Baseline Knowledge of Peripheral Arterial Disease and Factors Influencing Learning Material Preferences in the San Francisco Chinese-Speaking Community: A Survey Analysis

Abstract

Background: The influence of health literacy on PAD outcomes remains poorly understood, particularly in minoritized communities. The objective of this study is to examine the understanding of PAD within San Francisco’s Chinese-speaking population while discerning preferences regarding learning methods. Materials and Methods: An anonymous 14-question survey in Mandarin and English was conducted in two San Francisco Chinatown health fairs. Results: About one-third of the respondents (29/91) reported prior knowledge about PAD and that arthritis was the leading symptom related to PAD (32/65). Half of respondents (44/88) preferred consulting a family doctor for foot wounds, followed by a podiatrist (27/88) and a general surgeon (19/88). The top three methods to receive health information were radio, television and newspaper. Those who were 65 years old and above (OR 0.124, 95% CI [0.021–0.0728]) and participants who were proficient in English (OR 0.078; 95% CI [0.012–0.52]) less preferred using radio to receive health information. Male gender preferred newspapers to receive health information (p = 0.003, OR 5.26; 95% CI [1.76–15.69]). Discussion: Our findings may suggest a community-specific campaign to increase the awareness of PAD given that age, education level, gender and English proficiency may influence the media of choice to receive health information. Conclusions: The two cohorts that were surveyed had similar and suboptimal understanding of PAD, and a community-specific strategy is needed to address such inequity, which may improve awareness of PAD and health outcomes.

1. Introduction

Among many medical conditions, peripheral arterial disease (PAD) is a devastating condition, affecting around 10% of the United States population [1]. Its debilitating complications include gangrene, non-healing wounds, and lower extremity amputations, as well as ischemic pain [2]. Risk factors related to PAD are similar to other cardiovascular diseases. Although advanced age is a risk factor for developing PAD, the early recognition of the signs of PAD is imperative to mitigate the chance of limb loss, which is linked to an increased risk of mortality due to the decline of function after limb loss [3].

Recent advancements in medical imaging technology have significantly improved the diagnosis and treatment of PAD. Imaging modalities, such as Doppler ultrasound, magnetic resonance angiography, and computed tomography angiography, allow for more accurate and early detection of PAD, facilitating timely intervention. While treatment options are available, the advocacy for PAD prevention and recognition did not gain more attention until recently [4]. The impact of PAD and its complications on minorities is also disproportionately more prevalent than among non-Hispanic whites [5]. Given that the evidence has suggested that diabetic foot ulcers are related to lower socioeconomic status and that diabetes and its associated complications are associated with the increased risk of PAD development [6], a lack of understanding of the disease may be a contributing factor to limb loss due to PAD.

The impact of structural inequalities is well known to be a contributing factor to health disparities and negatively affects social determinants of health (SDoH) [7]. SDoH encompasses a wide range of socioeconomic and environmental factors, such as access to care, education and safety of the neighborhood, that can affect health outcomes. One example that demonstrates the implications of structural inequity is the historical racial discrimination housing policy, The Fair Housing Act, which is title VIII of the Civil Rights Act of 1968 [8]. This policy is commonly known as “the redlining” policy, which created barriers for specific minority groups to purchase real estate in certain neighborhoods. As a result, neighborhoods became isolated and segregated. Although the policy was abolished years ago, its effect on the populations in these neighborhoods continues to demonstrate worse health outcomes than the non-redlined neighborhoods to this date. In New York City, the historical redlined zones have higher stroke prevalence [9]. The negative impact of the redlining policy affects the younger population in these historical redlined neighborhoods, as well. In the Finger Lakes region of New York state, the historic redlined zones demonstrated a higher prevalence of preterm birth in a cohort from 2005 to 2018 [10]. In Seattle, WA, diabetes-related mortality rate and years of life loss were higher in the historical redlining areas [11]. A common theme among the populations in the above redlining areas is low socioeconomic status and education level.

To our knowledge, the understanding of PAD in subsets of minorities in the redlined neighborhoods is not well known. Health literacy, closely intertwined with factors like education, income, and access to healthcare, is pivotal in addressing health disparities [12]. Improving health literacy through interventions can empower individuals and communities to tackle social and economic determinants of health, enhancing the utilization of preventive services and adherence to medical advice [12]. By integrating health literacy with behavior change theories, interventions have the potential to significantly reduce disease burden and achieve greater equity in disease outcomes [13]. However, despite the promising effects of enhancing health literacy, public education about PAD lags appears to be behind other health conditions like diabetes, stroke or heart disease until recent years [2,14]. Low health literacy correlates with increased hospitalizations and emergency care usage and decreased preventive service utilization [15]. It also relates to challenges in interpreting health messages, poorer health status, higher mortality rates and elevated healthcare costs [16].

The factors that influence an individual’s health literacy can be multifactorial and complex. Anecdotally, we observe a knowledge gap in PAD and its complications among the Chinese-speaking population in San Francisco Chinatown, a historic redlining zone. Patients in this specific and isolated population often present chronic non-healing wounds and rest pain due to underlying PAD. Despite the effort from the providers to explain the relationship between wound healing and peripheral circulation, the idea was difficult to comprehend for the patients and families, and they would often focus on which topical ointment would heal the wound. This observation highlights the lack of awareness and baseline knowledge of PAD and its complications. To investigate the baseline understanding of PAD and its complications within the Chinese-speaking population of San Francisco, the primary objective of this study is to survey the foundational understanding of PAD and learning preferences. Through the findings of this project, we aim to uncover insights that can inform targeted educational initiatives and ultimately enhance the management and prevention of PAD within this specific demographic.

2. Materials and Methods

An anonymous 14-question survey written in Mandarin and English was designed to gauge the basic knowledge of PAD and the preferred method for obtaining health information [Supplementary file]. The paper survey was distributed at the health fairs in San Francisco Chinatown on 6 May 2023 and 14 October 2023. Respondents who were not able to read the survey completed the survey as the student volunteers or translators read the survey for them. The responses were marked on paper copies and transferred to Qualtric, where the data was stored. Survey consent was included on the first page. The study was approved by the Samuel Merritt University Institutional Review Board (SMUIRB #22-011).

Statistical Analysis

To our knowledge, this was the first attempt to investigate the baseline PAD knowledge and preferred method to acquire health information for a subset of the Chinese-speaking population. The analyses would focus on finding the associations between demographics and responses to the survey. As a result, Chi-squared analyses were conducted to identify significant differences in demographics between the two cohorts of the study. An additional Chi-squared test was performed to examine differences in the proportions of top learning styles across different age groups, genders, and educational levels. For this analysis, educational levels were categorized into two groups: those with a high school education or lower and those with education beyond high school (i.e., higher education). The cut-off was based on a number of prior studies that demonstrated that higher education influenced health-related decisions and knowledge [17,18,19]. ANOVA analysis was also performed to investigate associations between preferred learning methods and both gender and education level. Logistic regression was conducted to further assess the top three preferred learning methods against English fluency, gender, age, and educational level. The significance level for all statistical tests was set at a p-value of less than 0.05. All analyses were performed using Jeffreys’s Amazing Statistics Program (JASP; JASP Team 2024) and RStudio (RStudio Team 2024).

3. Results

3.1. Surveyed Population Demographics

Overall, a total of 94 respondents completed the survey at two different health fairs in San Francisco Chinatown (44 in May and 50 in October). The demographic characteristics of the respondents are summarized in

Table 1. Surveyed Population Demographics.

	May	October	p-Value
Gender			0.759
Female	30	34
Male	11	16
			N/A 1
Age (years)	0	3
under 35	0	3
35 to 44	0	2
45 to 54	0	5
55 to 64	24	22
65 to 74	15	14
86 or above	1	0
Education 2			0.155
High school and below	31	29
Above high school	10	20
Primary language			N/A 1
Cantonese	38	35
English	3	15
Mandarin	5	11
Toishanese	7	7
Vietnamese	0	3
Shanghainese	0	0
Other	0	1
English fluency			N/A 1
Extremely well	0	9
Very well	2	5
Well	3	6
Not well	8	7
Not at all	29	21

¹ Differences between the two groups cannot be analyzed between cohorts due to a number of groups having no subjects. ² Some categories for education level did not have any participants. For analysis purposes, education levels were grouped into high school and below versus above high school.

(not all respondents answered every question). The sample was predominantly female (64/91). The predominant age group was 65–74 years old in both cohorts. Regarding educational level, most participants had completed middle school (23/91). In terms of the primary language or dialect spoken, the majority of the participants spoke Cantonese (73/93). For proficiency in speaking English, most reported not being able to speak English at all (50/90); however, the October group had more participants who were more proficient in English than the prior group.

3.2. PAD Baseline Knowledge

Out of 91 individuals, 29 (32%) had prior knowledge of PAD. Diabetes was chosen as the primary factor leading to PAD (47/76 respondents) and affecting wound healing (40/78 respondents) [Figure 1 and Figure 2]. Additionally, participants recognized symptoms such as arthritis (32/65 respondents), leg cramping (31/65 respondents), and coldness/numbness in the feet (31/65 respondents) as most commonly associated with PAD [Figure 3]. In terms of healthcare-seeking behavior, a majority of respondents expressed a preference for consulting a family doctor (44/88 respondents) for foot wounds, followed by a podiatrist (27/88 respondents) and a general surgeon (19/88 respondents) [Figure 4]. There was a significant difference in awareness of PAD risk factors across different age groups. Paradoxically, respondents aged 74 and younger exhibited lower awareness compared to older counterparts (p = 0.04) [Figure 5].

3.3. Inferential Analysis on Age, Gender and Educational Level vs. Preferred Learning Methods

Among all demographic categories, age, gender and educational level demonstrated a statistically significant association with preferred learning methods. The top three preferred methods for receiving health information were radio (n = 49), newspaper (n = 35) and television (n = 32) [Figure 6]. We found a statistically significant association between participants’ educational level and whether the following methods were considered part of their top three learning styles: internet search (p < 0.001), TV (p = 0.008), radio (p = 0.043) and talking to clinical providers (p = 0.048) [Figure 7]. In logistic regression, age (p = 0.021) and English proficiency (p = 0.008) were statistically significant for using radio to receive health information for participants 65 years old and above (OR 0.124, 95% CI [0.021–0.0728]), and participants who were proficient in English (OR 0.078; 95% CI [0.012–0.52]) less preferred using radio to receive health information. Male gender was statistically significant in using newspapers to receive health information as opposed to female gender (p = 0.003, OR 5.26; 95% CI [1.76–15.69]).

When analyzing the relationship between the top three preferred learning methods and gender, 14/62 females preferred video/media, compared to just 1/27 males (p = 0.033). Additionally, 11/62 females preferred talking to providers, while only 1/27 males chose this method (p = 0.084). Conversely, 16/27 males preferred newspaper, while 19/62 females selected newspaper as one of their top three preferred learning methods (p = 0.008) [Figure 8]. Based on the analyses, age (p = 0.725), educational level (0.168), English fluency (p = 0.078), prior knowledge of PAD (p = 0.173) and awareness of PAD risk factors (p = 0.836) were not significantly different between the two genders in our cohorts.

4. Discussion

To our knowledge, this is the first attempt to understand the current baseline knowledge of PAD in the Chinese-speaking population in the United States. Overall, only 32% of the survey population (29/91) reported prior knowledge about PAD, while many survey respondents thought that diabetes was a leading cause of PAD (47/76) and that arthritis was the leading symptom related to PAD (32/65). These contradicting findings may further implicate the lack of knowledge of PAD in the survey population. The two cohorts that were surveyed had similar and suboptimal understanding of PAD and its complications, which confirmed a health literacy gap among the Chinese-speaking population, particularly in San Francisco Chinatown. The top three methods to receive health information were radio, television and newspaper. Interestingly, 65 years old and above (OR 0.124, 95% CI [0.021–0.0728]), as well as participants who were proficient in English (OR 0.078; 95% CI [0.012–0.52]), less preferred using radio to receive health information. Male gender was statistically significant for using newspapers to receive health information, as opposed to female gender (p = 0.003, OR 5.26; 95% CI [1.76–15.69]). Our findings may suggest launching a community-specific campaign to increase the awareness of PAD given that age, education level, gender and English proficiency may influence the media of choice to receive health information.

4.1. Age vs. Preferred Learning Methods

Learning theory, specifically the Social Cognitive Theory of Learning, suggests that learning is influenced by peers. The theory may partially explain that adult learning is different from children’s. For instance, life experiences and generational background may influence adult learners’ learning [20]. As a result, the subject of adult learning is a very complex topic with significantly wide variations. For example, in our cohort, 65 years old and above less preferred radio, a more traditional media, as a learning method for health information, but radio was selected as the number one learning method by the entire cohort. However, the younger generation (age 35 or younger) seemingly preferred email, as opposed to the older generations in our surveyed cohort; however, the small sample size limits the interpretation of this finding. Our findings indicate the choice of media to inquire about health information is likely not effective with a single method. Consequently, based on the Social Cognitive Theory of Learning, specific campaigns and the social media of choice will be designed and tailored to different age groups in the Chinese-speaking communities in San Francisco Chinatown in order to increase awareness of PAD and its complications.

4.2. Education Level vs. Preferred Learning Methods

Another factor that appeared to impact the preferred method of receiving health information is the level of education. Participants with higher education levels, such as some college or university graduates, preferred internet searches and video/media formats for obtaining health information. This is likely due to greater exposure to multimedia resources and, as a result, more familiarity and preference for these formats. In contrast, those with middle school education or below were more inclined to choose traditional media such as television, reflecting a digital divide linked to the level of education. The literature supports this observation, indicating that higher educational attainment is positively associated with e-health literacy among older adults, enabling them to seek and utilize newer multimedia formats [21]. These results suggest that health literacy interventions should consider the educational background of the population. Tailored programs that utilize multimedia resources may be more effective for those with higher levels of education; however, a more traditional approach may be necessary for those with lower educational levels. Tailoring educational methods this way may help bridge the digital divide and improve health literacy among elderly individuals.

Another interesting finding that may be related to the education level is the negative association between English proficiency and using radio as a preferred method to receive health information. Presumably, Chinese-speaking immigrants who are proficient in English are likely to have higher education degrees. Although the Chinese language may be their first language, they may feel more comfortable using methods that are English language-based. While the above finding is interesting, it is not surprising. The top three selected preferred methods—radio, newspaper and television—are readily available in the Chinese language in San Francisco Chinatown. Therefore, the age and education level of the surveyed community in San Francisco Chinatown, along with their English proficiency, are likely associated with media that contains the Chinese language.

4.3. Gender vs. Preferred Learning Methods

Methods to receive health information appeared to be different between reported genders. We found that female respondents demonstrated a statistically significant preference for Video/Media (p = 0.033) and Talking to Clinical Providers (p = 0.084) compared to their male counterparts in our population. This inclination towards multimedia formats aligns with broader societal trends, where women are more attracted to visual and interactive modes of communication. Conversely, males exhibited a preference for traditional learning methods, as evidenced by the results showing newspapers as one of their top three choices (p = 0.008) compared to females. Research in educational psychology suggests that females tend to engage more deeply with content presented through dynamic visual stimuli, finding it conducive to their learning styles [22]. Interestingly, while learning methods may differ, recent findings from Martelli et al. suggested that while women with chronic limb-threatening ischemia experience fewer co-morbidities than men, they have similar mortality rates, as women are diagnosed at an older age [23].

Albert Bandura’s Social Cognitive Theory emphasizes that individuals learn by observing and emulating role models, especially those they admire or perceive as successful [24]. This theory can be linked to our findings on the lack of knowledge about PAD in the Chinese-speaking population in San Francisco. The gaps in health literacy highlighted in the study suggest that targeted health education strategies should consider the social and cultural dynamics of the population. For example, trusted figures in the community, such as healthcare professionals or media personalities in Chinese-speaking media channels (radio, television and newspapers), could serve as influential role models for spreading accurate information about PAD. By using respected figures, a culturally tailored campaign could bridge the health literacy gap, encouraging individuals to emulate the health-seeking behaviors of these role models, such as seeking early diagnosis and treatment of PAD. This approach, in line with Bandura’s theory, would not only promote awareness but also foster behavioral change through social learning, thereby improving health outcomes within this community.

5. Conclusions

These findings highlighted the complexity of an individual population. In the study cohort, although they shared very similar ethnic and cultural backgrounds, the methods of inquiring about health knowledge were influenced by gender, age and level of education. As a result, a more comprehensive approach using multiple social media channels may be necessary to increase the awareness and understanding of a disease such as PAD. At the policy level, these findings underscore the need for comprehensive cultural and community-specific campaigns and healthcare programs to improve the awareness of PAD and to reduce the health disparities among minority populations. Future research may further investigate the effectiveness of these tailored health education strategies in increasing awareness and health outcomes. Finally, employing a strategy based on the Social Cognitive Learning Theory, which has been proven effective in adult learning, may solidify knowledge about PAD among individual populations.