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The population of the world is fast approaching 7 billion, according to U.S. Census data, and among those people lie vast differences in terms of culture, especially diet and attitudes toward health and wellness and healthcare professionals. Because the United States is a country founded on immigration that brings in people from all over the world, these differences are of particular import to healthcare workers here, including those working in retail pharmacy settings.
According to the Department of Homeland Security, there were 12.6 million green card holders in the United States in 2011, of whom 8.1 million were eligible to become naturalized citizens, compared with 12.45 million and 7.87 million in 2010. That’s not including 2011’s 10.8 million illegal immigrants.
Immigrants to the United States frequently encounter a more sedentary lifestyle and less healthy diets than the ones to which they’re accustomed. Thus, a combination of diet and possible genetic factors can put them at risk for chronic health conditions. “Obesity certainly increases, as the migrant has been in the United States for longer periods of time; so the longer they’ve been here, the more obese they get,” Ohio State University and Nationwide Children’s Hospital professor of pediatrics Reena Oza-Frank told DSN Collaborative Care, noting a similar tendency among immigrant populations for diabetes. In terms of possible genetic factors combining with lifestyle, Oza-Frank said South Asians were predisposed to having higher rates of diabetes at lower body weights. At the same time, Oza-Frank said, while rates of obesity and diabetes among foreign-born populations approach those of the native-born, they don’t surpass them.
In 2008, Oza-Frank and two other colleagues conducted a study published in the journal Obesity that calculated the risk of obesity among immigrants based on the age at which they arrived in the United States. They found that among immigrants who arrived at the age of 20 years or younger and had resided here for 15 years or longer, the likelihood that they were overweight or obese was 11 times greater than among those who had arrived when they were younger than 20 years and resided for a year or less. Those who had arrived at the age of 50 years or older showed no difference in overweight and obesity, regardless of how long they had been in the United States.
But the rise of immigrant populations with susceptibilities to various chronic diseases hasn’t gone unnoticed in the healthcare world. Last year, for example, sisters Yvonne Tsang and Priscilla Cheung opened eRxCity, a retail pharmacy in New York’s Chinatown that serves a predominantly Asian population whose members are disproportionately likely to have such conditions as diabetes, high cholesterol and chronic hepatitis B.
Meanwhile, Bria Chakofsky-Lewy, a nurse and supervisor of the Community House Calls program in the interpreter services department at Seattle’s Harborview Medical Center, found a useful approach to the chronic pain suffered by members of the city’s growing Somali refugee population: yoga and massage therapy. In 2009, Chakofsky-Lewy helped found Daryel — Somali for “wellness” — which she said attracts anywhere between eight and 18 women every Sunday.
Chakofsky-Lewy said that immigrants often bring vastly different attitudes about health, wellness and healthcare workers when they come to the United States, and medication adherence can sometimes be an issue. “There’s not much experience of taking medication for the rest of your life for any problem,” Chakofsky-Lewy told DSN Collaborative Care. Also, people in many countries view healthcare workers as authority workers and, for fear of disappointing them, will often report having taken their medications when they actually haven’t. “Without an interpreter in place, people smile and nod their heads because they want to be respectful and compliant, but that doesn’t mean they understand what’s being said.”
Many people also will seek to treat ailments with traditional herbal remedies, which can often interact with prescription drugs. Terry Teller, a pharmacist with the Indian Health Service in Arizona who also works as a weekend relief pharmacist at a nearby Walmart store, told DSN Collaborative Care in January 2011 that he often encountered this issue with Native American patients.
When attempting to get people to adopt healthier lifestyles, diet must be taken into account as well, Oza-Frank said. A South Asian might be a vegetarian, while someone from another country might consume a meat-heavy diet.
Many cultural traditions beyond the usual contents of a meal or traditional remedies can affect medication therapies, too. For example, Chakofsky-Lewy said, Muslim patients with diabetes may have to adjust their treatment regimens during the month of Ramadan, when most Muslims fast during the day. The same may be true for Ethiopian Orthodox Christians, whose Lenten season, Abiy Tsom, lasts 55 days, allows only one meal of cereals and vegetables per day after 2:45 p.m. and requires a total fast from Good Friday to Sunday.
Still, while developing health-and-wellness programs for specific populations may be challenging, the general idea is probably the same. “I think that the bottom line is that the message would be the same as it would be for a nonforeign-born population, with information about nutrition and physical activity,” Oza-Frank said. “In tailoring programs to foreign-born populations, cultural differences have to be taken into consideration.”
Still another area of importance is medication information. While many efforts have been made to offer medication information in foreign languages, Chakofsky-Lewy said that often members of immigrant populations can’t read in their own languages. “If you’re going to send home anything in a language other than English, I would send it home in English as well,” she said. “There could be someone at home who will be able to put the target language together with English, but nobody at home who reads the target language.”
One trend Chakofsky-Lewy found heartening was the rise in pharmacists who speak languages other than English, noting that she often saw signs at Bartell Drugs stores in Seattle saying there was a Vietnamese-speaking pharmacist on site. Also, she found many children of immigrants are attracted to the pharmacy profession.
Overall, Chakofsky-Lewy stressed the importance of education on both sides. “I think there’s a ton of education to do and also a ton of listening to do to understand the patient’s perspective of what’s going on,” she said.