Experience of Discrimination Among U.S. Chinese Older Adults

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1 Journals of Gerontology: MEDICAL SCIENCES The Author Published by Oxford University Press on behalf of The Gerontological Society of America. Cite journal as: J Gerontol A Biol Sci Med Sci November;69A(S2):S76 S81 All rights reserved. For permissions, please journals.permissions@oup.com. doi: /gerona/glu150 Advance Access publication October 18, 2014 Experience of Discrimination Among U.S. Chinese Older Adults XinQi Dong, 1 Ruijia Chen, 1 and Melissa A. Simon 2 1 Rush Institute for Healthy Aging, Rush University Medical Center and 2 Department of Obstetrics/Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Address correspondence to XinQi Dong, MD, MPH, Professor of Medicine, Nursing and Behavioral Sciences. Director, Chinese Health, Aging and Policy Program, Associate Director, Rush Institute for Healthy Aging, Rush University Medical Center, 1645 West Jackson, Suite 675, Chicago, IL xinqi_dong@rush.edu Background. Experiences of discrimination are detrimental to health and well-being. This study aimed to examine experiences of discrimination and responses to unfair treatment among community-dwelling U.S. Chinese older adults. Method. Guided by a community-based participatory research approach, 3,159 community-dwelling Chinese older adults aged 60 years and older in the Greater Chicago area were interviewed in person between 2011 and Results. Of the 3,159 participants interviewed, 58.9% were women and the mean age was 72.8 years. A total of 671 (21.3%) participants reported having experienced discrimination and 1,454 (48.2%) reported passive response to unfair treatment. Older adults living in Chicago s Chinatown had the lowest prevalence of perceived discrimination compared with those living in other areas. Younger age, higher education, higher income, fewer children, more years in the United States, more years in the community, poorer health status, lower quality of life, and worsening health over the last year were associated with higher frequency of discrimination reported. Younger age, higher education, higher income, being married, living with more people, having fewer children, more years in the United States, and better health over the past year were associated with engaged responses to unfair treatment. Conclusion. U.S. Chinese older adults suffered considerable discrimination, but tended to have passive responses to unfair treatment. Future longitudinal studies are needed to improve our understanding of the risk factors and outcomes associated with discrimination among U.S. Chinese older adults. Key Words: Discrimination Unfair treatment response Older adults Chinese. Received May 14, 2014; Accepted July 23, 2014 Decision Editor: Stephen Kritchevsky, PhD Experiences of discrimination may affect people s health by operating as a stressor and by triggering unhealthy health behaviors (1). Existing literature provides ample evidence suggesting that experiences of discrimination may lead to increased risk for high-blood pressure (2), chronic health conditions (3), psychological distress (eg, depression) (4), and even mortality (5). Yet the effect of discrimination on health and well-being may be moderated by responses to discrimination. Data from the 2004 to 2005 National Epidemiologic Survey of Alcohol and Related Conditions found that accepting and not disclosing experiences of discrimination was associated with higher risk for mood disorders among black adults and anxiety disorders among women than those who did not accept and disclose discrimination experience (6). Other research has demonstrated that active coping responses were more effective in alleviating the effect of depression brought on by discrimination than passive coping, which may exacerbate the effect of psychological distress (7). Experiences of discrimination differ by cultural and racial/ethnic groups. Although Asian Americans are often portrayed as a model minority, discrimination against this group is common in some areas. The National Latino and Asian American study reported that 62.4% of Asian Americans have experienced some racial/ethnic discrimination in their lifetime (8). A report by the Department of Housing and Urban Development indicates that one in five Asian Americans have encountered discrimination in home buying (9). Although there has been increasing research interest in discrimination encountered by Asian Americans, researchers tend to consider Asian Americans as a whole, despite vast subgroup heterogeneity (10). Thus, existing knowledge on discrimination faced by Chinese Americans is scarce, and even less is known about discrimination among U.S. Chinese older populations, who may be more adherent to traditional Chinese culture and less likely to share common traits with people in the mainstream culture. The traditional Chinese cultural value of collectivism and the belief that tolerance is a key moral virtue may shape the way Chinese Americans perceive and respond to discrimination, possibly exacerbating adverse health outcomes arising from discrimination. The population of U.S. Chinese adults aged 65 and older has increased by 55% in the past decade, far exceeding the general U.S. older adult S76

2 EXPERIENCE OF DISCRIMINATION AMONG CHINESE OLDER ADULTS S77 population growth rate of 15% (11). Chinese older adults in the United States are confronted by substantial language and cultural barriers, as well as disparities in utilization of health and social services (12), all of which may increase their vulnerability to discrimination. As the largest Asian American subgroup population in the United States and the first minority group that faced legally suspended immigration on the basis of race with the passage of the Chinese Exclusion Act in 1882, Chinese Americans have a long history of enduring discrimination, hostility, and violence. Although negative attitudes toward Chinese Americans have decreased over time, recent studies suggest that Chinese Americans still suffer from discrimination and prejudice (3,13).Given the potentially deleterious effect of discrimination, there is a need to improve our understanding of the experiences of discrimination among U.S. Chinese older adults. In this study, we aimed to (i) examine the prevalence of discrimination experienced by Chinese older adults in the Greater Chicago area, (ii) assess how Chinese older adults respond to unfair treatment, and (iii) explore the correlates of experiences of discrimination and responses to unfair treatment. Methods Population and Settings The Population-based Study of ChINese Elderly (PINE) ( 松年研究, sōng nián yán jiū) is a community-engaged, population-based epidemiological study of U.S. Chinese older adults aged 60 and older conducted in the Greater Chicago area. Briefly, the purpose of the PINE study is to examine the key cultural determinants of health and wellbeing among U.S. Chinese older adults. The project was initiated by a synergistic community-academic collaboration among the Rush Institute for Healthy Aging, Northwestern University, and many Greater Chicago area communitybased social service agencies and organizations. To ensure the study s relevance to the well-being of the Chinese community and increase community participation, the PINE study was guided by a community-based participatory research approach. A community advisory board played a pivotal role in providing insights for our research activities. Board members were community stakeholders and residents enlisted from over 20 civic, health, and social advocacy groups, community centers and clinics in the city and suburbs of Chicago. The board worked extensively with the investigative team to develop and test study instruments to ensure cultural sensitivity and appropriateness. Study Design and Procedure The research team implemented a targeted communitybased recruitment strategy by first engaging community centers in the Greater Chicago area. Over 20 social services agencies, community centers, health advocacy agencies, faith-based organizations, senior apartments, and social clubs served as the basis of study recruitment sites. Community-dwelling older adults aged 60 years and older who self-identified as Chinese were eligible to participate in the study. Each participant received a $15 gift card for participating in the study. Out of 3,542 eligible older adults approached, 3,159 agreed to participate in the study, yielding a response rate of 91.9%. Details of the PINE study design are published elsewhere (14). Trained multicultural and multilingual interviewers conducted face-to-face home interviews with participants in their preferred language (English or Chinese) and dialect (ie, Cantonese, Taishanese, Mandarin, Teochew). Based on available data drawn from the U.S. Census 2010 and a random block census project conducted among the Chinese community in Chicago, the PINE study is representative of the Chinese aging population in the Greater Chicago area (15). The study was approved by the Institutional Review Board of the Rush University Medical Center. Measurements Basic demographic information collected included age, sex, education, personal income, marital status, number of children, living arrangement, years in the community, geographic locations of residences, and years in the United States. Overall health status was measured by the question, In general, how would you rate your health? on a 4-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good). Quality of life was assessed by asking, In general, how would you rate your quality of life? on a 4-point scale ranging from 1 = poor to 4 = very good. Health changes over the last year was measured by asking participants, Compared to a year ago, how would you rate your health now? on a 3-point scale (1 = worsened, 2 = same, 3 = improved). Self-reported experience of discrimination. Experiences of discrimination were measured using the Experiences of Discrimination instrument, which has been widely used and validated in multiple studies of discrimination (16 18). Participants were asked whether they have ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following situations because of their race or color: at school (i); getting hired or getting a job (ii); at work (iii); getting housing (iv); getting medical care (v); getting service in a store or restaurant (vi); getting credit, bank loans, or a mortgage (vii); on the street or in a public setting (viii); and from the police or in the courts (ix). Among participants who answered yes to a situation, we followed-up with a question about the number of times the situation occurred. Participants indicated the frequency of discrimination in a particular situation using a 3-point scale (1 = once, 2 = two or three times, 3 = four or more times).

3 S78 DONG ET AL. Response to unfair treatment. To measure response to unfair treatment, all participants were asked the following items from the Experiences of Discrimination instrument: If you feel you have been treated unfairly, do you usually accept it as a fact of life; or (ii) try to do something about it? and If you have been treated unfairly, do you usually talk to other people about it; or keep it to yourself? We scored responses to unfair treatment into three groups: engaged (take action + talk to others); moderate (take action + keep to self; accept as fact of life + talk to others); and passive (accept as fact of life + keep to self) (16). Data Analysis We first used descriptive statistics to summarize the prevalence and frequency of discrimination in each situation and by different geographic area. Next, we used ANOVA to compare differences in sociodemographic and health-related characteristics among the three groups of responses to unfair treatment. Pearson Correlation coefficients and Spearman s rank correlations were calculated to determine the relationships between sociodemographic and health-related variables with experiences of discrimination and response to unfair treatment. All statistical analyses were undertaken using SAS, Version 9.2 (SAS Institute Inc., Cary, NC). Results Of the 3,159 Chinese older adults interviewed, the mean age was 72.8 years (SD = 8.3, range = ) and 58.9% were women. The majority of participants had equal or less than a high school education (78.9%) and 6.2% received no education at all. The majority of the participants (85.1%) had an annual personal income that was less than U.S. $10,000 and only 2.8% of the participants had an annual income of more than $20,000. Among the participants, 21% lived alone. A total of 26.7% of the participants had been in the United States for less than 10 years, and 57.5% had been in the community for less than 10 years. In all, 60.8% of the participants perceived fair or poor overall health status, 49.3% had a fair or poor quality of life, and 42.5% experienced worsened health status. Table 1 presents the prevalence of self-reported experiences of discrimination. In total, 671 participants (21.3%) reported having experienced discrimination. Among the nine situations, on the street or in a public setting (10.6%) was the most commonly reported situation where participants encountered discrimination, followed by at work (8.0%); getting service in a store or restaurant (3.1%); getting medical care (2.6%); getting hired or getting a job (1.8%); getting housing (1.1%); from the police or in the courts (0.9%); at school (0.6%); and getting credit, bank loans, or a mortgage (0.2%). Experiences of discrimination were more intensive in school and at work than in other situations. Among older adults who experienced discrimination at school, 55.6% experienced discrimination four Table 1. Prevalence of Self-Reported Experiences of Discrimination Yes, N (%) No, N (%) Experience of discrimination 671 (21.3) 2,479 (78.7) At school 18 (0.6) 3,105 (99.4) Once 1 (5.6) Two or three times 7 (38.9) Four or more times 10 (55.6) Getting hired or a getting a job 55 (1.8) 3,091 (98.3) Once 20 (36.4) Two or three times 15 (27.3) Four or more 19 (34.5) At work 251 (8.0) 2,896 (92.0) Once 51 (20.3) Two or three times 71 (28.3) Four or more 127 (50.6) Getting housing 36 (1.1) 3,112 (98.9) Once 16 (44.4) Two or three times 11 (30.6) Four or more 8 (22.2) Getting medical care 81 (2.6) 3,071 (97.4) Once 31 (38.3) Two or three times 27 (33.3) Four or more 23 (28.4) Getting service in a store or restaurant 99 (3.1) 3,054 (96.9) Once 39 (39.4) Two or three times 20 (20.2) Four or more 28 (28.3) Getting credit, bank loans, or a mortgage 7 (0.2) 3,144 (99.8) Once 1 (14.3) Two or three times 5 (71.4) Four or more 1 (14.3) On the street or in public setting 333 (10.6) 2,821 (89.4) Once 146 (43.8) Two or three times 99 (29.7) Four or more 85 (25.5) From the police or in the courts 27 (0.9) 3,120 (99.1) Once 20 (74.1) Two or three times 6 (22.2) Four or more 1 (3.7) Table 2. Experience of Discrimination by Geographic Area Yes, N (%) No, N (%) DF p Non-Chinatown 312 (24.6) 956 (75.4) Chinatown 359 (19.1) 1,523 (80.9) <.001 Non-Chinatown Chicago 217 (25.0) 652 (75.0) Chinatown 359 (19.1) 1,523 (80.9) <.001 Chinatown 359 (19.1) 1,523 (80.9) Non-Chinatown Chicago 217 (25.0) 652 (75.0) Suburban 95 (23.8) 304 (76.2) <.0001 Note: Chinatown: Older adults who reside in Chinatown (zip code: 60616) in the city of Chicago. Non-Chinatown: Older adults who live in the Greater Chicago Area but not in Chinatown of the city of Chicago. Non- Chinatown Chicago: Older adults who reside in the city of Chicago but outside the Chinatown area. Suburban: Older adults who reside in the greater Chicago area other than the city of Chicago. or more times. Similarly, for older adults who had experienced discrimination at work, 50.6% of them experienced discrimination four or more times. Table 2 presents the prevalence of experiences of discrimination by geographic areas. Compared with older adults

4 EXPERIENCE OF DISCRIMINATION AMONG CHINESE OLDER ADULTS S79 Table 3. Response to Unfair Treatment, by Sociodemographic and Health Status Characteristics A: Prevalence of Response to Unfair Treatment If you feel you have been treated unfairly, do you usually: If you have been treated unfairly, do you usually: residing in Chinatown, those who lived outside Chinatown reported a significantly higher prevalence of discrimination (24.6% vs 19.1%, p <.001). Similar trends were observed in subgroup analyses of participants living in the City of Chicago. Those living in Chinatown had a lower prevalence of experiences of discrimination compared with those living in the City of Chicago but outside Chinatown. With respect to response to unfair treatment (Table 3), the majority of the participants (74.3%) reported that they usually accept unfair treatment as a fact of life, while only 25.7% reported that they usually try to do something about it. In addition, 49.5% of participants reported that they usually talk to other people about it if they have been treated unfairly but 50.5% of participants usually keep it to themselves. With regard to the three groupings of response to unfair treatment, 48.2% of older adults had a passive response, 28.8% had a moderate response, and only 22.9% of the participants had an engaged response. With respect to the sociodemographic and health-related correlates of experiences of discrimination and responses to unfair treatment, younger age, higher education, higher income, fewer children, more years in the United States, more years in the community, poorer health status, lower quality of life, and worsened health over the last year were associated with more situations and higher frequency of discrimination experienced. On the other hand, younger age, higher education, higher income, being married, living with more people, having fewer children, more years in the United States, and better health over the past year were associated with engaged responses to unfair treatment. Discussion This study found that U.S. Chinese older adults still experienced considerable discrimination, with the majority of older adults tending to have passive responses to unfair Response N (%) Try to do something about it 768 (25.7) Accept it as a fact of life 2,223 (74.3) Talk to other people about it 1,486 (49.5) Keep it to yourself 1,514 (50.5) B: Characteristics of Study Population by Response to Unfair Treatment Mean (SD) Passive, N (%) N = 1,454 (48.2) Moderate, N (%), N = 870 (28.8) Engaged, N (%) N = 692(22.9) F value p Age 73.3 (8.3) 72.2 (8.1) 71.4 (7.8) 13.7 <.001 Years of education 8.2 (5.1) 8.7 (4.9) 10.1 (4.8) 34.9 <.001 Level of income 1.9 (1.1) 1.9 (1.0) 2.1 (1.5) Number of children 2.9 (1.5) 2.9 (1.4) 2.7 (1.5) Number of people in household 1.8 (1.9) 2.0 (1.9) 1.9 (1.9) Years in the United States 19.3 (12.8) 19.5 (12.2) 21.7 (14.3) Years in the community 12.1 (11.0) 11.4 (10.4) 13.0 (12.0) General health status 2.2 (0.8) 2.2 (0.7) 2.3 (0.8) Quality of life 2.6 (0.7) 2.4 (0.7) 2.6 (0.7) 13.9 <.001 Health changes 2.6 (0.8) 2.6 (0.7) 2.7 (0.8) treatment. Among the nine situations assessed, street and public settings were the places where discrimination was most likely to occur. Older adults who lived in places other than Chinatown, with higher socioeconomic status, and with lower health status were more likely to report discrimination. As the largest study on experiences of discrimination among U.S. Chinese older adults, this study provides empirical evidence about the magnitude of discrimination among this population. In addition to the prevalence of experiences of discrimination, this study also examined older adults responses to unfair treatment, providing insight into the coping strategies for discrimination among minority older adults. Furthermore, this study utilized a community-based participatory research model, through which we addressed language and cultural barriers pertaining to research in minority populations. We thus enhanced the trust between research assistants and participants, enabling us to collect more accurate and reliable data (19,20). Our study found that U.S. Chinese older adults experienced considerable discrimination (21.3%). In a study of discrimination among 1,800 older Americans, the prevalence of discrimination experienced among African Americans (47%) was higher than that of our study, yet the prevalence among European Americans (4%) was much lower than the prevalence of discrimination experienced by our Chinese older adults (21). The prevalence of discrimination in our sample of U.S. Chinese older adults was also higher than among Latino older adults (10.7%) in the National Latino and Asian American study (22). The variations in discrimination experiences across different racial/ ethnic groups underscore the need for exploring cultural differences when studying discrimination. The findings from our study are comparable to a study of 1,503 Chinese Americans aged 18 and older in the Greater Los Angeles area, which found a prevalence of 21% for lifetime experience of discrimination (11). However, comparisons of

5 S80 DONG ET AL. prevalence of discrimination across studies should be interpreted with caution because of the varying methodologies and settings used among these studies. Consistent with other studies (6,23), our study found that on the street and in public settings were the most commonly reported situations where discrimination occurred. The high prevalence of discrimination in these arenas warrants attention, as streets or public settings are places where older adults usually carry out daily activities. Discrimination in public settings may decrease older adults motivation for participating in outdoor activities, which in turn increases the risk for social isolation. Compared with studies conducted among other racial/ethnic groups (6,16), older adults in our study did not commonly report discrimination in situations such as in school and at work. One explanation is that the majority of Chinese older adults immigrated to the United States at middle or later age and did not attend schools in the United States, reducing opportunities for encountering discrimination in school settings. Regarding discrimination at work, Chinese immigrants tend to work in Chinese restaurants or grocery stores due to language barriers. Surrounded by Chinese colleagues, they may be less likely to encounter discrimination at work. Yet it should be noted that although discrimination encountered in school and at work were less common, the intensity of discrimination in these two situations was higher than that in other situations. One intriguing finding was that older adults living in Chinatown reported lower prevalence of discrimination compared with older adults living in other areas. Chicago s Chinatown is fairly segregated from other racial/ethnic groups and for Chinese older adults who do not speak English, there are ample services in Chinese to meet their needs, which may explain the lower reported experiences of discrimination. In addition, older adults living outside Chinatown may have higher acculturation levels, especially language fluency, than those living in Chinatown. Consequently, it is possible that they may be more likely to identify and acknowledge discrimination. The earlier-mentioned study on discrimination among Chinese Americans in Los Angeles also yielded similar findings, whereby Chinese adults living in neighborhoods with greater ethnic diversity were 1.5 times more likely to experience unfair treatment than those living among all Chinese (11). In our study, participants were more likely to report passive responses to unfair treatment. Specifically, when encountering unfair treatment, Chinese older adults were inclined to accept it as a fact of life and keep it to themselves. Our findings are in sharp contrast with a study among white and black adults using the same Experiences of Discrimination instrument, which found that 82.0% of whites and 68.6% of blacks usually responded to unfair treatment by talking to others and taking action (17). Cultural variations, substantial language barriers, and unfamiliarity with available services and resources may be the main contributors to differences in response to unfair treatment between Chinese older adults and other racial ethnic groups. Furthermore, as many immigrant older adults have waited for a long time to reunite with their families, fear of being deported may prevent them from actively responding to unfair treatment. Older adults of higher socioeconomic status were more likely to report experiences of discrimination in multiple situations, more frequent experiences in a particular situations, as well as engaged responses to unfair treatment. Higher socioeconomic status may lead to more opportunities and more frequent interactions with other racial/ethnic groups, which may result in greater exposure to discrimination. Despite the increased experiences of discrimination, older adults with higher socioeconomic status were also more likely to report actively coping with unfair treatment. Therefore, the effect of discrimination on health in this group may not be as severe compared with the effect of discrimination on health among individuals of lower socioeconomic status. How education and income moderate the relationship between discrimination and health outcomes requires further exploration. In this study, lower health status was correlated with more situations and higher frequency of discrimination. Discrimination may operate as a stressor that decreases older adults self-esteem and increases the risk of social isolation, thus leading to poorer health (24). The association between discrimination and health status has been well-grounded in prior empirical research (1,5 7), but the direction of the association cannot be determined due to the cross-sectional design of most studies. One longitudinal study used data from the National Survey of Black Americans and found that higher psychological distress or depression at wave two was not associated with racial discrimination at wave three, suggesting that poor health status did not predict discrimination (25). Future longitudinal studies should explore the association between health status and discrimination and the mechanisms underlying the association. Our study findings should be interpreted with limitations in mind. First, although our study examined a representative sample of Chinese older adults in the Greater Chicago area, the findings may not be generalizable to Chinese older adults in other geographic areas. Second, our findings were limited by the subjective nature of the self-report measures used, which may result in social desirability biases and underestimates of the prevalence of discrimination. Third, quantitative data provides a limited understanding of older adults perceptions in different cultural contexts. Furthermore, this study utilized a cross-sectional design and we were not able to postulate on potential temporal relationships. Despite these limitations, this study has important research and policy implications. First, our study found that a significant proportion of Chinese older adults experienced discrimination, suggesting the need for more rigorous research on the factors associated with discrimination encountered by U.S. Chinese older adults. Second, as the majority of older adults reported passive responses to

6 EXPERIENCE OF DISCRIMINATION AMONG CHINESE OLDER ADULTS S81 unfair treatment, community organizations should improve older adults awareness on discrimination, promote coping strategies, and improve the availability of coping resources related to discrimination. Community organizations should strengthen the collaboration with academic institutions to identify those who are at high risk for discrimination as well as promote culturally competent prevention and intervention strategies to reduce discrimination. Third, health care and other service providers should improve the cultural competence of services provided to Chinese older adults so as to reduce potential discrimination. Policy makers should support related efforts in counteracting discrimination experienced by minority older adults. Conclusion In summary, our study found that a considerable proportion of U.S. Chinese older adults in the Greater Chicago area experienced discrimination, although the prevalence was lowest among older adults residing in the Chinatown area. Moreover, Chinese older adults tended to passively respond to discrimination. The experiences and responses to discrimination varied significantly by different sociodemographic and health-related factors. This study sets the groundwork for future studies to explore the risk and protective factors as well as the outcomes associated with experiences of discrimination among U.S. Chinese older adults. Funding Dr. Dong and Dr. Simon were supported by National Institute on Aging grant (R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443, R34MH100393, P20CA165588, R24MD001650, and RC4 AG039085), Paul B. Beeson Award in Aging, The Starr Foundation, American Federation for Aging Research, John A. Hartford Foundation, and The Atlantic Philanthropies. Acknowledgment We are grateful to Community Advisory Board members for their continued effort in this project. In particular, thanks are extended to Bernie Wong, Vivian Xu, and Yicklun Mo with the Chinese American Service League (CASL); Dr. David Lee with the Illinois College of Optometry; David Wu with the Pui Tak Center; Dr. Hong Liu with the Midwest Asian Health Association; Dr. Margaret Dolan with John H. Stroger Jr. Hospital; Mary Jane Welch with the Rush University Medical Center; Florence Lei with the CASL Pine Tree Council; Julia Wong with CASL Senior Housing; Dr. Jing Zhang with Asian Human Services; Marta Pereya with the Coalition of Limited English Speaking Elderly; and Mona El-Shamaa with the Asian Health Coalition. References 1. Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135: Lewis TT, Barnes LL, Bienias JL, Lackland DT, Evans DA, De Leon CFM. 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