Duke University School of Nursing Associate Professor Hanzhang Xu, PhD’18, RN, leads an NIH-funded study of aging Chinese Americans, one of the fastest-growing aging populations in the U.S. and one of the least examined. The study is titled Developing a Mobile App-Based Intervention to Promote Cognitive Health in Older Chinese Americans and an important part of the project includes working closely with local Chinese communities to develop and test cognitive training intervention in this older population. To that end, Xu and her team collaborated with the Chinese club at the Cary Senior Center to deliver a lecture on dementia earlier this summer.

“Older Chinese Americans often perceive strong shame and stigma in relation to dementia and lack dementia-related knowledge,” Xu said. Based on previous focus groups conducted, Xu’s team shared information at the senior center about dementia, how to promote cognitive aging and available treatment options. The feedback and interactions with the community partner will inform Xu’s study, which aims to develop a mobile health (mHealth) app-based intervention that accommodates the unique immigration history, cultural values and linguistic properties of older Chinese Americans. 

As with many nonwhite groups, language and cultural barriers can impede people’s abilities to access treatment and information, which itself was often developed from studies of almost exclusively white populations.

“There are some training activities that might not be culturally relevant to older Chinese Americans, such as an activity that simulates a driving and navigation activity,” Xu said. Another example might be an activity called face-fact, in which participants are presented with a series of portraits labeled with names, hobbies and occupations. Some information and popular icons included in the training might not be familiar to older Chinese Americans, such as Cajun food, kale and country music singers. “That may create another layer of barrier for them to participate in the training.”

Familial relationships also play into how dementia affects older Chinese Americans, Xu said. “In Chinese culture, adult children share the responsibility to provide emotional and financial support for their older parents,” she said. “Our prior work has suggested that Chinese older adults often perceive a sense of responsibility to take good care of themselves and not to be a burden to their adult children.”

Because of that dynamic, Xu said she made sure to include adult children of older Chinese Americans in the study, which also addresses the effects of social determinants of health and health inequities experienced among this population.

“Although Chinese Americans are often perceived as a ‘model minority’ who achieve a higher level of socioeconomic status than other groups, the picture is incomplete,” Xu said. More than 70% of Chinese Americans are first generation immigrants and nearly 20% are living below the poverty line. Close to half have limited English proficiency.

“These socioeconomic disadvantages shared by older Chinese Americans not only contribute to an increased risk of developing dementia, but also to inequitable access to effective services and programs to promote cognitive health.”

Xu’s study focuses on using accessible technology to reach as many participants as possible, and partnering with technology developers in the industry to build the phone app. “The widespread use of mobile phones offers an unprecedented opportunity to deliver cognitive training interventions remotely to a large population at relatively low cost. This is particularly relevant to the immigrant populations as they often reside in ethnic enclaves and rely heavily on smartphones and apps to build social networks and to access local services,” according to the study.

The project leverages expertise from interdisciplinary academics, a commercial training app developer and community partners whose input helps co-design the app, Xu said. “We believe that this academic-industry-community collaboration offers tremendous potential to accelerate the dissemination and implementation of this intervention to a large population later at relatively low cost.”

This research is funded by a National Institutes of Health grant, project number 1R21AG075228-01.