Towards Respiratory Health Among Immigrants in South East Toronto:
Life Histories of Chinese and Caribbean Immigrants

Esme Fuller-Thomson, Ph.D. (P.I.), Ann Robertson, Dr. P.H., Nita Chaudhuri, M.Sc.,
Lorraine Purdon, Maureen Thompson, M.Sc.

Abstract

This research project built on a community-initiated process in South East Toronto to investigate the problem of respiratory illness among poor, inner-city immigrants. We used the life history qualitative research technique with 40 inner-city immigrants (20 Cantonese-speakers and 20 Caribbean-Canadians) to examine the coping strategies used. These immigrants’ major strategies for managing their illness include the following: the use of Western and traditional medicine, avoiding triggers and managing the environment, diet, exercise and educating themselves about the disease. Relevant research, program and policy implications suggested by this research include the need for further research on alternative medicine use in certain communities, diet and respiratory illness, the development of user-friendly information on respiratory illness in English and Chinese and of policies to improve access of immigrant physicians and nurses to Canadian professional accreditation.

Background

Respiratory illness is a common chronic health problem and places a significant financial burden on the health care system. Respiratory symptoms are significantly higher among poorer children, those in the inner city, and among minority populations. Immigrants from outside North America and Europe constitute over twenty percent of Metro Toronto residents, yet relatively little is known about their experience of respiratory illness. In Regent Park, one of this study’s focus communities, respiratory illness accounted for 9.3% of hospital admissions in 1995. With its impact on our health care system and disproportionate representation among inner-city immigrants and other marginalized segments of society, respiratory illness is a logical health problem on which to focus research. In addition to hospitalization costs, physician visits, personal suffering and productivity loss have considerable societal costs

Method

We conducted life history interviews with 40 immigrants (20 Cantonese-speakers and 20 immigrants from the Caribbean) in South-East Toronto experiencing respiratory health problems. South-East Toronto was chosen as the focus of our research for three major reasons: (1) Active community members had identified respiratory health as a key problem in their community. They approached university faculty to assist them with research on this topic. Over a three year period, joint meetings with community members, service providers and academics had served to build a working relationship. (2) Recent research has identified South-East Toronto as experiencing disproportionate rates of hospitalization due to respiratory illness (Glazier et al., 1995). (3) South-East Toronto is among the most economically disadvantaged and multicultural communities in Canada. We are interested in how disadvantaged groups experience and cope with respiratory illness. In addition, we are particularly interested in coping techniques used within poorer immigrant communities. For the purpose of this study we focused on two case study immigrant groups: Cantonese-speakers and English-speakers from the Caribbean. These two groups were chosen for four reasons: the community health centres have identified particular respiratory health needs in these immigrant groups; we wished to compare and contrast traditional, culturally specific coping strategies such as traditional medicines and herbs; we wished to minimize the heterogeneity of the sample by limiting the population to two groups; and our community health centre partners already had positive relationships with these communities, therefore recruitment was easier.

We chose to use qualitative techniques in our study because we felt relatively little was known about illness-management techniques among Cantonese-speaking Canadians and Caribbean Canadians. We believe a questionnaire would fail to uncover the whole range of techniques used in these communities. Life histories are a popular qualitative research technique of particular value to investigate the less dominant voices in the world, such as women and minority members (Smith, 1994; Fontana and Frey, 1994).

Recruitment occurred through referrals from local service providers, leaflet postings, and announcements in the ethno-specific media. We also did a number of presentations at community centres, English as a Second Language classes, and local gathering places. Several of our respondents were referred from other interviewees. Recruitment and interviews were done by a Cantonese-speaking Canadian graduate student and a Caribbean Canadian graduate student in their respective communities. These research assistants were integral to the project. They provided access to the community and promoted greater openness during the interviews. In addition, they provided culturally appropriate interpretation of the text during the analysis process. The interviews focused on the respondents’ experience of respiratory illness, using the following listed questions as probes to stimulate the discussion: (1) When did you first develop breathing problems? (2) Have your breathing problems changed throughout your life (including pre/post immigration to Canada)? (3) How do your breathing problems change throughout the day? (4) How have you managed your breathing problems? (5) Is there anything that would help you manage your breathing problems?

The life history interviews were recorded and transcribed. The interviews in Cantonese were translated into English. Four transcripts were independently coded by each of the five team members. The themes that emerged were then used as a tentative framework with which to code the remaining transcripts. Additional codes were added until saturation was reached. Once analysis was complete, all team members reviewed the themes to assess if the interpretations were appropriate and grounded in the data (Charmaz, 1983).

Results

The immigrants in this study used an extensive range of strategies for managing their illness. These self-management strategies included the use of Western and traditional medicine, avoiding triggers and managing the environment, diet, exercise and educating themselves. Western prescription medicine was the most prevalent strategy for managing respiratory illness. Some respondents had great confidence in the efficacy of their medication. A Caribbean Canadian woman stated "Certain medication, if I don’t take them I will dies . . .."

While there was not a great deal of difference within the two communities on the types of Western medication used, the traditional cures varied significantly between the two cultures. In both communities, however, these traditional cures were recommended to the respondents by many other people. It appears that traditional medications are well known in the communities. In the Caribbean Canadian community, Bush tea is one of the most prevalent techniques used to manage respiratory illness. Bush, also called Cold Bush, is a medication made from boiled herbs and consumed as a tea. The ingredients vary slightly from country to country but the most common herbs include the following: cerissy bush, marijuana, orange or lime bush, round-the-world, search-me-heart, leaf-of-life and sour sop leaf. Elders appeared to be keeper of this traditional form of medicine. Many respondents received the bush from older relatives in the Islands. One woman commented "Oh, my mom will boil cold bush and all these medicines and send it for them (the children) . . .. I don’t know the name of some of them. . .. (It is an) old people’s remedy."

Most Cantonese-speakers used traditional medicines. In general, there was a belief that Chinese medicine is helpful, however study participants are not in agreement about its relative merit in comparison to Western medicine. One mother stated, "sometimes I don’t give her the puffer, I give her some Chinese medicine. Chinese medicine can clear her symptoms better." ." In contrast, a father of young asthmatic stated, "Chinese medicine isn’t as effective as Western medicine. When her asthma and her coughing became worse she needs to take Western medicine." One of the most frequently cited treatments for respiratory problems were special soups, particularly alligator soup.

In both groups, avoidance of cigarette smoke was a key strategy to minimize respiratory symptoms. This ranged from not allowing smoking in the house to avoiding public places where people could be smoking. Another major trigger appeared to be dust. Many respondents reported that they cleaned and vacuumed their house often. To many respondents, it was important to control their apartment or house’s temperature to minimize the respiratory symptoms. Several of those who lived in apartments where this was not possible found it very frustrating. "You always have to leave a window open or leave it cracked. When we were living in Regent Park the rooms were so small and you don’t have enough space and it’s not properly ventilated." Many respondents found it more difficult to control the external environment. Some interviewees found the extremes of temperature particularly problematic. A major self-care strategy was to avoid time outside.

In both communities some interviewees mentioned the importance of avoiding certain foods and eating others to minimize respiratory symptoms. Several respondents tried to eat primarily at home. Some people used regular exercise as a coping strategy. Two Caribbean men participated in sports to control their asthma as well as to maintain general good health. A Cantonese-speaking woman took her asthmatic son swimming twice a day in the summer "to get him some exercise and get him stronger."

Almost all the respondents had invested a great deal of effort learning about the disease and management strategies. Many respondents turned to friends and family members for information and traditional cures. Most interviewees also expected their doctor to provide information, although some expressed dissatisfaction with the information provided.

No matter what combination of self-care strategies the respondents used, they consistently were vigilant to assess whether an attack was coming. Particularly among parents of asthmatic children, the need for constant awareness was underscored. One Cantonese-speaking respondent changed from full-time to part-time work in order to monitor her child’s symptoms and assure that he did not need to walk to school.

The coping techniques that were identified suggest that there is a rich collection of resources in the community for managing breathing problems. In this study, the principle strategies used for managing respiratory illness are Western medicine, traditional and/or traditional medicine, avoiding triggers and managing the environment, diet, exercise and educating oneself. Although both communities reported extensive use of traditional medicine, the types of traditional medicine varied dramatically.

Policy, Program and Research Implications

Qualitative studies are not designed to be representative nor generalizable. However, our findings do indicate areas for future research that may have important implications for policy development.

Our findings on the use of herbal products and over the counter medicine support the need for further research on the subject. In many communities, the use of non-prescription medication is relatively common (Blanc et al., 1997). While some studies have begun to look at the topic of Chinese medicine (e.g., Borchers, Hackman, Keen, Stern & Gershwin, 1997), more research is needed in the area. Particular attention is needed on the interaction between traditional and Western medicine as most respondents used them in combination. Bush tea, which was used extensively by the Caribbean respondents, provides an important, and neglected, area for future research.

There needs to be some recognition by the health care system that traditional medicines are widely used and often preferred. Present strategies of ignoring this fact are problematic. In order for a holistic health care plan to be developed, it is necessary to consistently explore with patients what alternative therapies are being used. With this knowledge, links between the traditional and Western health care systems can be constructed.

The respondents’ wish for more information indicates a need for easily accessible, consistent information, in both Cantonese and English, on respiratory illness, and recommended medical and self-care management strategies. This recommendation supports earlier demands for language specific medical information (Ontario Ministry of Health, 1994, Ontario Ministry of Health, 1995). A review of community-based asthma intervention programs for inner-city children suggests that three factors can enhance their effectiveness: (1) Community settings such as churches, public schools and community-based clinics should be used as sites for workshops and other interventions. (2) Health professionals need to be educated on asthma management. (3)There needs to be a multi-faceted approach to address housing, social and medical access problems of this population (Butz, Malveaux, Eggleston, Thompson, Huss, & Rand, 1994). Furthermore, these model programs had minority members recruiting and/or administering the intervention. Ethno-specific self-care management workshops based on these principles seems very promising for both the children and the adults in this study.

More research is needed on the relationship between diet and respiratory illness. The traditional Chinese belief that drinking ice water or cold drinks may induce or exacerbate asthma was recently supported in a clinical trial (Lin & Hsieh, 1997). Our research revealed foods that the respondents thought were beneficial (e.g., alligator meat) and others thought to be harmful (e.g., chicken).

Immigrant communities should be provided with more culturally sensitive and language-specific health care provision. To achieve this goal, it is important that policies improve access of immigrant physicians and nurses to Canadian professional accreditation (Ontario Ministry of Health, 1994, Ontario Ministry of Health, 1995). Cultural competency is a necessary component of all health care professionals’ education.

The respondents in this study spent a great deal of time and energy managing their respiratory illness. They have developed an impressive array of strategies for minimizing the disease’s negative consequences for their lives. The wealth of information gained from these life history interviews will be helpful in informing future research. The study also illustrates that asthma sufferers have vital information essential in improving community-based care. The findings indicate the need to understand respiratory health and illness from a broader ecological perspective including socio-cultural, economic and environmental factors.

One paper currently in press.
Esme Fuller-Thomson, Ph.D., Joan Lee, M.A., Erica Lawson, M.A., Nita Chaudhuri, M.Sc. & Maureen Thompson, M.Sc. (In Press). Self-Care Strategies for Managing Respiratory Illness in South-East Toronto: Life Histories of Chinese and Caribbean Immigrants. Canadian Journal of Regional Science.

One Conference Presentation
Nita Chaudhuri, M.Sc., Maureen Thompson, M.Sc., Lorraine Purdon, Esme Fuller-Thomson, Ph.D. (P.I.), Ann Robertson, Dr. P.H Community University Collaboration: The South East Toronto Experience. Association of Ontario Health Centers, May 29,1998.

Several papers currently being written.
Esme Fuller-Thomson, Ph.D., Nita Chaudhuri, M.Sc. Maureen Thompson, Ann Robertson, Ph.D., M.Sc. Erica Lawson, M.A., Joan Lee, M.A. Visible Minority Patients and the Four Principles of Family Medicine: The Experiences of Chinese and Caribbean Immigrant Asthmatics.

Nita Chaudhuri, M.Sc., Maureen Thompson, M.Sc., Esme Fuller-Thomson, Ph.D., Ann Robertson, Ph.D., Erica Lawson, M.A., Joan Lee, M.A., Lay Knowledge and Management of Asthma: Results of 40 Life History Interviews

Maureen Thompson, M.Sc., Nita Chaudhuri, M.Sc., Esme Fuller-Thomson, Ph.D., Ann Robertson, Ph.D., Erica Lawson, M.A., Joan Lee, M.A., Lay Knowledge and Management of Asthma: Implications for Health Care Practice.

Ann Robertson, Dr. P.H., Maureen Thompson, M.Sc., Nita Chaudhuri, M.Sc., Esme Fuller-Thomson, Ph.D., Erica Lawson, M.A., Joan Lee, M.A., The Construction of Lay Understanding of Risk.

Erica Lawson, M.A., Maureen Thompson, M.Sc., Nita Chaudhuri, M.Sc., Esme Fuller-Thomson, Ph.D., Ann Robertson, Dr. P.H., Joan Lee, M.A., Caribbean-Canadian Immigrants’ Interpretation of Treatment.

Dissemination Activities

In addition to the academic publications and conference presentation listed above, there are plans for several other forms of dissemination. Findings from our study will be presented to the doctors, nurses, social workers and other health professionals in each of the two collaborative community health centres. Our findings will also be presented to an ESL class of Cantonese-speakers in the Spring of 1999 and to a Respiratory Health Patient Group. The feed-back we receive from these two groups will provide additional participant validation of our findings and insight into relevant policy ramifications. When funding becomes available, we hope to produce a user-friendly general information booklet on Asthma in Chinese.

Nature of the Research Collaboration

The CERIS grant allowed us to further solidify our ongoing productive research collaboration between academia and local service providers. All members of the team were integrally involved in the design, recruitment, staff supervision, analysis and writing stages of this project. Without community partners identifying the health concerns and facilitating recruitment, community "buy-in" would not have been possible. Community partners presented the experience of this collaboration to their colleagues in other Ontario community health agencies. The breadth of data collected allows each team member, including students, to take the lead on a paper addressing their particular topic of interest. We are hoping, thereby, to advance the publication record of all partners, build academic writing skills and disseminate information as widely as possible.

Training Opportunities

Both research assistants were essential to the success of this project. They were both Masters students. Under supervision of the core team members, they enhanced their expertise in recruitment, question development, transcription, cultural interpretation, analysis and writing. They are co-authors on a peer-reviewed journal article currently in press and are also involved in other articles currently being written. Both anticipate becoming first author on papers concentrating on aspects specific to their respective communities. One student, Erica Lawson, has been accepted into the Ph.D. program at Ontario Institute for Studies in Education. As a result of her work on this project, she plans to do her thesis on indigenous knowledge and health care behaviors.

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