PERSPECTIVE

Achieving Equity in Asian American Health Care: Critical Issues and Solutions

Jed Keenan Obra, BS^1,2, Bryant Lin, MD, MEng^1,3, Lan N. Đoàn, PhD, MPH⁴, Latha Palaniappan, MD, MS^1,3 and Malathi Srinivasan, MD^1,3

¹Stanford Center for Asian Research and Education, Stanford University School of Medicine; Palo Alto, CA; ²Department of Neurobiology, Physiology, and Behavior, University of California Davis; Davis, CA; ³Department of Medicine, Stanford University School of Medicine; Palo Alto, CA; ⁴Department of Population Health, NYU Grossman School of Medicine; New York, NY

Equity is a fundamental goal of the US health care system. Asians comprise 6% of the US population, and 60% of the world’s population. Less than 1% of National Institutes of Health funding is directed toward Asian health. Asian health outcomes are often worse than non-Hispanic Whites (NHWS) in America. Increasing federal and foundation resources and funding toward Asian health research could illuminate these risks and develop precision interventions to reduce known health disparities. When disaggregated by race/ethnicity, Asian health risks are even more apparent. Here, we discuss critical health outcome differences between the six major Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) comprising 80% of the US Asian population, highlighting demographic, pharmacologic, disease prevalence, and mortality outcomes. We then outline seven critical issues contributing to Asian American health disparities, including aggregated Asian health data, undersampling, invalid extrapolations, underrepresentation in clinical trials, lack of funding and awareness of disparities, and the model minority myth. Building on the successes of national public health initiatives, we propose nine leverage points to improve Asian American health including the following: obtaining disaggregated Asian health data, improved Asian health research (oversampling Asians, improving clinical trial participation, and increasing research funding), stakeholder collaboration (national and with Asian nations), community engagement, providing culturally precise health care, and expansion of the Asian American research ecosystem. Achieving health equity takes deliberate practice and does not occur by accident. By addressing critical issues that perpetuate Asian health disparities, we grow closer to understanding how to effectively improve Asian health and build a nationally unified mindset toward action that emphasizes equitable care for all.

Key Words: Asian health ◾ health disparities ◾ health equity ◾ model minority ◾ Asian subgroups

 

 

Equity¹ is a fundamental goal of the US health care system,² in which individuals and populations have the necessary curated tools and resources necessary to achieve the same personal health outcomes. Over the past 20 years, progress has been made in addressing health disparities within the African American,³ Hispanic/Latinx,⁴ and Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+)⁵ communities, by first identifying differential health risks, then developing interventions to reduce those risks. While research has been rightfully focused on these communities, Asian health and health care has been largely left out of the effort to establish health equity.

The Asian American community comprises 6% of the total US population and is the fastest growing racial/ethnic group in the United States.⁶ However, Asian Americans have different health risks and often worse health outcomes than the non-Hispanic White population. Characterizing these health disparities has become even more critical as xenophobia toward visible minorities has accelerated during the COVID-19 pandemic.⁷ Moreover, Asian Americans are not monolithic (Table 1). Rather, drawing from origins in South Asian, East Asian, and Southeast Asian countries; Asian Americans comprise a diversity of ethnic, cultural, and racial groups, with over 70% from six countries (China, Korea, India, Japan, Thailand, and Vietnam). This heterogeneity lends itself to differential health risks, for instance with cancer,⁸ diabetes,⁹ and stroke.¹⁰ To improve health outcomes through precision medicine, which takes into account an individual’s genetic, environmental, and lifestyle background to determine appropriate care, we need a more focused lens on the research that will improve outcomes around Asian health.

Table 1. Demographics of Asian Americans by country of origin.

	Country of origin	% of US population
East Asian	China	23.4
	Japan	5.3
	Korea	9.9
	Taiwan	1.4
	Mongolia	0.1
South Asian	India	19.8
	Bangladesh	0.9
	Pakistan	2.5
	Nepal	0.4
	Bhutan	0.1
	Sri Lanka	0.3
	Maldives	>0.1
Southeast Asian	Philippines	17.8
	Vietnam	10.8
	Laos	1.3
	Thailand	1.2
	Singapore	>0.1
	Malaysia	0.1
	Cambodia	1.6
	Indonesia	0.4
Source: 2010 US Census Briefs.6

In this perspective, we share critical health outcome differences between Asian American groups, outline critical issues that must be addressed to reduce Asian health disparities, and propose an approach to improving Asian health research and education.

VARIATION IN ASIAN ETHNIC SUBGROUP HEALTH OUTCOMES

Currently, most decisions about Asian health are based on data from non-Hispanic White cohorts. Asians with origins in different countries have different metabolic, genotypic, and phenotypic traits that increase their risk to specific health outcomes. As such, Asian Americans have significantly different health outcomes for key conditions, depending on their country of origin (Table 2). Asians have higher rates of specific cancers (e.g. gastric cancer in Koreans), heart disease, and other chronic conditions, compared with their Caucasian counterparts. Specifically, Asian Indian and Filipino men have an increased risk of mortality due to heart disease,¹¹ and Japanese women have an increased mortality rate associated with pancreatic cancer.¹² Genotypic/phenotypic differences may also vary in efficacy for metabolizing drugs, such as those with CYP2C19 loss of function allele, which leads to decreased conversion of the anticoagulant clopidogrel¹⁰ to its active form, leading to more strokes and heart attacks in East Asian patients. Asians with other CYP2C9 allele variations may be more likely to bleed when prescribed warfarin.¹³ Furthermore, Asian Americans differ in sociocultural backgrounds, which include differences in diet,¹⁴ educational attainment,¹⁵ and English proficiency.¹⁶ These genotypic/phenotypic differences may account for the higher prevalence of diabetes mellitus type 2¹⁷ observed in Filipino and Asian Indian men (26.2 and 24.8%, respectively in comparison to the 17.9% prevalence of diabetes mellitus type 2 observed in the aggregate Asian population). While some Asian households are achieving socioeconomic success, income inequality is rising more rapidly among Asian Americans than other racial or ethnic groups,¹⁸ raising concerns over the income disparities in Asian subgroup households. For instance, Vietnamese, Korean, and Chinese poverty rates are 10.9, 11.2, and 12.9% respectively, which is 10.3% higher than the non-Hispanic White poverty rate.¹⁵ This income inequality parallels health disparities observed within these subgroups, since Vietnamese, Korean, and Chinese Americans have a greater than 2-fold higher mortality risk of gastric and liver cancers compared with their Caucasian counterparts.¹² Improving Asian health requires identifying the critical issues inhibiting appropriate health care for Asian Americans, starting with the research basis for understanding these disparities.

Table 2. Demographics and health outcomes of aggregate and disaggregated Asian subgroups in the United States.

						(Examples of Asian subgroup health outcome variation)
	US population* (margin of error)	Foreign-born population*	Median household income*	Poverty rate* (%)	Bachelor’s degree or higher* (% of population ≥25 years old)	Age-adjusted mortality rate per 100,000 for pancreatic cancer in women12	Percentage of mortality caused by heart disease in men11	Age- and-BMI standardized prevalence of diabetes mellitus type 2 in men17 (%)	Increased bleeding due to anticoagulation gene variant CYP2C19*2 (frequency %)
Non-Hispanic White	236,475,401 (±99,212)	20,328,281	$69,823	10.3	34.4	9.4	27	8.60	13.383
Aggregate Asian	18,636,984 (±39,562)	12,236,195	$93,759	9.6	55.6	7.0	25.1	17.90	28.483
Asian Indian	4,240,466 (±49,699)	3,007,151	$126,705	5.9	75.7	4.1	31.3	24.80	North Indian – 33.183 South Indian – 36.883
Chinese	4,404,678 (±46,036)	3,036,492	$86,281	12.9	57.7	6.8	23.2	13.20	3284
Filipino	2,983,596 (±45,214)	1,925,602	$100,273	5.8	49.8	6.2	28.2	26.20	3984
Japanese	755,672 (±17,639)	312,537	$85,007	7.3	53.7	9.8	27.8	13.50	2384
Korean	1,461,843 (±29,473)	1,013,129	$76,674	11.2	58.9	8.5	19.2	16.80	28.485
Vietnamese	1,873,707 (±40,947)	1,257,169	$72,161	10.9	32	4.9	17.8	9.40	2486
*2019 American Community Survey.15

CRITICAL ISSUES IN ASIAN AMERICAN HEALTH RESEARCH

Aggregating Asian American Health Care Data. Aggregating Asian Americans as a monolith masks increased disease prevalence and culturally specific risk factors of Asian American subgroups.^9,19–21 Asians comprise 60% of the world’s population. The aggregation of Asian subgroups is driven by policies of structural racism – in which diverse Asian subgroups are grouped under the umbrella ‘Asian American’ category when collecting demographics in national datasets, which perpetuate the misrepresentation of Asian American health. Additionally, mortality data provide important targets for earlier disease intervention.²² In 2003, the CDC recommended that states adopt a uniform death certificate format that included six Asian subgroups.²³ However, states have implemented this new standard inconsistently over an 18-year period. In 2017, the state of Wyoming still had not disaggregated Asians on death certificate demographic data.²⁴ Other national organizations adopted Asian subgroup demographics information in the past 10 years. Major disease registries (i.e. US Cystic Fibrosis Foundation) still have not included Asian subgroups in their data collection. Analysis of individual electronic health record (EHR) data is critical to understand the impact of prevention and interventions for health outcomes.²⁰ However, health systems have not uniformly collected disaggregated Asian demographic data, as this has not been a nationally enforced data collection standard.²⁵ Even in California where 16% of the population is Asian, major health systems do not routinely collect demographic information about Asian subgroups. Collectively, Asian health data aggregation leads to all Asians receiving uniform treatment despite unique differences.

Undersampling in National Surveys. To adequately represent any racial/ethnic minority population in a national study, these groups must be oversampled during data collection for reliable point estimates, particularly for small populations to avoid high within-group variation. However, oversampling racial/ethnic minority groups can be challenging because of the geographic distribution of subgroups, which means researchers are often limited to small subgroup populations based on the study region. ²⁶ For instance, the 2017 National Health Interview Survey (NHIS) had 4% Asians in their sample, at a time when 6% of the total US population was Asian²⁷ – emphasizing the importance of oversampling racial/ethnic minority populations for appropriate representation of the US population at a minimum, as well as necessary sample sizes to be able to test research hypotheses. These challenges lead to inconclusive and even contradictory results for Asian Americans, which raises generalizability concerns and risks inappropriate health care diagnosis and treatment for Asian American patients. Comprehensive analyses demonstrating the leading causes of disease nationally, by disaggregated Asian American subgroups, have not been updated in 10 years.^11,12,28 Regardless, current disaggregated research reveals clear differences from the Asian American aggregate data, which demands improved epidemiological data efforts at national, state, and local levels to accurately determine differentials in health risks among these subgroups.

Omission and Lack of Asian American Representation in US Clinical Trials. Asians are underrepresented in clinical trials and are prioritized lower compared with other racial groups in clinical trial representation. Most participants in clinical trials evaluated by the US Food and Drug Administration or Food and Drug Association (FDA) to bring new drugs to market are non-Hispanic White cohorts.²⁹ A recent report of clinical trials involving over 130,000 patients worldwide showed that only 12% of clinical trial participants were Asian, despite making up 60% of the world’s population³⁰ (Fig. 1). Despite efforts to include patients from minority backgrounds in clinical studies, 48% of adult trials did not meet the target recruitment goal for including underrepresented populations.³¹ Inclusion of Asian Americans in clinical research trials is important to understand if there are adverse effects in newly approved or commonly used medicines in certain Asian populations. For example, allopurinol, a medication used to treat gout, can cause a severe skin disorder in patients of Han Chinese, Korean, or Thai descent with a particular genetic variant (HLA-B^*58:01).³² Other examples of drugs that are ineffective or cause severe significant side effects in Asian populations include tamoxifen³³ and carbamazepine.³⁴ Without appropriate emphasis and data on the unique effects of clinical trials on AA subgroup populations, there remains a clear and concerning risk for Asian patients prescribed these medications.

Figure 1. Differences between global population and Asian research participation in clinical trials.

Poor Awareness of Asian Health Disparities. Asian health is frequently aggregated, misrepresented, or not mentioned in mainstream health literature and medical education.²⁰ As such, policymakers, physicians/providers, and most Asians are unaware of Asian health disparities.^35,36 With Asians primarily located in high-density populations in seven states (CA, FL, HI, IL, NJ, TX, VA, and WA),¹¹ policymakers have often not identified the differential health needs of the Asian American community. While there is little research on the impact of health care providers’ stereotypes of Asians, Asian patients report frequent health care provider’s misunderstandings of their culture,³⁵ which can happen especially when the encounters are not between ethnically/culturally congruent provider–patient dyads.³⁷ This may be due in part to provider unconscious bias, with negative implications of cognitive overload³⁸ and illusory correlations,³⁹ which increase provider susceptibility to medical decision-making based on automatic stereotypes. Additionally, Asian patients report that routine checkups and preventative care are not a norm in their countries of origin.⁴⁰ Use of complementary and alternative medicine⁴⁰ is highly ingrained within East Asian cultures, which often discourage Asians from seeking Western medical treatment. Beyond this, multilevel barriers in language accessibility,⁴¹ transportation,⁴⁰ and health insurance⁴² reduce Asian patient visits and mask the prevalence of disease within the Asian community. The lack of patient visits on a regular basis not only perpetuates the unawareness of the importance of seeking medical care early in the Asian American community but also masks disease prevalence specific to Asian American subgroups.

Extrapolation. In an absence of specific, precise data about Asian subgroups, health care provides generalized health trends from other groups using the data they have, often erroneously. For instance, the Ni-Hon-San study⁴³ showed Japanese men having lower rates of heart disease than their non-Hispanic White counterparts in San Francisco and Hawaii. Unfortunately, subsequent reports extrapolated these findings to all Asian subgroups,²⁰ masking the higher coronary heart disease (CHD) risk observed in Asian Indians and Filipinos (5.2 and 5.1% prevalence rate, respectively, in comparison to the 2.9% rate found in Japanese men and 3.9% rate in NHWS⁴⁴). In drug trials, the FDA inaccurately extrapolated studies of Japanese subjects to all Asian patients with dosage recommendations of rosuvastatin (Crestor).²⁰ With Asian subgroup data often being extrapolated to the aggregate Asian group, it is important that investigators understand ethnic differences between Asians to avoid inappropriate extrapolation toward health outcomes.

The Model Minority Myth. Further masking the health difficulties of the Asian American population includes the ‘model minority myth’ characterization that fosters the perspective of uniform and thriving health conditions among all Asian subgroups. The myth builds an oppression toward Asian Americans by excluding them from policy considerations and provisions.^45,46 However, multiple studies^47,48 have debunked this myth by highlighting stark disparities in preventable diseases between Asians and their white counterparts, and the major socioeconomic disparities within Asian subgroups.¹⁵ The model minority myth is not solely responsible for this lack of awareness, as clinicians and principal investigators note that patient’s skepticism, socioeconomic factors, and multilevel barriers such as language and transportation hinder Asian participation in health care and research.^49–51 The absence of disaggregated data and Asian representation further perpetuates the false idealization that Asian Americans do not possess health disparities.

Funding for Asian American Research. Lack of funding in Asian American health research poses barriers for investigators to conduct projects that yield reliable and valid data. From 1992 to 2018, clinical research projects focused on Asian American, and Native Hawaiian and Pacific Islander (NHPI) populations comprised only 0.2% of the total National Institute of Health (NIH) budget.⁵² Beyond NIH funding, philanthropic funding reveals no reported increase in grantmaking for 70% of Asian American communities in the last 5 years.⁵³ While the total amount of funding for Asian American health research has increased over time,⁵⁴ grant applications from Asian Americans, especially Asian women, were less likely than their white counterparts to be awarded funding.^19,55,56 Increasing funding is integral to the investigator’s ability to make research opportunities available and accessible for the Asian American community to participate in. Other possible sources of Asian American health research funding, including non-NIH governmental agencies, private organizations, and university institutions, have not yet been compiled and evaluated to understand current investments to advance Asian health equity.

POTENTIAL SOLUTIONS TO REDUCE ASIAN AMERICAN HEALTH DISPARITIES

Achieving equity in Asian health outcomes will require the same concerted effort by stakeholders that have reduced disparities in other minority groups such as African American, Hispanic/Latinx, and LGBTQ communities. By addressing disparity challenges, we not only decrease health risks but can also significantly increase cost savings for all ethnic populations. Hepatitis B studies have found that vaccinating 170 million children in China would cost the equivalent of 540 million US dollars but would save 1.4 billion US dollars over the lifetime of the children.⁵⁷ In the United States, screening for hepatitis B costs around $36,000–$40,000 per quality-adjusted life year (QALY), which is under the $50,000–$100,000 per QALY threshold of which the United States considers an intervention to be cost-effective.⁵⁷ Prevention is almost always more cost-effective than treatment, and cost-saving interventions will decrease the cost of negligence for failing to screen preventable illnesses, which bring additional physical, emotional, and social burdens to patients and their families. Reallocating funds toward Asian health requires political interventions and is clearly worth turf efforts for its financial implications. Here, we outline potential solutions that policymakers, funding agencies, academic researchers, industry leaders, health care providers, and communities should consider (Table 3).

Table 3. Potential solutions to reduce Asian health disparities.

Problem	Solution	Effect
Disaggregation of Asian subgroup data	Recording fluctuations in incidence and prevalence of disease among Asian American subgroups with electronic health records Analyzing effects of geographic variation in Asian American health Establish a patient registry that can allow for survey outreach beyond geographical regions typically surveyed by investigators Increase grant funding and opportunities for investigators Expand and studies to include at least the six largest Asian American subgroups	Influence health policy to support culturally relevant treatment protocols and re-establish priority areas for health research Increase publication count and knowledge of disaggregated Asian American health data Improve oversampling difficulties through increased survey outreach and accessibility for patients Identify specific gaps of knowledge among Asian subgroups More reliability and consistency with data collection Develop unique, culturally competent interventions to address unique disparities in health among Asian American subgroups
Clinical trial representation	Utilizing focus groups to identify barriers and build intrapersonal influences Collaboration of investigators with patient advocacy groups to positively communicate benefits of clinical research Implementing health policies that establish multilingual resources to describe research studies Greater diversity of the health care workforce	Encourage patients to enroll in clinical studies Increase awareness within the Asian community of the need for Asian representation in clinical trials Assess benefits and risks of particular medical treatments Decrease subject attrition and improve compliance within clinical studies Increase perspectives from ethnically diverse providers in the development of clinical trials to ensure Asian subgroup representation
Reducing the health care stigma through community engagement	Collaborative efforts between policymakers/physicians/health care providers and patient advocacy groups Emphasize the importance of research participation to Asian American patients Encouraging trusted sources such as family members of Asian patients to educate the importance of preventative care Academic institution commitment to Asian American focused research/scholars	Decreasing stigma among Asian patients to participate in Asian-focused health research Bring more visibility of the Asian American community to investigators Improve active communication between patient and health care provider Increasing minority representation in the biomedical workforce promotes sympathetic understandings between patients and providers of similar ethnic backgrounds Challenge the model minority myth of Asian Americans having better health outcomes than other demographics
Barriers to health care accessibility	Investing in transportation waivers, community health workers, language interpreters and translated materials, and health insurance programs rather than patient compensation when modeling subject incentives Implementing health policies that establish multilingual resources to describe research studies	Improve screening opportunities and health care visit frequency Bring more visibility of the Asian American community to investigators Improve willingness to participate in research studies among Asian American community
Funding for Asian American focused research	Establish a public database of funding opportunities for investigators Federal investment in Asian American health Evaluate multisector partnerships and collaborations to investigate equitable investment for Asian American health research	Increase awareness of research among potential donor organizations Increase grant applications, funding opportunities, project diversity, and project innovation Increasing multisector collaborations and interdisciplinary research teams

Study design

Disaggregating Asian Subgroups. Disaggregating Asian subgroups is critical to obtaining ethnic group level data in a manner that can improve precision health. In 2010, the Affordable Healthcare Act (ACA) legislation required all federally sponsored surveys to include standardized more detailed demographic information, including Asian subgroup data. This includes major national surveys such as the NHIS, the National Health and Nutrition Survey (NHANES), the National Medical Expenditure Panel Survey, the National Survey of Children’s Health, and the National Immunization Survey. Other American minorities have successfully sensitized health systems to their needs. For instance, health systems have included separate fields for LBGTQ demographic intake information, including preferred pronouns (e.g. he/him/his) and nonbinary gender identification.⁵⁸ Major next steps might include requiring health systems to track and report disaggregated Asian and other ethnic subgroups for the Healthcare Effectiveness Data and Information Set and other national reporting surveys, concordant with ACA and 2020 Census data collection standards, and allowing identification of multiethnic heritage by participation. Once individual ethnic/racial demographic information is obtained during patient enrollment/check-in, investigators can utilize EHR data for assessing disease risk, treatment, and outcomes.

Oversampling. While necessary, oversampling is challenging, even with the best intent. For example, in 2011, NHANES tried to oversample Asians in larger cities by working with Asian community and advocacy groups to increase their survey respondents, but still ran into difficulties enrolling Asian patients.²⁶ The California Health Interview (CHIS) survey has been successful in oversampling Koreans and Vietnamese populations by utilizing geographic targeting of surname list samples,²⁶ encouraging many population-based studies to reference CHIS. Strategies to improve Asian subgroup oversampling include increasing interviewer abilities to conduct surveys in appropriate Asian languages,²⁶ utilizing geographic distribution⁵⁹ to identify higher concentrations of Asian subgroup communities, working with community groups to understand local stakeholder perspectives⁶⁰ and increased financial investment in survey outreach.⁶¹ Successful oversampling will improve data reliability and validity specific to Asian subgroups.

Clinical Trial Representation. With Asians only representing 2% of US clinical trial participants despite composing 6% of the US population, increased efforts are necessary to accurately identify medicinal side effects most prevalent to Asians. Utilizing focus and patient advocacy groups to identify barriers,⁶² social media outreach,⁶³ and improving patient education^64,65 is promising approaches to encourage Asian patients to participate in clinical trials. For instance, Chinese, Korean, and Vietnamese-Americans were found to be more willing to participate in clinical trials after having some guarantee of treatment effectiveness and lack of side effects from their provider.⁶⁴ Furthermore, developments of patient navigation programs have seen low clinical trial refusal (4–6%) among African American, American Indian, and Native Hawaiian patients.⁶⁶ Implementing these programs with institutional support, such as with Johns Hopkins University’s EMPaCT (Enhancing Minority Participation in Clinical Trials) program where US universities have collaborated to boost minority participation in clinical trials,⁶⁷ is a promising approach to increasing Asian awareness and comfortability in regions with few or skeptical perspectives on clinical trial participation.

Community and precision medicine

Reducing the Health Care Stigma Through Community Engagement. Many Asians seek medical care only when ill,⁴⁰ are less likely to discuss stigmatizing conditions,⁶⁷ and are reluctant to participate in clinical trials.⁵⁰ Other Asians have had experiences in health care that leave them feeling marginalized.^36,68 Rebuilding trust among Asian patients who have felt alienated by the health care system requires proactive outreach to improve participation in health care and in research studies.^62,69 Through dialogue, active listening, and information sharing,⁶⁶ community organizations can effectively communicate the best intentions of investigators for the Asian community, thereby building trust in Asian communities. Culturally tailored information and policies can overcome disinformation and stigma. In 2005, Scotland’s See Me campaign successfully used education interventions to correct inaccurate portrayals of mental illness, with a 17% drop after 2 years in perceptions that people with mental health issues were dangerous.⁷⁰ With funds from the California Mental Health Services Act, the California Mental Health Services Authority launched mental health initiatives that increased Californians’ willingness to interact with people experiencing mental illness.⁷¹ Families play important roles in health decisions among Asian patients, and other groups with strong multigenerational family structures, and interventions to expand decision-making beyond the provider–patient relationship to the provider–patient–family relationship may help improve adoption of better health behaviors.^65,72,73 Having health care providers who share the same ethnic background as their patients may encourage Asian patients to continue seeking health care through the establishment of trust with their provider.⁴⁰ Academic institutions (Table 4) are important stakeholders in diversifying the biomedical workforce and can increase minority representation in the health care field. New York University, Stanford University, University of California, Davis, University of California, San Francisco, University of Chicago, and Temple University are among the many institutions that have built programs focused on Asian health. Furthermore, some universities have Asian subgroup specific centers that address major health inequities, such as Stanford University’s South Asian Translational Heart Initiative (SATHI) and University of California, San Francisco’s Asian Health Initiative, that have conducted South Asian and Chinese health-focused research, respectively. Utilizing trusted influences among the Asian population to discuss the importance of preventative care visits is key assets to increasing Asian patient turnout and challenging the model minority myth that Asians experience uniform health outcomes.

Table 4. A sampling of academic centers and institutes focused on overall Asian health.

Center name	Institution	Focus
Stanford Center for Asian Research and Education (CARE)	Stanford University, Palo Alto, CA	The Center for Asian Health Research and Education was founded on October 2018 to provide a common place for research, education, and clinical care support for Asians, allowing disparate faculty, staff, community members and trainees to share ideas and common resources
Stanford Asian Liver Center (ALC)	Stanford University, Palo Alto, CA	The Asian Liver Center at Stanford University addresses the disproportionately high rates of chronic hepatitis B infection and liver cancer in Asians and Asian Americans. The ultimate goal of the center is to eliminate the transmission and stigma of hepatitis B and reduce deaths from liver cancer and liver disease caused by chronic hepatitis B
Stanford South Asian Translational Heart Initiative (SSATHI)	Stanford University, Palo Alto, CA	To help South Asians better understand their risk for heart disease, the Stanford South Asian Translational Heart Initiative (SSATHI) offers health assessments and treatment strategies among other clinical services. SSATHI’s research will help develop technologies to predict and treat patients who are at the highest risk of developing heart disease and prevent their disease from occurring
Asian American Health Coalition of the Greater Houston Area	HOPE Clinic, Houston, TX	Asian American Health Coalition (AAHC) was established in 1994 as a forum and a convener for rallying community resources to reduce the widening health disparity gap faced by rapidly growing Asian populations residing in the greater Houston area
Asian American Center on Disparities Research (AACDR)	University of California, Davis, Davis, CA	The mission of the Asian American Center on Disparities Research (AACDR) is focused on this aspect of disparity – ethnocultural factors that influence the effectiveness of treatment. The center supports and coordinates the efforts of a network of researchers who study the mental health issues most salient to Asian Americans
Collaborative approach for Asian Americans & Pacific Islanders Research and Education (CARE)	University of California, San Francisco, San Francisco, CA	To address the gap and reduce disparities in research participation among Asian Americans and Pacific Islanders (AAPI) through the creation of a registry of AAPI who are interested in participating in various types of research such as Alzheimer’s disease and related dementias (ADRD), aging, and caregiving-related research that affects our health across the lifespan
Asian American Research Center on Health (ARCH)	University of California, San Francisco, San Francisco, CA	ARCH maintains an open and collaborative environment to carry out the vision, which is to be a leader in Asian American health research to promote health and health equity in partnership with Asian American communities
Asian Health Institute	University of California, San Francisco, San Francisco, CA	The mission of the UCSF Asian Healthcare Institute is to improve health outcomes, eliminate health care disparities in Asians, as well as increase their medical access. AHI strives to emphasize healthy lifestyle practices and preventive medicine through raising health literacy levels of the Asian American community in language- and culturally appropriate health education programs. AHI looks forward to becoming one of the strongest research, academic, and clinical Asian health care resource hubs in the nation
NYU Center for the Study of Asian American Health (CSAAH)	New York University, New York, NY	CSAAH applies innovative and rigorous approaches to harness the power of community health workers, technology, and electronic health record-based strategies in ways that have not previously been adapted or systematically tested among Asian American communities to improve access to care
Center for Asian Health	Temple University, Philadelphia, PA	The Center for Asian Health research encompasses a range of health issues that reflect both national priorities as well as scientifically identified community concerns. The Center, in cooperation with a large network of community, institutional, and clinical partners, has focused on four broad areas of health disparity research that include cancer, tobacco, cardiovascular, and chronic diseases; translational health; and global health.
Center for Asian Health Equity (CAHE)	University of Chicago Medicine, Chicago, IL	CAHE is a unique academic and community partnership between the University of Chicago and Asian Health Coalition (AHC), a community-based organization dedicated to the study of primarily Asian American health and disparities. The Center takes a multidisciplinary, collaborative approach to addressing gaps in clinical medicine and public health through a comprehensive program for research, health education, training, community engagement, policy, and information dissemination
Asian Health Initiative	Tufts Medical Center, Boston, MA	The AHI identifies public health issues of particular prevalence or concern to the local Asian community and seeks to work collaboratively with community-based organizations to help address those health issues in a culturally and linguistically appropriate setting
Healthy Mind Initiative	National Institute on Minority Health and Health Disparities, Bethesda, MA	The mission of the Healthy Mind Initiative (HMI) is to increase mental health awareness and promote suicide prevention in AAPI adolescents. Launched in 2018, HMI is a collaborative effort among the US Public Health Service, federal and county government partners, and AAPI community organizations and leadership. It highlights the importance of mental health literacy by educating about mental illness, substance misuse, and suicide among AAPI youth, with a focus on prevention and early detection
The Rutgers Asian Resource Center for Minority Aging Research (RCMAR)	Rutgers, The State University of New Jersey, New Brunswick, NJ	RCMAR aims to understand the cross-ethnic variations in the social, cultural, and behavior mechanisms of trauma, stress, and resilience across US Asian populations; it explores the differential health outcomes associated with trauma, immigration, and mechanisms of resilience in US Asian populations. In addition, it supports early-career researchers through funding, education, and training, and build community capacity to address health disparities and improve health outcomes

Breaking Barriers to Health Care Accessibility. Appropriate health care has been a struggle for some less advantaged Asian patients,⁴⁰ especially around transportation and communication. Several unique opportunities have recently emerged. In 2019, The US Department of Transportation approved a $9.6 million project to improve transportation accessibilities for expanding health care, but this initiative has not prioritized underserved Asians.⁷⁴ With the rapid growth of telemedicine during the COVID-19 pandemic,⁷⁵ transportation barriers could be reduced for technology savvy patients with internet access. Directing resources toward improving technological accessibility and telemedicine are strong practices to improve health care access. While interpreter services can improve communication, rigorous translator training prior to patient interpreter services to ensure that ethnic minority patient (Latinx,⁷⁶ etc.) viewpoints are appropriately represented. This becomes more relevant when interpreters of an Asian patient’s dialect or language are not available. In addition, with COVID-19-related changes to American society, and an increase in Asian-specific xenophobia, investigators should accurately reassess barriers to care faced by Asians, including access to care (transportation, insurance, and language), screening, prevention, and treatment.

Funding and collaboration

Funding for Asian American focused research. With the NIH as the primary source of funding for Asian American health research,⁵¹ inclusion of underrepresented populations in the federal agenda is necessary for establishing long-term investments in Asian health. Funded research produces more peer-reviewed papers and increases the likelihood of being published in widely read journals, which strongly influences health literature dissemination via high citation rates.⁷⁷ Expedited clinical trials that accelerated the creation of the COVID-19 vaccine demonstrate how effective data collection can be facilitated by an increased priority of funding.⁷⁸ With increased financial support, investigators conducting Asian-American-focused research can similarly gather comprehensive data at faster rates. Funding should be sufficient to promote multi-institutional collaborations and networking between research institutions⁷⁹ and investigators⁸⁰ in order to ask and answer substantial questions necessary to improve Asian American health across the nation. A centralized public database of funding opportunities and grants for Asian American health-focused investigators will pave the way for increased essential research in Asian America health.

Collaborating with Asian nations. By pairing with leading country-specific health care institutions, universities, and national agencies, Asian American health researchers can understand the effects of immigration, acculturation, and conducting cross national research about relative differences in Asian health. Current international collaborations, such as the Pulmonary Vascular Research Institute and the American Thoracic Society, have been successful at increasing global awareness for pulmonary vascular disease.⁸¹ With international collaborations increasing the likelihood of publication in high-impact journals,⁸² Asian American health researchers can work toward long-term international collaboration by contacting other investigators publishing in local and international Asian-health-focused medical journals (Table 5). International collaborations should increase investigator’s knowledge of differences between Asian native and immigrant populations, which may shed light on the causes for differing Asian health outcomes.

Table 5. A sampling of journals focusing on overall Asian and Asian American health (not country of origin specific journals).

Journal name	Country/editorial office	Impact factor* (JCR)	Impact factor* (SJR)
Journal of Asian Health	United States/Palo Alto	Relaunching	Relaunching
Asian Biomedicine	Thailand/Bangkok	0.324	0.2
Asian Journal of Psychiatry	Netherlands/Amsterdam	2.529	0.74
Asian Nursing Research	South Korea	0.988	0.51
Asian Journal of Surgery	Taiwan/Taipei	1.838	0.49
Asian Pacific Journal of Allergy and Immunology	Thailand/Bangkok	1.247	0.34
Asian Pacific Journal of Tropical Biomedicine	China/Hainan	1.903	0.51
Asian Pacific Journal of Tropical Medicine	China/Hainan	1.940	0.54
Asia-Pacific Journal of Public Health	Australia/Perth	1.459 (2014)	0.55
Southeast Asian Journal of Tropical Medicine and Public Health	Thailand/Bangkok	0.245	0.26
American Journal of Chinese Medicine	United States/Chicago	3.682	0.89
Asian Pacific Journal of Cancer Prevention	Iran/Tehran	2.52 (2014)	0.5
*All impact factors are from 2019 unless otherwise stated.

Expanding the Asian American Research Ecosystem. Making a significant change necessitates involving the stakeholders in Asian American health (Fig. 2). While coalitions among Asian American research organizations can increase opportunities for project implementations, funding, and community member participation, it is equally important to keep research community-centered and community-led to ensure that projects are meaningful and implemented appropriately. Investigators should regard community expertise as equal to ‘researcher expertise’ and are likewise properly compensated.⁶⁰ Improving policy on an institutional level will pave the way for nationwide awareness and action toward accurate and consistent data collection among Asian subgroups. From this, health care providers can develop and implement culturally tailored, evidence-based interventions (Fig. 3) that will not only effectively treat individual Asian patients but also build trust among the Asian community in a health care system that has seemed to ignore its health care needs.

Figure 2. Stakeholders of Asian American research.

Figure 3. Action plan for crafting effective health policy that supports long-term precision medicine.

CONCLUSIONS

Diversity is part of the American fabric. Achieving health equity takes deliberate practice and does not occur by accident. In this manuscript, we have outlined critical issues that, if addressed, can improve equity in Asian health and health outcomes. While equity is our next milestone for Asian health, beyond equity is an aspiration toward personalized, culturally competent precision medicine, which values each person in their culture, socioeconomic background, their similarities and differences. As we steadily grow closer to understanding the means to effectively improve Asian health, we establish a more national solid mindset toward action that emphasizes equitable care for all.

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