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Assessing the Cultural in Culturally Sensitive PrintedPatient-Education Materials for Chinese AmericansWith Type 2 DiabetesEvelyn Y. Hoa, Henrietta Tranb & Catherine A. Cheslab

a Department of Communication Studies, University of San Franciscob Department of Family Health Care Nursing, University of California at San FranciscoPublished online: 21 Jan 2014.

To cite this article: Evelyn Y. Ho, Henrietta Tran & Catherine A. Chesla (2015) Assessing the Cultural in Culturally SensitivePrinted Patient-Education Materials for Chinese Americans With Type 2 Diabetes, Health Communication, 30:1, 39-49, DOI:10.1080/10410236.2013.835216

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Health Communication, 30: 39–49, 2015Copyright © Taylor & Francis Group, LLCISSN: 1041-0236 print / 1532-7027 onlineDOI: 10.1080/10410236.2013.835216

Assessing the Cultural in Culturally Sensitive PrintedPatient-Education Materials for Chinese Americans With Type 2

Diabetes

Evelyn Y. HoDepartment of Communication Studies

University of San Francisco

Henrietta Tran and Catherine A. CheslaDepartment of Family Health Care NursingUniversity of California at San Francisco

Type 2 diabetes affects Chinese Americans at an alarming rate. To address this health disparity,research in the area of cultural sensitivity and health literacy provides useful guidelines forcreating culturally appropriate health education. In this article, we use discourse analysis toexamine a group of locally available, Chinese- and English-language diabetes print documentsfrom a surface level and deep structure level of culture. First, we compared these documentsto research findings about printed health information to determine whether and how thesedocuments apply current best practices for health literacy and culturally appropriate healthcommunication. Second, we examined how diabetes as a disease and diabetes managementis being constructed. The printed materials addressed surface level culture through the use ofChinese language, pictures, foods, and exercises. From a deeper cultural level, the materialsconstructed diabetes management as a matter of measurement and control that contrasted withprevious research suggesting an alternative construction of balance. A nuanced assessment ofboth surface and deeper levels of culture is essential for creating health education materials thatare more culturally appropriate and can lead to increased health literacy and improved healthoutcomes.

Asian Americans are the fastest growing racial immigrantgroup in the United States, and Chinese Americans (CAs)are the largest Asian ethnic group at 4 million people(U.S. Department of Commerce, 2013). After adjusting forbody mass index (BMI), the odds of type 2 diabetes preva-lence in Asian Americans are 60% higher than Whites(King et al., 2012). However, studies find heterogeneityamong Asian Americans regarding diabetes prevalence withNative Hawaiians (King et al., 2012), South Asians, andFilipinos having higher prevalence than CAs (Lee, Brancati,& Yeh, 2011). In addition, CAs with low BMIs and largewaist circumferences have a higher risk for diabetes than

Correspondence should be addressed to Evelyn Y. Ho, Department ofCommunication Studies, KA 340, University of San Francisco, 2130 FultonStreet, San Francisco, CA 94117. E-mail: eyho@usfca.edu

similar Whites (Rajpathak & Wylie-Rosen, 2010). Giventhese health inequities, in this article, we examine to whatextent printed health communication materials are designedto address the culture-specific needs of Chinese Americanswith type 2 diabetes to reduce health disparities for thisparticular group.

CULTURAL APPROPRIATENESS, HEALTHLITERACY, AND HEALTH DISPARITIES

Originally introduced in the United States in 2000 by theOffice of Minority Health (OMH), the National Standards forCulturally and Linguistically Appropriate Services (CLAS)were created to guide the nation’s health providers and healthcare organizations toward reducing healthcare disparities(U.S. Department of Health and Human Services [DHHS],

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40 HO, TRAN, AND CHESLA

2001). Recognizing the increasing diversity in the UnitedStates, the importance of culturally competent health care,and long-standing health disparities, the CLAS was recentlyenhanced and updated (in 2013), adopting a more complexdefinition of culture that moves beyond just race, ethnic-ity, and language and also focuses on geography, religion,spirituality, and biological and sociological characteristics(OMH, 2013). The enhanced CLAS now has as its principalstandard, to “provide effective, equitable, understandable,and respectful quality care and services that are responsiveto diverse cultural health beliefs and practices, preferredlanguages, health literacy, and other communication needs”(OMH, 2013, p. 13). The continued evolution of CLASstandards demonstrates that health care and health commu-nication in the United States can still be improved regardingthe needs of culturally diverse people.

One reason for the difficulty in improving culturallyappropriate care may stem from the different ways cul-ture is conceptualized and studied in health communicationresearch. Resnicow et al. (2000) distinguish between surfaceand deep levels assessments of culture. Surface-level struc-ture “involves matching intervention materials and messagesto observable social and behavioral characteristics of a tar-get population” (p. 273), such as using pictures of peopleor familiar music, language, foods, brand names, or loca-tions. These surface-level indicators of cultural sensitivityare treated as static traits that act as predictable variables fordeveloping health communication strategies. On the otherhand, a deeper analysis examines cultural dimensions ofhealth care such as “how members of the target populationperceive the cause, course, and treatment of illnesses as wellas perceptions regarding the determinants of specific healthbehaviors” (Resnicow et al., 2000, p. 274). As Resnicowet al. conclude, attention to surface structure culture is use-ful for receptivity and comprehension, while a focus ondeep structure should lead to salience and increased impact.Therefore, assessments of cultural appropriateness shouldexamine culture on both levels.

Culturally competent health communication and healthliteracy are integrally related, and both research areas areconcerned with decreasing health disparities (Lie, Carter-Pokras, Braun, & Coleman, 2012). Health literacy has beendefined in many ways (Cameron, Wolf, & Baker, 2011), withsome definitions focusing on health literacy as a clinical riskand others conceptualizing health literacy as a personal assetor outcome of health education (Nutbeam, 2008). In thisarticle we use the latter understanding focusing on healthliteracy as “an outcome to health education and communica-tion that supports greater empowerment in health decision-making” (Nutbeam, 2008, p. 2074). Instead of a barrier tohealth communication, tailored health communication andeducation can lead to improved health literacy, which canlead to better health decision making and outcomes.

Many scales and measurement devices exist to assess thehealth literacy of any given print communication and aretypically designed to allow for a relatively quick assess-ment (for one overview see Cameron et al., 2011). One

widely used measure specifically designed for testing printedmaterials that takes into account culture is the SuitabilityAssessment of Materials (SAM) instrument (Doak, Doak,& Root, 1996). One of the six dimensions of the SAMinstrument related specifically to culture is cultural appro-priateness and includes two scores: (a) match in logic,language, and experience, and (b) cultural image and exam-ples. While both of these scores can be used to evaluatesurface and deeper structures, the instructions for SAM focusmore on surface-level attributes. For example, the first scorementions that including vegetables such as asparagus andromaine lettuce may not be culturally matched if those inthe target audience do not eat those vegetables. The SAMinstrument is designed to allow a scorer to assess a printhealth document and obtain a numerical score of suitabil-ity in about 30 minutes. Its strengths are its systematicassessment criteria, speed, and relative ease of use. However,such quick assessments may fail to uncover any deeperstructure cultural assumptions/constructions, and both areimportant for evaluating a document’s receptivity andsalience.

Despite efforts to improve health literacy, unfortunately,national studies indicate that only 12% of Americans areproficient in health literacy and as many as 14% fallin the “below basic” category of health literacy (Kutner,Greenberg, Jin, & Paulsen, 2006). Low health literacy (LHL)is often associated with cultural/ethnic/racial differencesin health interactions (Lie et al., 2012) and lower overallhealth status (Sentell & Braun, 2012). These associationsmay be exacerbated by limited English proficiency (LEP).In a study of California residents, Sentell and Braun (2012)found that individuals with LEP and LHL had the highestprevalence of poor health. Specifically, Chinese Americanswith LEP showed the highest rates of LHL (68.3%), com-pared to 18.8% of Whites with LEP, 17.9% of Latinos, andonly 8.1% of Vietnamese. The authors conclude that thesediscrepancies may align with differences in some groups’access to and use of translators or in-language materials.This is especially troubling given that nationwide 75% ofChinese Americans speak a language other than English inthe home and 42% have LEP (APALC & AAJC, 2011). At aminimum, as a surface-level consideration, printed healtheducation materials need to be created in Chinese for LEPCAs.

While spoken Chinese has hundreds of dialects, thereare two common written scripts—traditional and simpli-fied. Mainland China adopted simplified characters in the1950s–1960s to be used as its standardized writing system,whereas Taiwan, Hong Kong, and Macau are still using tra-ditional characters (Kane, 2006). Knowing traditional char-acters enables readers to learn simplified characters becausesimplified ones are derived from traditional characters withreduced strokes and simplified radicals. However, movingfrom simplified to traditional is more difficult. In healthcare increased attention is paid to the varied literacy needsof Chinese throughout the world, and numerous scales thatwere previously available only in English or traditional

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MATERIALS FOR CHINESE AMERICANS WITH DIABETES 41

Chinese are being translated and validated into simplifiedChinese.1

There is a small but growing body of work examin-ing type 2 diabetes specifically among CAs. Research hasdescribed Chinese Americans’ health beliefs (Chesla, Chun,& Kwan, 2009) and practices (Xu, Pan, & Liu, 2010),and tested culturally-tailored diabetes self-management edu-cation programs (Wang & Chan, 2005). A recent reviewestablished best practice guidelines for overall health com-munication with CAs about type 2 diabetes (Ho, Chesla, &Chun, 2012). Especially relevant for printed health materials,the Ho et al. (2012) review concluded that health messagesshould focus on both the social and physical consequencesof diabetes, address patients’ beliefs and practices regard-ing Chinese medicine, foods, and eating, and engage familymembers as part of the diabetes self-care. However, researchhas not yet examined (from both a surface and deep struc-ture level) the cultural appropriateness of available healthdocuments.

Printed health information is just one source of healtheducation materials. However, given how pervasively thesematerials are used, they constitute an extremely importantsource of potentially culturally and linguistically appropriatehealth information for those with diabetes—one that patientscan repeatedly come back to for reference outside medicalestablishments. Scholars recognize the importance of healthcommunication outside the clinical encounter, and printmaterials are one way of increasing the amount of materialthat a clinician can communicate with a patient (Cameronet al., 2011). Because they are written in Chinese, they alsoserve as a linguistically appropriate form of health commu-nication for those whose preferred language is Chinese. In astudy of Chinese Americans with diabetes, Hsu et al. (2006)found that participants preferred using diabetes health infor-mation from health providers or newspapers, as opposed tousing printed health information. The authors explain thatthis may have been caused by a lack of suitable Chinese-language health education materials. In Chinese Americans,as in the general public, print materials are an importantresource for affecting health behavior. More recent studiesare not available about preferred sources of health informa-tion for CAs, but as more printed health information for thispopulation is developed, it is important to assess the cul-tural relevancy of such materials. Therefore, the researchquestions that guided this work were:

1. What is cultural about printed type 2 diabetes healthinformation for Chinese Americans?a. What surface-structure markers of culture are

used?b. What deep-structure markers of culture are used?

1 Numerous very specific examples abound, ranging in scope from theIowa Infant Feeding Attitude Scale (Chen et al., 2013) to the Core OutcomeMeasures Index (COMI) for low back pain (Qiao et al., 2013).

2. Are the materials culturally appropriate for ChineseAmericans with type 2 diabetes?

METHOD

Documents and Data Collection

Data consisted of 16 fliers, pamphlets, and booklets col-lected from five different organizations. The documents wereprinted in either separate Chinese or English versions or acombined bilingual version presenting Chinese and Englishside-by-side. These handouts were chosen because thesewere the print resources available in many health clinicsserving CAs in the San Francisco area. Many of these docu-ments were distributed in print as patient education materialand/or were accessible as downloadable documents on localhealth agencies’ websites. We decided to include these dia-betes materials because these were the documents availableto the community with whom we work.

In San Francisco, Asian Americans constitute 33%of the city’s population, and CAs are the largest AsianAmerican group, representing one out of every five resi-dents (152,000 individuals). The majority of CA adults inSan Francisco (81%) are immigrants, 50% report speakingEnglish poorly or not at all, and they are more likely tohave lower household incomes than Whites (NICOS, 2004).Despite the presence of several health agencies that caterto monolingual CA immigrants, access to formal diabeteseducation programs in Cantonese or Mandarin are limited.Although these services are increasing, in one recent study,the majority of CA patients (60%) obtained their diabetesknowledge from primary care providers rather than withinformal classes (Chesla et al., 2013).

The texts ranged in size from a one-page handout to a67-page booklet. Because some organizations had differ-ent versions of the same material, some of the documentswere redundant. See Table 1 for more detailed informationabout each of the texts. Some of the documents were cre-ated by local health agencies, including those from ChineseCommunity Health Resource Center (CCHRC), CaliforniaPacific Medical Center (CPMC), and Northeast MedicalServices (NEMS). The other documents were created bynational organizations/corporations (Merck, The NationalDiabetes Education Project). Some of the documents wereused specifically in diabetes education programs (see Sun,Tsoh, Saw, Chan, & Cheng, 2012), and all were available toproviders to distribute to patients with diabetes. We includedall materials that were available in health clinics catering toCA populations.

Data Analysis

Most of the documents were printed in both Englishand Chinese. The second author is fluent in English and

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42 HO, TRAN, AND CHESLA

TABLE 1Printed Health Education Materials

Publication Name Publication Type Goals Language(s)

Merck Today’s Your Day 29-page booklet Education/management/record keeping Chinese, EnglishMerck Diabetes & Me Front-to-back handout adapted from

bookletGeneral education Chinese, English

The National Diabetes Education Project(NDEP) Take Care of Your Heart

Front-to-back handout Diabetes heart health Chinese, English

NDEP Two Reasons Front-to-back handout Prediabetes and diabetes prevention Chinese, EnglishNDEP 4-Steps to Control 17-page booklet Education/management/record keeping Chinese, EnglishChinese Community Health Resource

Center (CCHRC), San Francisco67-page booklet Education/management/record keeping Chinese and English

Diabetes ManagementCCHRC Diabetes; Blood Sugar; Carb

Count; Dental; Eye; Foot; Gestational;Sample Meal

Nine separate one- or two-page fliersmostly adapted from booklet

Topics included diabetes general,carbohydrates, blood sugar, dental, diet,eye and foot care, sample meal, andgestational diabetes

Chinese, English

California Pacific Medical Center(CPMC), San Francisco Meal Planning

One-page flier Food guide—text Chinese, English

CPMC Asian Food Guide Six-page handout Food guide with illustrations ChineseNortheast Medical Services (NEMS), San

Francisco Diabetes Affects the EyeSix-fold pamphlet, one page

front-to-backEye information English and Chinese

NEMS Keeping Your Eyes Healthy Six-fold pamphlet, one pagefront-to-back

Eye health management English and Chinese

NEMS Treatment for Diabetic Retinopathy Six-fold pamphlet, one pagefront-to-back

Eye disease treatment English and Chinese

Cantonese and is able to read both traditional and simplifiedChinese characters. She compared document translationsand noted any places where translations were not exact eitherbecause of colloquial phrasing used in English and Chineseor as just a difference in translation. She then translatedthese sections into English for analysis.2 Generally speak-ing, there were very few places of difference—around 1–2%of the documents had these discrepancies—and the trans-lation quality and clarity in both languages were very highand easily understandable. Discrepancies, although rare, didoccur in two forms. First, some Chinese and English sec-tions had different wording. This is to be expected, as noteverything in English has a literal translation into Chinese(and vice versa), and strong translations should not haveexact equivalents. One example is an English document thatstates, “With the support of your family and friends, yourhealthcare team, and your community, you can take chargeof your diabetes” (emphasis added). In the Chinese docu-ment, the phrase used for take charge is “ ,” whichcould literally be translated as “assertively face” instead of“take charge.” However, the meaning in this sentence (about

2 We did not use a professional translation service in reading the Chinesedocuments. However, to confirm the work of the second author, we gave asample of the materials (one full document and a selection of translationdifferences) to a Chinese language and linguistics professor who has doneprofessional translation work. He confirmed the points made by the secondauthor.

facing your diabetes in a positive/assertive fashion), whilenot literally equivalent, is semantically equivalent. Second,the Chinese and English documents may have had similarwording when they should not have. For example, in a sen-tence about creating an “exercise program” in English, theChinese document used the term “ ,” which means exer-cise, but in the sports/training sense of the term. A bettertranslation/phrase could have been “ ,” meaningan exercise program. We noted each of these discrepanciesto see what if any effect they had on the overall readabil-ity of the documents. Because they did not affect the overallmeaning, we felt comfortable analyzing the English versionsof the documents and English translations of any discrepantsections.

We analyzed the texts using discourse analysis focus-ing on how meanings—especially of health and culture—aresocially constructed (Tracy, 2001). First, we read the docu-ments for how they delivered health messages in light of thebest practices presented earlier (Ho et al., 2012) using a rel-atively surface-level structure examination of culture such aslanguage and cultural images. The first two authors agreedon these instances. Second, the documents were further ana-lyzed for their deeper structure from a discourse-analyticperspective (Gee, 2011), paying attention to how the textsconstruct, maintain, or contest particular cultural understand-ings of diabetes and diabetes treatment and downplay orignore other understandings (Dutta, 2007). In this analysis,we examined culture both in terms of what might be labeled

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MATERIALS FOR CHINESE AMERICANS WITH DIABETES 43

Chinese-specific understandings, worldviews, or health prac-tices and in terms of cultural practices and understanding ofdiabetes management itself. We also examined the transla-tion discrepancies to see whether these pointed to importantcultural differences. We conducted this analysis iteratively,going back and forth from initial analysis back to texts torefine our analysis until we settled on the themes of man-agement, control, and balance. The first two authors thenwent back through all texts to look for examples of diabetesmanagement, control, and balance and reached agreement onexemplary quotations. In the next sections we present ourfindings.

SURFACE STRUCTURE MARKERS OF CULTURE

The four most obvious surface-level cultural markers weretheir printing in Chinese, pictures of Asian people, inclusionof Chinese foods, and reference to Chinese exercises. Usingthe criteria of match in language and use of cultural imageand examples, these documents were overall very strong, andat times, these sections showed glimpses of deeper level cul-ture. In the following sections, we discuss in more detailhow each aspect worked to increase or decrease the culturalcompetency of the documents.

Language

At the most basic level, health messages need to be dis-seminated in appropriate and preferred languages, andthe widespread availability of these health materials inChinese and English meets established baseline best prac-tices. As mentioned earlier, the Chinese-language versionsof materials were well written and were equivalent in mean-ing to the English documents. The example presented earlierof the translation discrepancy of the Chinese “assertivelyface” versus the English “take charge” demonstrates that thedocuments were well crafted in a linguistically appropriatemanner for Chinese readers. However, the documents thatwe collected were all printed using traditional characters.For that reason, these documents may not be as cultur-ally sensitive to the literacy needs of more recent Chineseimmigrants from mainland China who use simplifiedcharacters.

Pictures

All the Chinese-language documents that used pictures ofpeople included only Asian models. On the other hand, manyof the English equivalent documents presented a multicul-tural motif including many different non-White models. Forexample, in the “4 Steps to Control your Diabetes for Life”brochure, the English cover had five photos, only two ofwhich used noticeably Asian people. The Chinese versionof the same brochure only used two pictures (different from

the English version) on the cover of Asians. From a practicalstandpoint, this makes sense as the English version is likelydistributed to a wider audience than the Chinese languagepamphlet. The inclusion of appropriate pictures is what isimportant from a surface-level reading.

Food

There were many surface-level examples of culturally appro-priate foods. From lychees to rice porridge, all of the locallyproduced documents that gave food examples (CPMC,CCHRC) included common Chinese foods. The Merck andNDEP brochures did not mention Chinese-specific foods andinstead presented information about healthy foods such as“fruits and vegetables, fish, lean meats, chicken or turkeywithout the skin” (NDEP 4 Steps). While Chinese peoplecertainly eat these foods, there was a difference between thispresentation and “Limit white rice, rice porridge, glutinous(sticky) rice and rice products such as cheong-fun, mei-fun,ho-fun, rice dumplings, rice balls, and rice cakes” (CCHRCDiabetes Management). The former may still be culturallyappropriate. However, the latter is likely culturally stronger.

Food was a topic that allowed for a deeper level analy-sis of culture. For example, one document called Asian FoodGuide (in English) was available in other languages includ-ing Cambodian, Chinese, Korean, Laotian, and Vietnamese.The guide included such Asian foods as congee, wontonwraps, lychee, and winter melon. However, the Chinese lan-guage version of this document was titled “Chinese FoodGuide,” not “Asian Food Guide,” and contained the exactsame foods listed. While this is a subtle translation differ-ence, it may point to the fact that what makes the guideChinese is the fact that it is written in Chinese, not that thereare different Chinese (as opposed to Laotian or Vietnamese)foods included. In other words, the title should probably read“Asian Food Guide” in English (focusing on Asian food).But in Chinese, it should read “Chinese Food Guide” (focus-ing on using Chinese language). In addition, not all of thefoods listed were obviously Asian or Chinese. In fact, italso included foods such as mayonnaise, cottage cheese, andhamburger buns, which are not elements in an Asian dietbut may be eaten by some Asian Americans, depending onacculturation and personal preferences. What this demon-strates is the difficulty in clearly determining what might beconsidered Asian or Chinese in an effort to provide culturallysensitive materials.

Besides the actual foods, the documents also presenteddifferent ways of eating foods. A subtle difference in trans-lation around how to eat demonstrated a glimpse at a deeperlevel cultural sensitivity. In three out of eight documents thatprovided explicit food measurement recommendations, theChinese term for bowl was used for the English measurementterm cup. A previous study of CAs and diabetes managementdemonstrated that while CAs know to adjust their diets, theydo not regularly measure the amount of food consumed as

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44 HO, TRAN, AND CHESLA

part of their dietary changes (Washington & Wang-Letzkus,2009). In that study, in the few instances in which peopledid report measurements, participants typically spoke aboutamounts of food in less explicitly numeric ways, such as “abowl of ‘hot soup’ or ‘cup of ‘vegetable juice’” (Washington& Wang-Letzkus, 2009, p. 314). These descriptors focusedon how something is consumed (in a bowl or cup) as opposedto measurements such as measuring cups or ounces. In ourdata set, this translation discrepancy may more closely alignwith Chinese understandings of food and eating and in factmay be more culturally appropriate. The CCHRC DiabetesManagement booklet provided suggestions for the amount ofstarchy carbohydrates to eat at each meal. This booklet wasprinted with English on one side of the page and Chineseon the adjacent side. The Chinese stated “Approx. 1 bowlcooked rice/noodle/cereal . . . 1 bowl = 8 oz” and in theEnglish, it stated “Approx. 1 cup cooked rice/noodle/cereal. . . 1 cup = 8 oz” (emphases added). While the differenceis subtle, the Chinese may be more culturally appropriateand may begin to link the measurements that are actuallyused (a bowl used to eat rice or noodles) with quantita-tive measurements (8 oz) and thus assist Chinese who arenot as accustomed to measuring their food. At the sametime, it is important to recognize that the pamphlet also pro-vided a quantitative measurement for a bowl because bowlsobviously range in size.

Exercise

Most of the documents with exercise recommendations sug-gested activities such as walking, bicycling, and other low-impact exercises. Only one document recommended whatmight be recognized as Chinese exercises: Tai Qi and LooTung Chuan (CCHRC Diabetes Management). These werepresented in a list of exercises along with walking, swim-ming, and others. The document also recommended avoidingChi Kung, Qi Gong, heavy weight lifting, and other high-impact exercises. While it is culturally important to includeexercises with Chinese origins, the mere inclusion of theseis relatively surface-level in its cultural sensitivity. Insteadof the document talking about how Tai Qi might functionas a foundation for health and stimulating Qi, Tai Qi wasmerely listed as one of many exercise options, equivalent toswimming or walking.

These health documents had little to no information aboutthe use of medicinal foods, herbs, or other Chinese medicinetreatments for diabetes. Despite research that demonstratesthat CAs often use everyday foods and specialty medicinalfoods to treat diabetes and other illnesses (Chesla & Chun,2005), there was no mention of this practice or any sug-gestions for how this practice could be incorporated intodiabetes-related diet suggestions. The lack of herb recom-mendations is easily explained in part because there is littlescientific evidence in human studies to guide such recom-mendations (Covington, 2001). However, the lack of any

recognition that patients are using herbal medicines andeating Chinese medicinal foods is clearly not culturally rele-vant. Health education materials, while not advising the useof Chinese herbal medicine, could at least guide persons withdiabetes to discuss their herbal medicine use with their healthcare providers. This is especially important because someCAs receive herbal medicine recommendations from friendsand neighborhood herbalists and may not think to disclosethis information to health providers (Wang & Wylie-Rosett,2008).

CULTURAL CONSTRUCTION OF DIABETES:DEEPER STRUCTURE CULTURE

The overarching goal of all of the printed health materialswas to educate readers about diabetes and how to managethe disease. Therefore, it is not surprising that a major themethat arose from the materials was management. However, bydeepening our notion of cultural, we can begin to under-stand these pamphlets as both reflecting and reinforcing aparticular cultural understanding of health that may not alignwith CAs’ own health ideas. The overarching goal of thesepamphlets—to manage and control—is typical of how dia-betes self-management is usually presented and can be seenas a goal of biomedical care for diabetes (Gomersall, Madill,& Summers, 2011). Underlying both of these constructionsis the assumption that people want to take control of theirdiabetes as an important life priority. This stands in con-trast to a Chinese understanding of health and health carethat focuses more on the idea of balance and homeostasis(Chesla et al., 2009). Physical health may be an importantpriority, but emotional, spiritual, psychological, and socialconsiderations also play a role in determining how to bal-ance one’s life. Examining culture on these deeper levelsproblematizes taken-for-granted conceptualizations of healthand healing that are not actually universal. In the follow-ing sections, we examine the pamphlets’ cultural construc-tion of diabetes care as management and control and thenexplore the possibilities for an alternative construction usingbalance.

Manage

Successful diabetes management is presented as the ulti-mate goal for those with diabetes. However, successfulmanagement is also portrayed as extremely complicated,encompassing a wide scope of activities, mostly dealing withphysical health. The major domains for diabetes manage-ment that are addressed in every comprehensive pamphletincluded measurement and recording of blood glucose, dietand exercise guidelines, and foot and eye care. Successfuldiabetes management focused on two related issues: (a) theimportance of measurement and (b) managing the dialectic

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MATERIALS FOR CHINESE AMERICANS WITH DIABETES 45

between management as a daily process and management asa preferred end state.3

Management and measurement go hand in hand in thesetexts. In fact, blood glucose management was centrallyimportant in all pamphlets and has been described as thegoal of a Western/biomedical approach to diabetes treat-ment (Covington, 2001). While measurement is certainlyimportant for managing a chronic disease such as diabetes,previous research has also shown that many CAs do notunderstand what effect diet and exercise have on their mea-surements (Jayne & Rankin, 2001). In fact, the pamphletsdiffered in how much instruction was given about what to dowith those measurements:

Example 1: “Record your targets and the date, time, andresults of your checks. Take this card with you on yourhealth care visits. Show it to your health care team”(4 Steps to Control Your Diabetes for Life).

Example 2: “Talk to your health care team about your bloodglucose targets. Ask how and when to test your blood glu-cose and how to use the results to manage your diabetes”(4 Steps to Control Your Diabetes for Life).

Example 3: “Learn to recognize the symptoms of low bloodsugar, which may include feeling nervous, shaky, sweaty,or tired . . . If you have signs of low blood sugar, test yourblood right away. If your blood sugar level is less than60 mg/dL, eat or drink a carbohydrate immediately, suchas a cup of juice (4 oz.), 3 teaspoons of honey, or 3 to5 pieces of hard candy. You may need to have a meal oranother snack within 30 minutes” (Merck Today’s YourDay) .

In Example 1, the act of checking, recording, and report-ing appears to be what counts as good management.Example 2 presents the idea that measuring and recording,with the help of a health provider, is the basis for mak-ing useful adjustments for better management. However, inboth cases, neither document explains how an individual canuse the information collected. Compare these with the thirdexample, which offers concrete and specific measurementsand explains how to make adjustments (eat or drink, eatagain in 30 minutes) based on the measurements. This lastexample provides the best form of self-appraisal informa-tion. However, this was not typical and was the only exampleof such detailed instructions.

Managing diabetes is both a daily task and a learned setof skills to be patiently and diligently mastered over time,leading to a useful lifetime process:

3 People with type 2 diabetes monitor current blood glucose levels(using a finger-stick and a glucometer), as well as long-term blood glucoselevels using the hemoglobin A1C (a blood test that indicates variations inblood glucose over the last 3 months). Maintaining stable glucose levels isimportant to preventing more serious problems such as heart disease, kidneydisease, amputation, or blindness.

You don’t have to make all these changes at once. Take smallsteps. Set a manageable goal each day, and work to achieveit. Celebrate every improvement you make, no matter howsmall. Feel good about your efforts to manage your diabetes.(Merck Diabetes & Me)

These supportive statements recognize that diabetes manage-ment is a difficult process that takes time to fully achieve.

Despite the recognition that diabetes management is anongoing daily process, documents also focused on presentingdiabetes management as an end goal as well. As one book-let stated: “Combined with a healthy diet, regular physicalactivities may lower your need for insulin or diabetes med-ications. In fact, some people can manage their diabetes bydiet and exercise alone” (CCHRC Diabetes Management).While health providers understand that only those patientsin the early stages of diabetes may be able to manage with-out drugs or with fewer drugs, a possible interpretation fromthis pamphlet is that one could, through diligent regular man-agement (diet and exercise), use fewer or no drugs and stillmanage their disease. We discuss this further in the sectionon balance.

Control

While management seems to imply dealing with the con-stant flux and movement of blood glucose and diabetes ingeneral, the ultimate goal of diabetes management is pre-sented as control. Diabetes as a disease itself needs to becontrolled and patients are taught to control the measurementindicators of diabetes such as blood glucose. For example,sometimes control is aimed at the indicator: “People withdiabetes must work to control their blood sugar, blood pres-sure, and cholesterol to help prevent the negative effects ofdiabetes” (Merck Today’s Your Day). At other times, it isthe diabetes itself that needs to be controlled: “It may helpto realize how much control you do have over your diabetes”(Merck Today’s Your Day).

Control is presented as an achievable end goal, and all ofthe documents recognize how difficult these efforts are thatmust be taken to achieve control. People with diabetes must“work to control” but “your efforts can help control the dis-ease and help you to live a long, healthy, happy life” (MerckToday’s Your Day). In these documents, the implication isthat having diabetes is already seen as being out of control.People are reminded that they can regain control of certainparts of their bodies: “Even if you have been diagnosed withdiabetes, you can take control to keep your eyes and bodyhealthy” (NEMS Keeping Your Eyes Healthy).

One main focus of control is on stability, ensuring bloodglucose levels do not vary too much from an acceptablerange. Stability is both a desired outcome and a key markerthat one is under control and therefore healthy. As onedocument stated:

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It is common for people who are getting their blood sugarsunder control to experience fluctuations in their vision whilethe sugars normalize at a new, good level. (NEMS DiabetesAffects the Eye)

In this example, the expressed goal is to control and sta-bilize blood sugar. One side effect of fluctuations in bloodsugar is corresponding fluctuations in vision. This statementis both informative (explaining that fluctuations can be antic-ipated) and persuasive (once one is able to control bloodsugar, vision will also be stabilized).

While diet, exercise, and foot care were all described asimportant to diabetes management, these three areas werenot presented using the terminology of control. Instead, thedocuments point only to controlling one’s weight as a goalof diet and exercise. For example:

Exercise regularly: physical activity strengthens the heart,helps to control weight and improves blood sugar control.It may even decrease your need for insulin or medication.(CCHRC Diabetes)

In this case, control functions in successive steps. Exerciseworks to control weight, which works to improve bloodsugar control. The positive benefit of such control is thedecreased need for medication and insulin.

Contrast the preceding examples with the Merck Diabetes& Me pamphlet that explains: “Uncontrolled high bloodsugar, when present for a long time, can cause health prob-lems, such as heart disease, kidney disease, blindness, andpoor circulation, which may lead to limb amputation.” Theprevious two examples focus on positive benefits of control.This example, contrastingly, persuades through presentinga threat. Previous health promotion research concludes thatwhen using fear appeals, it is important to present threats thatare fear-inducing enough to be taken seriously along withactions that a person feels capable of accomplishing that canavoid those threats (Murray-Johnson & Witte, 2003). In thiscase, the action of control is implied, rather than stated. Onemight read that since uncontrolled blood sugar leads to thethreat of heart disease and other problems, controlling bloodsugar will prevent those threats. This action component ismore explicitly stated later in the same pamphlet:

Between 60% and 70% of patients with diabetes have nervedamage, mostly in the nerves of the feet and legs. Controllingyour blood sugar can help prevent or delay nerve damage andrelated problems. (Merck Diabetes & Me)

Notably, the documents that use fear appeals (such as loss oflimbs or vision, and death) all present information about howto avoid those losses using control vocabulary as opposed tomanagement. For example: “Controlling your blood sugarand blood pressure can help prevent or delay kidney dis-ease” (Merck Diabetes & Me). Control, thus more seriousthan management, is presented as the key to avoiding majordiabetes-related problems.

Although research recognizes the importance of familyand social support for CAs with diabetes (Chesla & Chun,2005), the health documents primarily suggest that dia-betes control is an individual responsibility. Only the Merckdocuments explicitly mention getting support from family,friends, or support groups as a way for you, the individual,to “take charge of your diabetes” (Merck Today’s Your Day).Another document used family as an incentive. The flier con-tains a picture of an older Chinese man and woman walkinghand-in-hand with a young boy and the title reads: “Tworeasons I find time to prevent diabetes . . . my future andtheirs” (NDEP Two Reasons). In another example, whichmore explicitly focuses on individual control, the documentstates in English:

Controlling diabetes is very much about making goodlifestyle choices—things that you can control. Use the powerof information to help you actively take control. (MerckToday’s Your Day)

The implication of individual personal responsibility isemphasized in the use of the boldfaced you. Individualresponsibility ignores any of the social, economic, and polit-ical conditions that may affect one’s ability to control theirdiabetes (Gomersall et al., 2011), and only one documentincluded a resource section describing Medicare, MedicarePart D, and prescription services assistance (Merck Today’sYour Day).

Balance

Despite recognition that CAs may understand balancein health care better than control (Chesla et al., 2009;Covington, 2001), very few health documents even mentionthe term and none use the concept of balance. In fact, theterm appears only seven times in two different documentsboth published by Merck (one is a smaller version of thelarger document). Of these seven cases, three are repeated inboth pamphlets such that there are really only four differentuses of the term balance. In all of those instances, the termused is actually imbalance, which is used to define diabetes:

Sometimes the liver makes more sugar than the body needs,which causes the blood sugar level to get even higher and outof balance. (Merck Diabetes & Me and Today’s Your Day)

All instances of imbalance were similar to this example,focusing on blood glucose imbalance as the main physicalproblem of and explanation for diabetes.

From a holistic Chinese medical perspective, imbal-ances are the disease states, and the goal of treatment isto fix disharmonies to return to, as close as possible, astate of homeostasis not just regarding diabetes but in thewhole body physically, psychologically, and emotionally(Covington, 2001; Kaptchuk, 2000). Unlike biomedicine,which views diabetes as an insulin imbalance, there arethree types of xiao ke (the closest equivalent of diabetes in

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Chinese medicine). The types correspond to yin deficien-cies in the lung, stomach, or kidneys and manifest symptomsof excessive thirst, excessive hunger, or excessive urination,respectively (Covington, 2001). The documents’ use of theterm imbalance is similar, but not equivalent to, the Chinesemedical understanding of balance that focuses on holism.While one could read a holistic interpretation into these dia-betes materials (a goal is to maintain blood glucose balancethrough a combination of diet, exercise, and drugs, to avoiddiabetes complications), the documents seem to only focuson imbalance as an explanation for diabetes, as opposed topresenting balance as a goal for diabetes self-management.Take this second example:

In this type of diabetes, the body does not make enoughinsulin or the insulin that the body makes does not work theway that it should. The body may also keep making sugareven though it does not need it. Once a person has type2 diabetes, it does not go away. (Merck Today’s Your Day)

As this demonstrates, diabetes is a lifelong illness and thegoal for living with diabetes is either management or controlto avoid worse complications. This may run counter to someCAs’ beliefs for two reasons. First, there is the belief thatdiabetes is a curable (not chronic) disease (Jayne & Rankin,2001) and that if sugar consumption is controlled, glucosemonitoring, diet, and exercise are not necessary (Washington& Wang-Letzkus, 2009). Like others with diabetes, someCAs have a hard time taking early-stage diabetes seriouslybecause there are few negative symptoms (Jayne & Rankin,2001) and other priorities, such as family harmony and largesocial eating rituals, may be more immediately important.Second, some CAs may additionally have a hard time think-ing of controlling their diabetes, given their holistic sense ofhealth. A discussion of balance/imbalance may fit more eas-ily into their cultural health expectations because in Chinesemedicine diagnosis, subtle imbalances and disharmonies canbe assessed through tongue and pulse diagnosis long beforethey manifest into diseases (Kaptchuk, 2000). Therefore,Chinese medicine treatment is always a matter of correct-ing imbalances even when no outstanding symptoms exist.In other words, health education materials (regardless ofthe language) that present diabetes as this kind of holisticimbalance that requires lifestyle changes and support fromfamily/social networks may be more successful at achievingbehavior changes than those that emphasize only the per-manent imbalance of diabetes and the near impossibility ofmaintaining control over this imbalance.

CONCLUSION

Health education materials are continuously being improvedto meet cultural appropriateness/health literacy standards.From a surface level, this may include such traits as using the

appropriate language (e.g., simplified Chinese) and includ-ing culture-specific activities, pictures, and testimonies.From a deeper level, understanding the complexity of what iscultural about a document means acknowledging the impor-tance of different understandings of health that may be takenfor granted even beyond the language itself. What has typ-ically been treated as the norm—a biomedical approach tothe understanding and treatment of diabetes that focuses onmanagement and control—may not be as culturally relevantto CAs who begin with different health beliefs. In this article,we explore an alternative framing of balance but also recog-nize that even among CAs there is heterogeneity of healthbeliefs. Not all CAs believe in holism, and the idea of balanc-ing yin/yang may be more foreign than the idea of measuringand controlling blood glucose.

A nuanced assessment of both surface and deeper levelsof culture is essential for creating health education mate-rials that can increase health literacy that leads to betterhealth outcomes. On a surface level, the documents need tobe culturally relevant and minimally accessible in order tomeet culturally appropriate health literacy standards. In otherwords, they need to be readable and understandable by thoseusing them. However, from a deeper level, these health edu-cation materials may not be used if they do not addresshealth and health care in culturally appropriate or understoodways. From a literacy perspective, these documents may bereadable, but they may not actually be very persuasive.

This study is limited by the materials used for study.Future research should examine more health education mate-rials including online sources and include materials dis-tributed in other geographic areas in the United Statesand elsewhere, including China, Hong Kong, Taiwan, orother areas with many Chinese. In addition, ethnographicresearch can be conducted with CAs to see how they actu-ally read these documents. Although our analysis focusedon cultural constructions of health, we do not know howactual CAs would read and interpret the documents andtheir health constructions. We also recognize the limitsof not using professional translators to examine in fulldetail each Chinese/English discrepancy. Future researchcould certainly take a fine-tuned linguistic comb to thesedocuments to search for even more deep cultural con-cerns. Additional research should also examine CA healthbeliefs around the idea of balance as it is applied to dia-betes. It is currently unknown whether a state of balancecan be achieved, given the seemingly permanent imbal-ance that is diabetes. Knowing more about how CAsapproach diabetes and whether the treatment goals shouldbe framed as management/control or whether balance is apossibility may lead to more culturally appropriate healtheducation.

Despite these limitations, this study has important impli-cations for health educators and health providers. Whileculturally sensitive health education materials are now morewidely available for CAs, those materials can always be

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improved at both a surface and a deeper level. For example,rather than merely listing Asian foods, health educationmaterials could better recognize and address how CAs eatthose foods. Culturally appropriate devices for gauging foodamounts (bowls with measurements) could be consistentlypresented. New approaches, like the “plate method” ofcomposing a meal, could be developed for a Chinese dietwhere bowls may be more common. Guidance is needed forpatients to work with the social context of meals (e.g., largefamily gatherings and meals prepared by others). In addi-tion, health materials could present more extensive exerciserecommendations. Rather than merely listing the exercises,understanding how CAs practice something like Tai Qi—inSan Francisco, often in public and with friends—may lead tobetter implementation of these exercises.

Explicit acknowledgment of holistic health beliefs includ-ing balance and homeostasis that likely form a backgroundhealth understanding for many CAs might increase boththe receptivity and the salience of educational materials.Although care must be taken in communicating the chronic-ity of the disease, presenting diabetes care expectationsaround a goal of balance is culturally syntonic, and requiresa relatively minor shift in imagery away from control. Subtlechanges in writing can work to construct a different wayof approaching diabetes management. For example, recom-mendations for exercise type and amount might explicitlyreference how exercise can help balance glucose levels inthe body. Similarly, recommendations for glucose monitor-ing might be presented as “finding the right balance thatworks for you and your diabetes.” In Chinese there are multi-ple terms for balance. The term means balance and canbe used in health situations but does not imply homeostasis.However, (with the same last two characters forbalance) means homeostasis. Both of these forms of balancecould be used to usefully present diabetes self-managementgoals in a more culturally syntonic way.

While researchers and health care providers alike recog-nize the importance of providing culturally appropriate care,it is not always clear exactly how to do so. Even the best ofefforts to hit the checklists of best practices can sometimesleave some areas unaddressed. In this article, we used a moreexpansive understanding of culture—from both a surface anda deep structure—to look beyond static traits and recognizecultural understandings of disease etiology and experiencein an effort to improve health disparities for CAs with type2 diabetes.

FUNDING

This research was supported by a Research RecoveryAct Administrative Supplement (3 R01 NR010693-03S1).We thank Christine Kwan for her help in collecting thepamphlets.

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