demands for minority health data, various components of NCHS's programs have introduced changes in race coding so that Asian/ Pacific Islanders may be counted separately. Thus, in the vital statistics system itwaspossible to distiguish Chinese, Japanese, and Filipinos as far back as the late 1960s. But in the National Health Interview Survey, persons of Asian backgrounds were identified as belonging to "other race" on the basis of interviewer observations until 1976.51 Since 1976, as a by-product of efforts to improve the quality of the racial classifications used in the National Health Interview Survey sample, respondents have been allowed to identify themselves in the interview as "Asian or Pacific Islander." In spite of these well-intended modifications, none of the programmatic surveys conducted by NCHS in the last 25 years have provided useful, valid, and reliable information on subgroups of Asian/Pacific Islanders. During the mid-1970s, the vital statistics system improved its ability to identify different ethnic minorities by expanding the race codes to include nine categories: White, Black, (American) Indian, Chinese, Japanese, Hawaiian, Filipino, other Asian/ Pacific Islanders, and other races. However, the "other Asian/Pacific Islander" category includes persons "identified as Asian Indian, Burmese, Cambodian, Ceylonese, Chamorro, Dutch East Indian, Fijian, Gilbertese, Guamanian, Javanese, Korean, Laotian, Malaysian, Maori, Marshallese, Pakistani, Ponapean, Samoan, Siamese, Thai, and Vietnamese."52(p16) For research and program planning purposes, this residual categoxy is nebulous, meaningless, and scientifially useless. sponse

Cuffet Race-Coding PAices At present, NCHS uses the generic Asian/Pacific Islander label for all its survey programs and a nine-categoxy race code (noted above) for all itsvital statistics data. The former follows the Office of Management and Budget classification of race into four major categories (White, Black, American Indian or Alaskan Native, and Asian or Pacific Islander).53 "Ethnicity' is broken into just two categories (Hispanic origin and not of Hispanic origin). Several problems are readily apparent from the above classification

systems. First, precisely how membership in a racial group is to be determined is far from clear. Ample evidence exists that classifications based on self-reports do not always agree with those based on the survey interviewers' observations.54 Changing social contexts can also lead some persons to switch identity from one racial category to another. This occurs commonly among persons of mixed parentage. Second, NCHS's race and ethnicity definitions ignore the conventional and sociological distinctions betweenrace (the biological classification of Homo sapiens by certain phenotypical and genotypical traits) and ethnicity (the sociobehavioral definitions of physical attributes that emerged as a result of migration, promotion of a dialect to the status of a language, consolidation of forces in the face of impending threat from an aggressor, annexation or changes in political boundaries, or schisms within a religion).55 As three recent publications have noted,56-58 the federal government's race and ethnic classification systems have generated a great many confusions, miscounts, and misclassifications in different ypes of surveys and vital statistics programs. In the remainder of this paper, we use the term "race/ ethnicity" to refer to the distinct ethnic minorities that the Office of Management and Budget classifies as racial groups. Three major limitations exist in regard to NCHS's race-oding practices that compromise the quality of health data for Asian/Pacific Islanders: (1) inadequate emphasis on ethnic diversity, (2) infeasibility of interpreting pooled data, and (3) inattention to racial or ethnic misclassifications.

Ethnic Diversity The term "Asian/Pacific Islanders" covers a great number of cultures and at least 32 linguistic groups whose ancestral origins can be traced to places that include Mongolia to the north, the islands near Australia to the south, India and Pakistan to the west, and Hawaii to the east. The inhabitants ofthese vast land masses differ immensely in terms of racial stock, language, religion, life-style, diet and health behaviors, and other characteristics. Just as one would not merge statistical data files that display widely differing characteristics or distributions, so too it makes little sense to aggregate extremely diverse groups into a single category. Although NCHS's vital statistics program has separate codings for Japanese, Chinese, and Filipinos, many rapidly growing groups of Asian immigrants and refugees (e.g.,

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Asian Indians, Koreans, Vietnamese, Laotians, Cambodians, Thais, Hmongs, and Pakistanis) continue to be lumped together as one racial group. As a result, we have no national estimates ofthe mortality rates for these Asian minorities.

Pooled Data At one time, it was thought possible to pool data from different years of a particular survey program in order to produce a sufficiently large sample size for purposes of analysis. But as Yu et al.59 demonstrated, there exist serious problems in interpretation and meaning when the specific "mix" of Asian/Pacific Islander populations is, in fact, undetermined and constantly in flux as new immigrants and refugees increase at an astounding rate. This kind of methodological problem abounds in all of NCHS's survey data sets with respect to the extrapolation of Asian/ Pacific Islander health data.

Race/Ethnic Misclassifications Evidence of race/ethnic misclassifications in the Asian/Pacific Islander birth and infant death files has been documented in a couple of statewide studies.60,61 Not until the 1983 through 1984 National Linked Birth-Death Files were established, however, was it possible to gain an appreciation of the direction and magnitude of race-recording errors in the US infant mortality data.22 The latest report, based on examination of national linked birth and infant-death files from 1983 through 1985,57 provides solid documentation that inconsistency in the coding of race at birth and at death is low for Whites (1.2%), somewhat greater for Blacks (4.3%), and greatest for races other than White or Black (43.2%). For Chinese, the error rate is as much as 33.3%; for Japanese, 48.8%; and, for Filipinos, 78.7%. In 87% of all the inconsistent racial classifications, the direction of the error is toward classifying infants as White at death. (However, despite adjustments for these racial misclassifications, the infant mortality rates of Chinese, Japanese, and Filipinos remained lower than the rate reported for Whites during the same period.) Data for other subgroups of Asian/Pacific Islanders remain unavailable. Under these circumstances, it is important to resist the temptation to extrapolate findings from the older, more established Asian Americans to the more recently arrived refugees and immigrants who cannot be identified in NCHS's existing records and who may have unfavorable infant mortality rates compared with White Americans. December 1992, Vol. 82, No. 12

New Developments in Race Codings Beginning with the 1992 data year, NCHS introduced a new code structure for its data on natality, mortality, fetal deaths, and induced termination of pregnancy. This new code structure will increase the total number of race codes to 14, as follows: White (includes Mexican, Puerto Rican, and other Caucasian); Black; Indian (North American, Central American, South American, Eskimo, and Aleut); Asian or Pacific Islander, which is subclassified to allow the separate identification of Chinese, Japanese, Hawaiian (including part-Hawaiian), Filipino, Asian Indian, Korean, Samoan, Vietnamese, Guamanian, and other; other races; and not classifiable. These codes thus parallel the Asian/Pacific Islander codes included in the 1990 census. However, in 1992, the expanded Asian and Pacific Islander categories (i.e., Asian Indian, Korean, Samoan, Vietnamese, and Guamanian) are being implemented only in the following vital registration areas: California, Hawaii, Illinois, New Jersey, New York State, New York City, Texas, and Washington. All others will continue to use the pre-1992 code structure. As funding becomes available, NCHS hopes to expand use of the new code structure to all 54 registration areas (John E. Patterson, written communication, January 1992). These changes make NCHS the most responsive of all federal data collection agencies to the improvement of minority health data. However, the progress made by NCHS to improve the quantity and quality of Asian health data will be nugatory unless two other events follow in quick succession: changes in NCHS's existing sampling scheme to allow oversampling of selected Asian/Pacific Islander subgroups in its national surveys and improvements in the denominator data used for the calculation of mortality and morbidity rates.

groups to allow meaningful analysis. It seems practicable at this juncture to capitalize on the knowledge gained from the 1990 census that 79% of the Asian/Pacific Islander populations live in just 10 states (California, New York, Hawaii, Texas, Illinois, New Jersey, Washington, Virginia, Florida, and Massachusetts) and design a special-year survey that would augment NCHS's sample size through oversampling of specific subgroups of Asian/ Pacific Islanders in these states. For such a plan to come to fruition in the short run, an increase in congressional funding to support NCHS's surveys will be necessary. In the long run, a responsibility to improve the quality of the denominator data obtained from the Bureau of the Census is also inescapable.

Improving the Denominator Three serious limitations exist with the denominator, which is supplied by the Bureau of the Census: population undercount, lack of intercensal estimates, and inconsistent reporting of racial/ethnic origins.

Population Undercount Estimates for the total US population

Needfor Oversampling

census undercount have ranged from 4.7 million62 to 9.7 million people.63 Officially, the nationwide undercount is acknowledged at 5.27 million, or about 2.1%.64 Estimates published by the Bureau of the Census (cited in Reference 65) put the Asian/Pacific Islander undercount at only 2.7%. However, a census underenumeration study conducted in one area of New York's Chinatown indicates that the undercount of Chinese is as high as 18%.66 (In her confidential report, Sung documented remarks by a Chinese postman who indicated that only about 45% of the residents in his postal delivery routes [Site A16] were given the census forms in 1990, even though he had so informed his superiors at the US Post Office where he worked. Residents of a newly converted

NCHS's current survey practice of sampling in proportion to population size means that, on average, about 2.9% of its representative national sample, plus or minus the sampling error, will be Asian/ Pacific Islanders. Thus, even if detailed Asian/Pacific Islander subgroup identifications are specified on its national survey interview forms, no single-year (or even cumulative-year) data will provide a sufficient sample size of any specific sub-

44-unit condominium never received a single census form. Verification of the housing list prepared by the census bureau against postal addresses showed numerous missing addresses on the census's housing list. The census mail return rate for Site A16 was 52%.) Additional studies of undercounts in other geographic areas and for other ethnic groups besides Chinese are sorely needed and should be pursued with the Bureau of the Census.

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Intercensal Estimates Intercensal estimates for subgroups of Asian/Pacific Islanders are needed if we are to fully use NCHS's vital statistics records and calculate mortality rates between censusyears. Inasmuch as birth and death data for Asian/Pacific Islanders have not been critically assessed until recently, valid estimates of the annual excess of Asian/Pacific Islander births over deaths have yet to begin. Furthermore, although immigration statistics are available, there are no figures on emigration for Asian Americans. Hence, the intercensal denominators needed to calculate the national mortality and morbidity rates of Asian/Pacific Islanders are simply nonexistent. Questions have been raised as to whether the current population surveys that are conducted annually around specific topics could be used as a mechanism to provide some rudimentary estimates of counts of Asian/Pacific Islanders. Because of the current practice of sampling in proportion to population size, however, the number of Asian Americans and Pacific Islanders surveyed in any given year of the current population survey will always be too small to warrant separate analysis. Unless changes are instituted in the sampling procedure used by the current population survey, it will not be a suitable vehicle for producing the needed denominators between censusyears, even if it were to redirect its data collection activities for the sake of obtaining estimates of Asian/Pacific Islander births and deaths in the United States.

Inconsistent Reporting of Race/Ethnic Origin Inconsistent reporting of race/ethnic

origins has occurred in the denominator data supplied by the Bureau of the Census. This inference is based on several studies of Blacks, Whites, Hispanics, and American Indians.67-72 Unfortunately, not as many studies have been conducted to examine the consistency of reportng of race/ethnic origin among Asian Americans or Pacific Islanders. A single study54 conducted by NCHS documents that 32.3% of self-reported Asians were classified as either "White" or "Black" by the interviewers. Shifts in self-reports of Asian identity as a function of changing social circumstances have not been described in print, although there are anecdotal impressions that Chinese-speaking immigrants from Southeast Asia, Africa, the Canbbean, and Latin America may 1648 American Journal of Public Health

not always report their ethnicity consistently across situations. Likewise, Filipinos have been known to report their ethnic background as Pacific Islander, Spanish surnamed, Asian American, or, in the case of the mestizos ("mixed blood"), White. A 1969 study by NCHS69 on the comparability of race information between the death certificate and matching census records indicates that inconsistent reporting of race was more frequent for Filipinos than for Chinese. Given the fact that Chinese and Filipinos are the two largest subgroups of Asian Americans, an incongruent reporting of ethnicity on their part is likely to shift the denominator, if not bias the health estimates, in any study. Hence, it is important to determine the degree of consistency in the reporting of ethnicity among Asian/Pacific Islanders, especially Chinese and Filipinos.

Research Agenda for the 1990s Alternative approaches to obtain useful numerator and denominator data for Asian Americans and Pacific Islanders must be explored during the 1990s. With regard to the denominator, since a national intercensal count is impractical, a feasible approach is to concentrate federal and local efforts in the three states (California, New York, and Hawaii) where the majority of Asian/Pacific Islanders lived in 1990, expanding-as resources permit-to the 10 states where 79% of Asian/Pacific Islanders resided in 1990. It is also important to recognize that 15 metropolitan statistical areas have been the most significantly affected by the rapid growth of Asian/Pacific Islanders: Los Angeles-Long Beach, New York, Honolulu, San Francisco, Oakland, San Jose, Anaheim-Santa Ana, Chicago, San Diego, Seattle, Houston, Sacramento, Philadelphia, RiversideSan Bernardino, and Boston. Hence, it is possible to plan special multisite coordinated ethnic-group-specific sample surveys around a limited number of health topics to obtain precise estimates of particular morbidity rates or health characteristics in areas where Asian/Pacific Islanders are found in large numbers. However, the success of such types of surveys will depend on the completion of a series of developmental studies on how best to draw a cross-national sample of Asian/Pacific Islanders, the development and validation of culturally appropriate measures and instruments, and the cost efficiency of different modes of interview.

Sampling Issues A difficult methodological issue in epidemiologic studies of Asian Americans and Pacific Islanders is the selection of respondents from the ethnic mosaic that characterizes America's cities. For example, in surveys of Chinese Americans, the usual area probability sampling strategies are not suitable, except for those living in New York's and San Francisco's Chinatowns, because of the prohibitively high cost of screening required prior to the task of respondent selection. Even in the census tracts where the Chinatowns of major US cities are located, there is a substantial proportion of non-Chinese residents. In surveys of the general US population, the use of telephone directories is a viable alternative to face-to-face interviews, even though it excludes those who do not have a listed telephone number. We lack information as to whether the older and foreign-born segments of the Asian/Pacific Islander populations will accept telephone interviews as well as do the majority of Americans. Some investigators have conducted surveys on Asian/ Pacific Islanders by using sampling lists purchased from commercial marketing firms or sampling survey companies that merge directories obtained from numerous sources (e.g., credit card holders, driver's license registrations, motor vehicle registrations, school enrollments). But such lists need to be periodically updated, and their overall accuracy in identifying specific subgroups of Asian/Pacific Islanders has not been subjected to critical evaluations. Random-digit dialing is a technique that can overcome the limitations of telephone directories due to unlisted numbers and new telephone installations. It is considered most appropriate for the central cities of large statistical metropolitan areas where the fraction of households with unlisted numbers is greater than 5%. However, a major cost of random-digit dialing is the large number of unused numbers and nonresidential phones. In addition, one can expect a low "hit" rate because Asian/Pacific Islander households are widely dispersed. There is also the difficulty of anticipating which Asian language or dialect will be spoken in the household that is successfully reached by the random dialing technique. To the best of our knowledge, the cost efficiency of random-digit dialing in sampling Asian/ Pacific Islanders remains to be documented. A concerted effort should be mounted to explore or develop scientifically defensible methods of sampling nonDecember 1992, Vol. 82, No. 12

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English-speaking Asian/Pacific Islanders in selected US cities (or states) in a manner that would be cost effective.

CuluraDly Appropniate Measures and Instwnents In future epidemiologic studies of Asian/Pacific Islander communities, we will need to prepare multilanguage versions of culturally appropriate measures and standardized instruments if we are to be able to study groups other than Japanese Americans (a large majority ofwhom are primarily native speakers of English). Multilingual instrument development is necessary because an overwhelming majority of Asian/Pacific Islanders are foreign born, and a large proportion of them are also partially, if not totally, foreign educated. (For the United States as a whole, the 1980 census indicated that the foreignborn percentages for the major Asian/ Pacific Islander subgroups are as follows: Chinese, 63%; Filipino, 65%; Japanese, 28%; Asian Indian, 70%; Korean, 82%; Vietnamese, 90%; Laotian, 94%; Thai, 82%; Cambodian, 94%; Hawaiian, 2%; Samoan, 36%; and Tongan, 75%. The 1990 census tabulation for Asian/Pacific Islanders is not yet available.) Their adult populations, especially the elderly, are primarily non-English speakers. Multilingual instrument-development studies are a necessary step in future health surveys in order to produce parallel and comparable non-English versions of research protocols. There are two strong reasons for this recommendation: (1) to ensure equivalence in concepts and meaning across ethnic groups and (2) to provide a context for comparing findings obtained from special surveys of Asian/Pacific Islanders with the national health estimates obtained from the general population by NCHS. The need to use NCHS data as a reference for comparison is self-evident. Without establishing comparability, there will be no basis for setting priorities in health services expenditures. A major hurdle in instrument development, however, is the diversity of language and culture within the Asian/Pacific Islander populations. Even within an ethnic group, dialects can be sufficiently different as to be mutually unintelligible. In some tpes of epidemiological surveys, inclusion of different dialectal groups from the same ethnic group may be necessary in order to ensure sufficient sample size and to increase generalizability. Variations in the use of the same language by different dialectal groups also raise interesting problems. For example, some CanDecember 1992, Vol. 82, No. 12

tonese (Chinese), particularly those from Hong Kong, make use of Cantonese-specific characters that non-Cantonese Chinese are unable to read (even though there is only one written Chinese language). Investigators conducting research on this population, therefore, need to be familiar with a wide spectrum of issues related to cultural and linguistic diversities. A related topic, often mentioned but little understood, is the problem of instrument translation and validation. The former goes beyond the use of back translation as a means of checking translation accuracy; the latter requires not only cultural but also technical and substantive expertise. As one expands the translation to include major linguistic groups, so begins the ominous task of ensuring that the different dialect or language versions are the same when compared with one another and when compared with the original English version. Endless pretests are required to establish equivalence between different dialectal and language versions of the same instrument. As can be expected, the cost of translation checks and validation studies increases proportionally each time a new dialect group is included. This cost needs to be budgeted into all health surveys of Asian/Pacific Islanders.

Modes of Internew There is an abundance of studies on the cost effectiveness of different modes of interviews with the general US population. But there has not been a single systematic study of Asian/Pacific Islanders regarding the feasibility of one type of health survey interview (e.g., telephone voiced interviews or computer-assisted telephone interMlews) over other types of data-elicitation procedures. Answers are needed on questions such as the following: What are the sociodemographic (especially age and education characteristics) and ethnic-specific profiles of respondents who are able and willing to respond to telephone interviews? What kind of response rates might one expect with doorto-door interviews compared with telephone interviews? How can the response rates be improved? What types of questions are best asked in a telephone-interview setting compared with face-to-face contacts? Are telephone interviews efficient in surveys of populations that have had a histoxy of political oppression and distrust for strangers or that speak several dialects and languages? Will interviewers participating in computer-assisted telephone interviews of, say, Chinese Amer-

icans be required to learn Chinese word processing systems or do simultaneous translations from English to Mandarin, and possibly further translations from Mandarin to Cantonese, Toisan, Taiwanese, Hokkien, Hakka, and other dialects? What is the magnitude of the interviewing errors when the interviewers are given the latitude to do simultaneous translations? Some have suggested that the new translators' service offered by AT&T may be a feasible approach to use in interviewing foreign-born Asian/Pacific Islanders. Such a suggestion has yet to be tested empirically. Given the level of technical skills and language competency required to perform computer-assisted telephone interview surveys of Asian/Pacific Islanders, what is the cost of such "high-tech" interviews? These issues need to be discussed and evaluated in the 1990s.

Recommemdations We believe that the time has finally come to confront the methodological

problems in studying the health of Asian Americans and Pacific Islanders. In spite of the economic recession, Congress has appropriated funds for research on understudied and underserved populations. The Disadvantaged Minority Health Improvement Act of 1990 (Public Law 101-527) has authorized NCHS to invest up to $22.5 million over a 3-year period to improve our knowledge of the health of racial and ethnic populations or subpopulations. Furthermore, on October 24, 1991, President Bush signed the Decennial Census Improvement Act (Public Law 102-135), which authorized the US Department of Commerce (parent federal department of the Bureau of the Census) to contract the National Academy of Sciences to conduct a 3-year study on how the US population might best be counted. Funds required for this study are included in the 1992 appropriation for the Department of Commerce signed by President Bush on October 28, 1991 (Public Law 102-140). A total of $1.2 millionwas allocated in November of 1991 to the National Academy of Sciences' Committee on National Statistics. The latter is required to submit an interim report in 18 months and a final report in 3 years. It is extremely important to have Asian and Pacific Islander experts included in the scientific panel. The work of this panel should provide benchmark data that can benefit future investigations on the health of Asian/Pacific Islanders in the United States. The 1990s could thus mark the beginning of a major turn of events for teams American Joumal of Public Health 1649

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of researchers and policymakers interested in Asian/Pacific Islander health data. Under the favorable circumstances described above, we make the following recommendations: 1. NCHS should implement its new 1992 race coding in vital statistics beyond the current 8 registration areas to include all 10 states where 79% of Asian/Pacific Islanders are concentrated according to the 1990 census, and by the year 2000 extend the new code structure to all 54 registration areas. 2. This new code structure should be extended beyond the vital statistics system to include all survey programs maintained by NCHS (including those that are based on surveys of existing medical abstracts or records, both the patient's and the hospital's, and not just face-to-face interviews). 3. Other federal government agencies (such as the Alcohol, Drug Abuse, and Mental Health Administration, the Agency for Health Care Policy Research, and the Health Care Financing Administration) that continue to classify Asian/ Pacific Islanders as one racial group should adopt NCHS's new race-coding structure in their forthcoming surveys so that we may have better data on subgroups of Asians and Pacific Islanders. 4. NCHS and the Bureau ofthe Census should conduct a series of basic "foundation" studies focused on obtaining estimates of the population and health characteristics of Asian/Pacific Islanders, assessing consistency in reporting of ethnicity by these populations, and improving the intercensal count of Asian/Pacific Islander populations in specific ethnic neighborhoods. 5. NCHS should work with independent investigators and community organizations to plan special methodological studies, primarily focused on sampling and secondarily on modes of interviewing Asian/Pacific Islander populations. 6. NCHS should encourage and fund developmental research jointly conducted with independent investigators around selected health topics in anticipation of using the products of these studies as supplements to future National Health Interview Surveys or NHANES surveys. 7. NCHS should encourage the development of multilanguage versions of some of its upcoming surveys (e.g., the National Health Interview Survey CORE Survey, NHANES, the National Survey of Family Growth, the National Matemal and Infant Health Survey, and the Na1650 American Journal of Public Health

tional Mortality Followback Survey) so that comparable interview instruments will be available to conduct special studies of specific subgroups of Asian/Pacific Islanders, parallel to and comparable with NCHS's ongoing programmatic surveys of the general US population. 8. For reasons of cost containment, the foundation studies should, at the minimum, target ali 10 leading states and top 15 metropolitan statistical areas with the largest numbers of Asian/Pacific Islander populations. 9. Through the mechanisms of grants and contracts, some ofthe research sites should be selected as data centers. The latter's function would be to conduct special health surveys on various Asian/ Pacific Islander subpopulations through an innovative sample design that would take maximal advantage ofthe presence of different combinations of Asian and Pacific Islanders in these specific locations. 10. NCHS should take advantage, in planning the next cycles of the National Maternal and Infant Health Survey and the National Mortality Followback Survey, of the availability of more detailed ethnicity identifiers in the vital statistics data and include separate samples of at least one, if not two, of the following groups: Chinese, Filipino, Japanese, Asian Indian, Korean, Vietnamese, Hawaiian, Samoan, or Guamanian. Thus far, NCHS has provided the best national data on the health of the US population. It has the statistical expertise to design special surveys and to obtain valid and precise estimates of emerging groups of Asian/Pacific Islanders, if funding is made available. But NCHS is not currently equipped or staffed to undertake the critical task of multiple-language instrument development. This is where collaboration with independent investigators and community organizations would be most beneficial. As future appropriations become available, we must be cognizant of the methodological and linguistic issues involved in surveys of Asian/Pacific Islanders. The 1990s provide the best opportunity yet for mainstream researchers and Asian/Pacific Islander investigators to work cooperatively in designing and implementing cross-national surveys on the health of special ethnic populations. O

berg, Jennifer Madans, Al Sirocco, Arlene Seller, Karen Allen, Madelyn Lane, and many other staff of the National Center for Health Statistics (NCHS) for their prompt response to inquiries made about NCHS's survey programs and vital statistics system. Thanks are also due to Chris Strobel and Terry Ann Lowenthal for providing information about the status of the Decennial Census Improvement Act.

References 1. US Department of Commerce. Race and Hispanic Origin. 1990 Census Profile Number 2, June 1991. Washington, DC: US Bureau of the Census; 1991. 2. Population ofMetropolitanAreas by Race and Hispanic Origin 1990. Washington, DC: US Bureau ofthe Census; 1991. CB91229. 3. Chung CS, Tash E, Raymond J, Yasunobu C, Lew R. Health risk behaviors and ethnicity in Hawaii. Int JEpidemioL 1990;19: 1011-1018. 4. Curb JD, Aluli NE, Kautz JA, et al. Cardiovascular risk factor levels in ethnic Hawaiians.AmJPublicHealth. 1991;81:164167. 5. Kato H, Tillotson J, Nichaman MZ, Rhoads GG, Hamilton HB. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California: serum lipids and diet. Am JEpidemioL 1973;97:372-385. 6. Reed D, Yano K. Epidemiological studies of hypertension among elderly Japanese and Japanese Americans. Asia-Pacific J Public Health. 1987;1:49-56. 7. Robertson TL, Kato H, Rhoads GG, et al. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California. Am J Car-

Acknowledgments

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Support in part by National Institutes of Health Grant 1 R01 CA49569-03 is gratefully acknowledged. We are grateful to John E. Patterson, Ed Hunter, Paul Placek, Jae Choi, Harry Rosen-

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