Factors that Influence Asian American College Students Use of Mental Health Services: A Systematic Mixed Studies Review

Abstract

Introduction:

Only 8.6% of Asian Americans (AA) sought mental health services compared to 18% of United States population. AA college students report higher levels of mental health concerns compared to White students.

Aim:

The purpose of this systematic review was to identify the factors that influence AA students’ mental health help seeking behaviors.

Method:

Employing a data-based convergent synthesis design. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the sample. Inclusion criteria were peer-reviewed studies published in English, focused on AA college students’ mental health seeking attitudes in United States.

Results:

The final sample was forty-four studies. Four themes emerged: acculturation, ethnic identity, racism, and stigma. There were discrepant findings regarding how acculturation affects mental health help-seeking attitudes. Several studies included more than one theme in their analyses. The different concepts included across studies make it difficult to compare the findings.

Discussion:

There is some overlap between acculturation and ethnic identity that could affect the analysis in studies where both concepts are included. Personal stigma negatively influences mental health help-seeking attitudes.

Implications for Practice:

Defining culture to include acculturation, ethnic identity, personal stigma can help in understanding their effect on mental health help-seeking attitudes.

Background

There is a significant barrier to seeking and participating in mental health services (Corrigan, 2004; Corrigan et al., 2014). In fact, more than 100 peer-reviewed research studies have reported the negative impact of a lack of access to mental health services in the general population (Clement et al., 2015). Some overall societal beliefs regarding people experiencing mental illness include that they are dangerous and unpredictable, that they are responsible for their illness, and that they are unable to achieve life goals (Angermeyer & Dietrick, 2006).

Only 8.6% Asian Americans (AAs) reported seeking mental health services compared to 18% of the general population (Spencer et al., 2010). This may be due to a noted difference between Western and Asian conceptions of emotion and mental health. Culturally influenced explanatory models of mental illness (Kleinman, 2004) suggest that culture influences how individuals understand mental health issues and their help-seeking behaviors. South and East Asian populations underutilize mental health care (Marshall et al., 2006; Tiwari & Wang, 2008). Each Asian ethnic group has its own cultural history that affects how they view mental health (Gellis, 2003). For example, the Korean word Han describes a feeling of regret or resentment about the neglect of children or parents that in Western society is labeled ‘shame’ or ‘guilt’ (Cho et al., 2015; Pang, 1998). Traditional Confucian ethic of filial piety emphasizes the duty of children to be obedient and tend to the needs of their parents (Bedford & Kuang-Hui, 2019).

The term mind-split-disease has been used to define schizophrenia with many Asian countries adopting a similar translation (Chung & Chan, 2004). Western-style psychotherapy which often emphasizes self-disclosure and emotional expression contrast with Asian preferences for assistance from family and friends (Leong & Lau, 2001). Mental illness is thought to be caused by a lack of harmony of emotions or evil spirits leading to delay in treatment (Chiu et al., 2018).

Another difference across cultures is the values and attitudes about suicide, with permissive cultural attitudes towards suicide among Asian societies being associated with an increased risk (Jeon et al., 2013). Depression has been shown to be the leading barrier to college student success and retention (Wallin et al., 2019). Mental health resources are important to address this problem; however, many students who are struggling do not seek mental health services. A survey of 274 institutions found that 88% of counseling providers reported an increase in severe psychological problems among students (Pedrelli, et al., 2015), with the rates of major depression prevalence a salient problem among AA students (Fu et al., 2020). This may be due to having multiples selves in multiple words (Cooper, et al., 1998). These youth are essentially living in different worlds between traditional Asian families and United States societal values and beliefs.

The model minority myth is a belief that may also affect mental health seeking behavior. This myth stems from Asian Americans’ tendency to isolate themselves as a means of adaptation and are seen as academically successful (Kim, 1973; Lim, 2015). Secondary to higher social expectations placed upon them, stigmatization (self-stigmatization as well as from others) can occur if they do not meet these expectations (Chen et al., 2014).

AA students were more likely to seek counseling for academic and vocational problems but not emotional or interpersonal concerns (Kim, 2007). Although AA students report higher levels of mental health concerns compared to White students (Wong et al., 2011) they do not seek help until they experience a high degree of severity (Sue et al., 2012). As previously discussed, cultural attitudes and belief in the model minority myth may play a role in whether a student seeks mental healthcare. It is important to examine factors that contribute or create barriers to mental healthcare seeking among AA students. Awareness of these factors could lead to interventions employed by mental health providers, including nurses to decrease depression and anxiety among AA emerging adults.

The Review

Aim

The purpose of this systematic mixed studies review was to identify factors that affect AA college students’ mental health help seeking behaviors.

Design

This is a systematic mixed studies review (Pluye & Hong, 2014); therefore, not requiring Human Subjects Institutional Review Board approval. Results-based convergent synthesis design (Hong et al., 2017) was employed to initially analyze quantitative and qualitative data separately then synthesize the findings. We chose this design to allow for integration of a diverse group of studies to include qualitative and mixed methods studies.

Search Methods

From reviewing the literature to develop the search question it was clear that a broad scope would be needed since there were few studies that focus on AA students. Databases were chosen keeping in mind that the focus was AA college students and their mental health help-seeking behaviors. CINAHL, ERIC, JSTOR, SocIndex, PsycARTICLES, PsycInfo, and PubMed were searched for articles published using the search terms ‘Asian or Asian American’, ‘stigma or attitude’, parent perception or attitude’, and ‘emerging adults or college students or young adult’. Included studies were full-texted peer reviewed, quantitative, or qualitative data-based studies that focused on factors that contribute to mental health seeking behaviors. Inclusion criteria were AA college students in the United States (U.S.) between the ages of 18–26 years of age. A minimum of two individuals completed the review of each paper included in the sample independently then the full team reviewed all the studies to increase interpretive consensus.

Search Outcome

The original search from databases and hand-searching resulted in 1610 articles, of those 1410 were excluded due to not meeting the inclusion criteria. Two hundred title and abstracts were reviewed with duplicates (n=47) and those not meeting inclusion criteria (n=88) were removed leaving 65 remaining articles for full review. The final sample was 44 studies (See Figure 1).

Figure 1.

PRISMA Flow Diagram

Quality Appraisal

Table 1 contains concise information about each study including authors, design, sample, setting, and factors. We used the Mixed Methods Appraisal Tool (MMAT) to evaluate the studies (Hong et al., 2018). The latest version of the MMAT encourages a descriptive quality appraisal rather than a numerical score. The product of this appraisal can be found in Table 2.

Table 1:

Table of Evidence

	Author	Design	Sample	Setting	Factors
1	Arora, Metz & Carlson (2016)	Quantitative, Cross-sectional	160 south Asian student	Large southern university	Personal stigma positively correlated with ATPPS (r=.25, p<.001) R2=.10, F(4,159)=4.18, p=.003 with personal stigma (B=−1.13, SE=.34, ß=−.26, t=−1.43, p<..001) and gender (B=1.37, SE=.68, ß=.16, t=2.03, p<.005) were significant. Greater personal stigma toward others with mental health concerns and being male were associated with lower scores on help-seeking attitudes.
2	Atkinson & Gim (1989)	Quantitative, Cross-sectional	263 Chinese American, 185 Japanese American, and 109 Korean American	major west coast university	More acculturated AA students were more likely than less acculturated AA students to recognize personal need for profession psychological help (low M=20,SD=3.8; high M=22.0, SD=4.0), to be tolerate of the stigma (low M=13.2,SD=2.4; high M=14.7, SD=2.8), and to be open to talking about problems with psychologist (low M=17.4, SD=2.6; high M=19.8, SD=3.4).
3	Augsberger et al. (2015)	Mixed-study	AA women (M=22.5 years) N=701 nationally for survey n=17	Qualitative: parents dismissive, parents emphasize saving face, community view mh problems as taboo, lack of culturally appropriate interventions	Divided sample into 3 groups by risk F1 no hx of depression or suicidal ideation, G2 either current depression or lifetime suicidal ideation, & G3 current depression and lifetime suicidal ideation Quant results: those in G3 were more likely to use mh care although overall mh care in G3 was low Qualitative results: used count data 47% n=8 stated parents dismissive of mh concerns and emphasize saving face; 32% n=5 stated community views mh problems as taboo subject and disapproves of burdening others with problems, and 82% n=14 felt a lack of culturally appropriate intervention models and women left alone to find alternative coping
4	Chang & Chang (2004)	Quantitative Cross-sectional	109 students (47% return) 109 (71 female) Asian American and Asian international students	A large east coast university and a large midwestern university	Students had more positive attitudes toward seeking face-to-face help rather than online help (F(1,102)=68.86, p<.001. Asian international students having more positive attitudes f-2-f than on-line (F(1,105)=4.05, p<.001). AA negative attitudes about seeking mh traditional (M=1.47, SD=.55) versus on-line (M=0.96, SD=1.22) Asian international although same direction as AA more accepting of both types of help f-2-f (M=1.54, SD=.54 versus on-line (M=1.11, SD=.59)
5	Chang et al. (2013)	Quantitative, Cross-sectional, secondary analysis Of the NLAAS data	2,095 Asians (46% male) 32% 18–34 years	National data set	AA dx with mh concerns (OR=6.24, p<.001, 95%CI [4.25,9.21]) and who perceived a need to seek prof heal (OR=11.69, p<.001, 95% CI[6.68,20.49]) were more likely to access care Family conflict was more pronounced in 2nd generation than in 3rd AAs after controlling for co-variates (OR= 1.23, p<.05, 95% CI[1.04,1.47]) 2nd generation AAs more likely to have lifetime service use (OR= 1.68, p<.05, 95% CI[1.09,2.60])
6	Chen & Mak (2008)	Quantitative, Cross-sectional descriptive	747 undergraduate students from US, Hong King & mainland China 1919 students in US, 170 in Hong Hong, and 192 in China	Survey Group comparisons	Significant difference across the four groups F(3,739)=13.80, p<.001 with Hong Kong Chinese (M=2.51, SD=0.74) significantly lower likelihood of seeking help than Chinese American (M=2.84, SD=0.69) and EA (M=2.00, SD=0.72, ps<.05. Mainland Chinese scored (M=2.78, SD+ 0.74) significantly higher than Hong Kong Chinese Significant relations between culture and help-seeking X2(4, N=747)= 228.41 social worker,466.58 psychologists, 601.74 psychiatrist, & 542.86 university counseling centers
7	Chen et al. (2014)	Quantitative, Cross-sectional	113 API students	Survey one campus western US campus (M=21.7 yrs, SD=2.19); 75% reported parents were their financial support; 57% male; heterosexual (85%)	25 % reported that people act as if they are better than them and 4% reported that people assume their English is poor Overall multivariate model showed the data fit the model (F(9,104)=3.81, p<.001, R2=.265 with perceived discrimination and the interaction between PD and ethnic identity having significant independent paths. Although ethnic identity was not independently significant there was an interaction between ethnic identity and perceived discrimination (B=−1.34, SE0.33, B=−0.37, p<.01) on somatic symptoms as DV.
8	Cheng (2015)	Quantitative, RCT	437 participants (78% AA) 66% female Mage=21, SD=2.4)	Western US	Significant main effect F(3,188)=3.99, p=.009, np2=.06 those who received social explanation were more willing to be near someone with depression than those who received a genetic (p=.001) or neurobiological explanation (p=.08). Significant conditional effect of fear F (3, 189)=4.60, p=.004, np2=.07 with those given social explanation were significantly less fearful of someone with depression than those given a genetic (p=.008 neurobiological (p= .001) or no explanation (p<.008)
9	Cheng, Kwan & Sevig (2013)	Quantitative, Cross sectional model testing	609 racial and ethnic minority students, 166 AA(M=22.6, SD=5.4)	midwestern US university	Model explained 29% of variance in perceived stigma by other and 29% of variance in self-stigma for AA X2(345)=558.86, p<.001, CFI=.96, TLI=>(4, SRMR=.05, RMSEA=.06
10	Cheng, Wang et al. (2017)	Quantitative, Cross-sectional design	8.6% sample Asian American	Survey at midwestern large public university in US	Being male (B=−.26, SE=.03, ß=−.22, p<.001), AA(B=−.13, SE=.04, ß=−.08, p<.05), depression (B=−.09, SE=.02, ß=−.07, p<.001), and no hx of psych services (B=−.36, SE=.03, ß=−.28, p<.001), reported less favorable attitudes toward seeking psychological help Accounting for 54% of the variance Students who were male, AA, higher depressive symptoms and no hx of past services reported less favorable attitudes of seeking help
11	Cokley et al. (2013)	Quantitative, Cross sectional	240 ethnic minority students; 111 AA (M=20.5, SD=2.14 years)	Large southwestern university	Significant main effect for ethnicity F(4, 456)=3.03, p<.05, n2=.03 with AA (M=3.09, SD=.65) reported higher imposter feelings than did African (M=2.56, SD=.71) and Latinx (M=2.80,SD=.72); AA(M=44.52,SD=19.73) reporting significantly higher psychological distress that African Americans (M=37.81,SD=23.55) or Latinx (M=37.64, SD=22.70) AA(M=67.72,SD=22.70) reporting significantly lower psychological well being that African Americans (M=75.33,SD=20.14) or Latinx (M=76.73, SD=20.14)
12	de Luna & Kawabata (2020)	Quantitative; Cross-sectional	Filipino American students (n=110)	In Guam	There was a generational status significant effect F(2,106)=3.81, p<.05 3rd generation (M=18, SD=6.45) and 2nd generation (M=17.24, SD=5.35) had more positive attitudes to help-seeking as compared to 1st generation (M=14.22, SD=4.34). Enculturation negatively associated with help seeking (r=−.34, p<.01). Self-stigma positively associated with enculturation (r=.36, p<.01). Mental health problems positively associated with self-stigma (r=.25, p<.01). With DV as help seeking attitudes and enculturation as IV and self-stigma as mediator controlling for co-variates the model showed a good fit to data X2(6,N=103)=8.293, p=.217, CFI=.952, RMSEA= .061, SRMR-.037. Self-stigma fully mediated association between enculturation and help-seeking
13	Dong, et al. (2020)	Qualitative exploratory study	19 AA undergraduate students	Facebook recruitment	Helps:1)Social environment facilitates help-seeking 2)Psychological and physical distance from family facilitates help-seeking Barriers: 1) family dysfunction 2)belief mental health is private 3) Stoicism 4) cultural factors 5) stigma
14	Eisenberg et al. (2009)	Quantitative, Cross sectional	5555 students from select universities across the US 10% AA (43% response rate)	student from 13 participating universities	Personal stigma was elevated in males, younger AA international students who reported more religious or from a poor family.
15	Gee et al. (2020)	Quantitative, Cross sectional	153 AA 136 EA	Large mid-Atlantic university	AA and EA did not significantly differ in their use of mental health services X2(1, N=289)=0.086, p=.769 Also not difference between East and South Asian participants in service use X2(1, N=129)=2.57, p=.109 Comparison of EA, AA reported greater barriers to help seeking t(280)=6.18, p<.001, d=.74 Exploratory analyses comparing east asia and south Asians no difference on Asian values t(127)=−1.12, p=.26, d=.20; loss of face concern t(127)=−.79, p=.43, d=.14; or barriers to help seeking t(127)=−.2.29, p=.023, d=.41 For AA lower loss of face concern was associated with greater odds of service use (B=−.57, SE=.21, OR=.57, 95% CI [0.37–0.86], p<.01)
16	Goodwill et al. (2020)	Quantitative, Secondary analysis of Health Minds	153,635 students that completed survey 2007–2018	University students across US	International AA students reported lower odds of suicide ideation (OR=.62, 95% CI[.53, .72]) but higher suicide attempt (OR=1.87, 95% CI [1.33, 2.61]) compared to White students.
17	Hampton et al. (2014)	Quantitative, Cross sectional	330 university students (76 AA)	Southwest US	Significant culture effect Wilks’s Λ =.90, F(10,552)=2.77, p=.002 AA students had lower mean scores on Family External Shame (FES) subscale when compared to Latinx (p=.03) and Whites (p=.01)
18	Han & Pong (2015)	Quantitative, cross-sectional	66 AA community college students 33 female (50%)	One of the largest community colleges in CA	Begin first generation negatively predicted help-seeking behaviors (OR=0.15, p< .05)
19	Kam et al. (2019)	Quantitative, cross-sectional	Total multiethnic psychological undergrad sample (n= 735) Total sample age (M=20.48 years; SD=5.18) AA undergraduate students (n=174; 72% women)	A southeastern public university	Ratio of direct mh help-seeking was lower in AA compared to Latinx, White & Black groups Wald x2s=9.18, ps<.01 Ratio of knowing someone close dx with mh issue lower in AA (23%) then Latinx (41.9%), White (68.3%) and Black (35.2%) groups Wald x2s>3.87, p <.05
20	Kim & Kendall (2015)	Quantitative, cross-sectional	AA college students (n=232) Mean age= 20.10 years; SD=1.76 Female (n=159) Male (n=72)	Four 4-year institutions from the Pacific Northwest region	Biological etiology beliefs and spiritual etiology beliefs (Called help-seeking attitudes) as moderators between r/t of emotional self-control and willingness to see counselor.
21	Kim, Kendall & Chang (2015)	Quantitative, Cross-sectional	153 self-identified AA undergraduates (M=19.81,SD=1.62)	Northwestern university	External shame B=.064, SE=.029, ß=.174, t=2.202, p= .028 model help-seeking attitudes regressed on prior counseling, emotional self-control, external shame, and subtle racism R2= .027; inverse r/t between subtle racism and favorable help-seeking attitudes B=−.081, SE=.039, ß=.158, t=−2.051, p= .040 [for discussion---maybe they turn to informal sources]
22	Kim & Lee (2014)	Quantitative, cross-sectional	AA college students (n=106) 68% female US-born (76.4%)	A private 4-year institution in the Northwest region	Proportion of variance in help-seeking attitudes R2=.13, F(3,102)=5.09, p=.003; internalized model minority myth was significant predictor of help-seeking, B=−.10, t(102)=−2.11, p= .038. Model testing for indirect effects of internalized model minority myth on help-seeking attitudes through intrapersonal and interpersonal values, controlling for school year and prior counseling statistically significant R2=.22, F(8,97)=3.51, p-.001 Emotional self-control the only indirect effect on of internalized model minority myth on help seeking attitudes (B=−.052, SE=.030, 95% CI [−.129, −.009])
23	Kim & Omizo (2003)	Quantitative, cross-sectional	AA college students (n=242) Age range from 18–57 (M=21.89; SD=6.75)	Several large universities in Mid-Atlantic & Hawaii	DV attitudes toward seeking help: F (5, 237)=18.60, with age (ß=.28, t=4.33, p<.001) and Asian Values Scale score ß=.−25, t=−4.24, p<.001) the only significant variable accounting for 28% of variance on DV Suggest that highly enculturated AA students are associated with less positive attitudes toward seeking help which in turn are related to less willing to see counselor
24	Kim & Park (2009)	Quantitative, Cross-sectional, Theory model testing	AA undergraduate students (n=110) Mean age=19.15 years (SD=2.06) 59% female	A Midwestern university	Subjective norms negatively correlated with Asian values (r=−.21, p<.05) and positively correlated with willingness to see a counselor (r=.38, p<.01). The r/t between Asian values and subjective norms was negative (B=−.23, SE=.10, p<.05) More positive attitudes toward seeking help associated with more willingness to see counselor (B=.39, SE=.09, p<.001) 28% of variance on wiliness to see counselor was attributed to attitudes toward seeking help and subjective norms
25	Kim & Zane (2016)	Quantitative, cross-sectional	Total sample (n=656) AA students (n=395)	Western university	Model for AA X2(=44.37 (26) CFI .97, TLI-.94, RMSEA=.04 09% CI [.02, .06], SRMR=.04
26	Lee et al. (2009)	Qualitative, Focus group	Two focus groups Total sample (n=17) Age range 18–30 years Female (n=12) Male (n=5)	Eight AA communities in Montgomery county, Maryland	1.potential sources of stress: parental pressure to succeed, difficulty balancing two cultures, communicating with parents, family obligations based on strong family values, discrimination due to racial/cultural background 2.deterrents of help seeking: stigma, lack of awarenss of mh issues, avoid worrying parents, lack of culturally appropriate care, parents’ lack of knowledge of mh issues , and cost 3. recommendation for future programs: education awareness, increase AA linguistically and culturally competent HCPs, directory of AA mh providers, educate parents, involve school system CBOs and FBOs, appeal to youth
27	Leong et al. (2011)	Quantitative, Cross-sectional	AA undergraduate students (n=134) 34% male; 66% female	Major universities and community colleges in West Coast	High acculturation significantly positive correlated to favorable attitudes toward help-seeking (r=0.34); however, it was the separated (r=0.42) and marginalized (r=0.35) acculturated individuals that had significant positive associate with attitudes toward help-seeking. Individuals who adhered greatly to Asian culture did not recognize the need for professional help (B=−0.27, t(1,128)=−2.66, p<.01) and were not open to discussing their problems (B=−0.30, t(1,128)=−3.23, p<.005)
28	Lispon et al. (2018)	Quantitative, cross sectional	Total multiple ethnic sample (n=43,375) 10% AA students	National data set of healthy minds	Asians have a 64% lower odds of medication use and 51% lower odds of therapy
29	Loya et al. (2010)	Quantitative; Cross sectional	128 college students Asian N=54, 42% sample (years of age M=17, SD=6)	Northern CA	Direct effect of ethnicity on help seeking controlling age and gender (ß=−0.75,CI99[−1.18,−.33]) such that Asian students showed less positive attitudes than Whites. Direct effect of ethnicity on help seeking attitudes reduced ($\Delta$ß=−0.26, CI99=[−0.56, −0.03]; ßfull=−0.50) showing partial mediation of personal stigma accounting for 32% of direct effect on help seeking attitudes
30	Masuda & Boone (2011)	Quantitative; Cross-sectional	466 students 166 AA AA age M=1916, SD=1.53	University in Georgia, US	Main effect of ethnic group on help-seeking attitudes F(1,353)=17.77, p<.001. stigma tolerance re seeking care F(1,353)=22.73, p<.001, interpersonal openness F(1,353)=28.01, p<.001, mental health stigma F(1,353)=19.84, p<.001, and self-concealment F(1,353)=16.68, p<.001 in that AA significantly less favorable views on help seeking, lower stigma tolerance, lower interpersonal openness to seeking, greater mental health stigma, and great self-concealment that EA group Mental health stigma (ß=−.24, B=−.36, SE=.13, t=−2.78, p=.006) and self-concealment (ß=−.24, B=−.32, SE=.12, t=−2.74, p=.007) found to be unique predictors of help seeking in AA accounting for 18% of variance on help seeking attitudes
31	Masuda et al. (2009)	Quantitative; Cross-sectional	518 students (M=20.4, SD=4.48) AA n=82	Large public university in Southeast US	AA female students had received care than whites (X2=28.79, p<.001), less likely to be close to someone who got help (X2=35.52, p<.001), and less likely to report knowing someone with a mh concern (X2=27.47, p<.001).
32	Miller et al. (2011)	Quantitative; Cross-sectional	296 students (M=20.8, SD=3.7)	Mid-Atlantic university	Foreign born n=107 higher behavioral enculturation (t=5.69, p<.001, d=0.69) and acculturation stress (t=2.23, p<.05, d=0.27). US born higher behavioral acculturation (t=−2.85, p<.01, d=0.34).
33	Mokkarala et al. (2015)	Secondary data analysis, Cross-sectional	61 SAA and 116 non-Hispanic white	Facebook page of several student government and South Asian student organizations at universities throughout the United States, Survey	Nearly half of white individuals had previously consulted a mental health professional, only about ¼ of SAAs. Mean perceived shame was slightly higher for SAAs, mean family support for help seeking was significantly higher for whites.
34	Pedersen & Paves (2014)	Cross-sectional	386 students (39.6% Asian)	Introductory psychology courses at a large west coast university, Survey	The step 1 model for personal stigma was significant, R2 = 0.01, F(4,381) = 4.08, p = 0.003. Asian participants (compared to other ethnicities) and males (compared to females) reported greater agreement that they would view someone negatively if they sought treatment.
35	Shahid et al. (2021)	Cross-sectional	155 participants, 18–40 y/o (m=25.23), Majority men (104, 67.1%)	Asian American college students were recruited from Amazon’s Mechanical Turk (MTurk), Survey	Greater adherence to Asian American values (and specifically emotional self-control) predicted less positive attitudes toward seeking mental health help, whereas stronger ethnic identity, in the domain of affirmation, was associated with more positive attitudes toward seeking mental health help.
36	Sue et al. (1976)	Cross-sectional	62 Asian American and 81 Caucasian college students	Introductory psychology course and introductory Asian American studies course, During regular class sessions, Self-explanatory questionnaires	Asian Americans were still more likely to believe that mental health was due to the avoidance of morbid thoughts and that mental illness was due to organic factors.
37	Tang & Masicampo (2018)	Cross-sectional	Total = 186 Asian = 96 Excluded non-Asian and non-Whites and non-American = 159	426 student organization groups at 150 colleges and universities, A mix of Asian and non-Asian organizations, Online survey	Asian American college students, relative to their White counterparts, appear to be high in two well-documented risk factors for suicide--perceived burdensomeness on others F(1,157)=19.2, p<.001) and thwarted belongingness F(1,157)=19.2, p<.001 with others. Asian students less willing to seek help F(1,156)=7.22, p=.007 AA students’ elevated perceptions of burdensomeness mediated their lack of willingness to seek help
38	Ting &Hwang (2009)	Cross-sectional	107 AA college students, Email inviting ethnic minority students, International students not included	Rocky Mountain region of U.S., Online survey	Degree of need (level of psychological distress) was not associated with help-seeking attitudes among Asian American college students. For Asian Americans, social conflict may be a more important variable to consider than social support in understanding help-seeking attitudes and stigma tolerance. --Controlling for distress, age, social support and conflict, acculturation, and stigma tolerance on help seeking attitudes F(1,98)=17.68, p<.001, R2=.28 observed power =.87 Stigma tolerance only significant association ß=.62, t=.38, p<.001 in model…also directly association with help seeking (r=.38, p<.001)
39	Tummala-Narra et al. (2018)	Cross-sectional survey design	Email invites to Asian student cultural and religious groups at universities and colleges; AA college students from across US 465 AA college students (M=20.09, SD=1.61 years); 75% female;86% heterosexual; 77% US born	On-line survey	Stronger commitment dimension of ethnic identity was associated with less favorable help-seeking attitudes (ß=−1.057, p=.037). Both subtle and blatant racism has a positive association with depressive symptoms (ßsublte = 3.546, p<.001; ßblatant = 3.541, p<.001) and anxiety (ßsublte = 3.878, p<.001; ßblatant = 3.302, p<.001)
40	Tummala-Narra et al. (2020)	Secondary analysis; Cross-sectional	173 Chinese ethnic college students, 18–24 y/o, 141 (81.5%) U.S. born and 32 (18.5%) foreign-born, Email invitations sent to AA student cultural and religious organizations, faculty, and multicultural affairs offices.	Participants were drawn from a larger survey-based study conducted in 2016. From U.S. colleges and universities in urban, suburban, and rural areas. Questionnaires	Acculturation-based intergenerational family conflict predicted a significant portion of variance in depressive symptoms, F = 16.15, p<.001, ß=.55, p=.002 and anxiety F=11.90, p<.001, ß= ,31, p=.04. Both commitment F=5.10, p=007 and exploration F=4.38, p=.01 dimensions of ethnic identity were significant predictors of depressive symptoms (ßcommitment=5.69, SE=1.82, t=3.11, p=.002; ßexploration=−4.07,SE= 1.71, t=−2.37, p=.01 and anxiety symptoms (ßcommitment=4.43, SE=1.59, t=2.78, p=.006; ßexploration=−3.62, SE= 1.49, t=−2.42, p=.01 Ethnic identity predicted help-seeking attitudes F=3.26, p=.04 BUT family conflict did not predict help-seeking
41	Wong et al. (2018)	Quasi-experimental	23%; N = 949 were 18–24 y/o, 8%; N = 327 were AA	Individuals who attended a contact-based educational program delivered between May 9, 2013 and March 24, 2015 that was part of the CalMHSA statewide stigma and discrimination reduction initiative were eligible for the study. Pre-post survey	Compared to older adults, young adults aged 18–24 experienced significantly greater reductions in negative beliefs about people with a mental illness, recovery, and treatment seeking. Contact-based educational programs also yielded significantly better outcomes for females than males.
42	Wong et al. (2010)	Cross-sectional	238 AAs, 105 from undergraduate participant pool, 133 from mailing lists of AA organizations	A large public university and electronic mailing lists of AA orgs throughout the U.S. Questionnaires and a vignette	Asian Americans who strongly adhered to Asian values were more likely to attribute the cause of depression to internal factors, which in turn made them more likely to prefer disengagement coping strategies and less likely to prefer engagement coping strategies. Model good fit to data X2/df=0.92, CFI=1.00, RMSEA=.00, SRMR=.02 explaining 12% of variance in attribution of cause, 10% in engagement coping, and 23% in disengagement coping
43	Yang et al. (2020)	Secondary data analysis of NSDUH 2012–2016	40,470 whites ages 18–25; 3,262 Asians ages 18–25	National data	Asians were significantly less likely to receive mental health treatment in the past year in the overall sample. Compared with whites with perceived need, Asians with perceived need were less likely to have received mental health care in the past year.
44	Yeh & Wang (2000)	Cross-sectional	470 AA undergraduate and graduate students	From nine universities and colleges from East and West Coast, Survey	Asian American undergraduate and graduate students in the sample reported coping w/ psychological problems by seeking help from familial and social sources of support.

Table 2.

Mixed Methods Appraisal Tool (Hong et al., 2018)

Quantitative Randomized Controlled Trails	Are there clear research questions?	Do the collected data allow to address the research questions?	Is randomization appropriately performed?	Are the groups comparable at baseline?	Are there complete outcome data?	Are outcome assessors blinded to the intervention provided?	Did the participants adhere to the assigned intervention?
Cheng (2015)	Yes	Yes	Can’t tell, not enough info	No	Can’t tell	Yes	Yes, 4 conditions
Quantitative Non-randomized	Are there clear research questions?	Do the collected data allow to address the research questions?	Are the participants representative of the target population?	Are measurements appropriate regarding both the outcome and intervention (or exposure)?	Are there complete outcome data?	Are the confounders accounted for the design and analysis?	During the study period, is the intervention administered (or exposure occurred) as intended?
No studies in this design	--	--	--	--	--	--	--
Quantitative Descriptive	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the sampling strategy relevant to address the research questions?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research questions?
Arora et al. (2016)	Yes	Yes	Yes	Yes, for South Asian college students in Southern US	Yes	Can’t tell	Yes
Atkinson & Gim (1989)	Yes	Yes	Yes	Yes, for Chinese, Japanese, and Korean American college students	Yes	Yes, overall usable response rate is 68.2%	Yes
Quantitative Descriptive	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the sampling strategy relevant to address the research questions?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research questions?
Chang & Chang (2004)	Yes	Yes	Yes	Yes, AA and Asian international college students	Yes	No, return rate for questionnaire packets is 47%	Yes
Chang et al. (2013)	Yes	Yes, from the NLAAS	Yes, from the NLAAS	Yes, Latino and Asian Americans	Yes	Yes, nearly 76% for Latino Americans and 66% for Asian Americans	Yes
Chen & Mak (2008)	Yes	Yes	Yes	Yes, European & Chinese Americans and Hong Kong & Mainland Chinese college students	Yes	Can’t tell	Yes
Chen et al. (2014)	Yes	Yes	Yes	Yes, API college students	Yes	No, response rate = 23.3%, 80.7% completed with less than 5.5% missing data	Yes
Cheng et al. (2013)	Yes	Yes	Yes	Yes, REM (African, Asian, Latino American) college students	Yes	Can’t tell	Yes
Cheng et al. (2017)	Yes	Yes	Yes	Yes, White, Asian, Latino, African American college students	Yes	No, 19% participated in survey	Yes
Cokley et al. (2012)	Yes	Yes	Yes	Yes, Asian, Latino, African, biracial college students	Yes	Can’t tell	Yes
De Luna & Kawabata (2020)	Yes	Yes	Yes, interested in Filipino students	Yes, Filipino university students	Yes	No, no mention of missing data	Yes
Quantitative Descriptive	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the sampling strategy relevant to address the research questions?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research questions?
Eisenberg et al. (2009)	Yes	Yes	Yes	Yes, college students in general	Yes	No, 44% participation rate	Yes
Gee et al. (2020)	Yes	Yes	Yes, from a larger study of Asian and European American college students	Yes, Asian and European American college students	Yes	Can’t tell	Yes
Goodwill & Zhou (2020)	Yes	Yes	Yes, from a large national college student dataset	Yes, multiracial college students including Asian	Yes	Can’t tell	Yes
Hampton & Sharp (2014)	Yes	Yes	Yes	Yes, with Southwestern US	Yes	Can’t tell	Yes
Han & Pong (2015)	Yes	Yes	Yes	Yes, Asian college students in California region, US	Yes	Can’t tell	Yes, however data not fully presented
Kam et al. (2019)	Yes	Yes	Yes	Yes, with Southeastern region, US	Yes	Can’t tell	Yes
Kim & Kendall (2015)	Yes	Yes	Yes	Yes, with Pacific Northwest region, US	Yes	Can’t tell	Yes
Kim et al. (2016)	Yes	Yes	Yes	Yes, with Northwest region, US	Yes	Can’t tell	Yes
Kim & Lee (2014)	Yes	Yes	Yes	Yes, with Northwest region, US	Yes	Can’t tell	Yes
Kim & Omizo (2003)	Yes	Yes	Yes	Yes, with mid-Atlantic and Hawaii, US	Yes	Can’t tell	Yes
Kim & Park (2009)	Yes	Yes	Yes	Yes, with Midwestern, US	Yes	Can’t tell	Yes
Quantitative Descriptive	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the sampling strategy relevant to address the research questions?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research questions?
Kim & Zane (2016)	Yes	Yes	Yes	Yes, with West coast region, US	Yes	Can’t tell	Yes
Leong et al. (2011)	Yes	Yes	Yes	Yes, with West coast region, US	Yes	Can’t tell	Yes
Lispon et al. (2018)	Yes	Yes	Yes, random sample in national universities	Yes, across the US	Yes	Yes	Yes
Loya et al. (2010)	Yes	Yes	Yes	Yes, with Northern California, US	Yes	Can’t tell	Yes
Luna & Kawabata (2020)	Yes	Yes	Yes	Yes, with Guam, US	Yes	Can’t tell	Yes
Masuda & Boone (2011)	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Masua et al. (2009)	Yes	Yes	Yes, students comparing AA to African American and European American	Yes	Yes	Yes	Yes
Miller et al. (2011)	Yes	Yes	Yes	Yes, AA students. Born in US and foreign born	Yes	Yes	Yes
Mokkarala et al. (2015)	Yes	Yes	Yes	Yes, compare South Asian and White students	Shame measure low alpha	Can’t tell	Yes
Pedersen & Paves (2014)	Yes	Yes, students comparing white and AA	Yes	Yes, students comparing white and AA	Yes	Yes	Yes
Quantitative Descriptive	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the sampling strategy relevant to address the research questions?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research questions?
Shahid et al. (2021)	Yes	Yes	Yes	Yes, AA students	Yes	Can’t tell	Yes
Stanley et al. (1976)	Yes	Yes	Yes	Yes, compared AA to white students but small sample	No, not enough info given on measure	Can’t tell	Not sure
Tang & Masicampo (2018)	Yes	Yes	Yes	Yes, compare AA to white students	No, psychometrics not presented from previous studies	Can’t tell	Yes
Ting & Hwang (2009)	Yes	Yes	Yes	Yes, AA students	Yes	Can’t tell	Yes
Tummala-Narra et al. (2018)	Yes	Yes	Yes	Yes, AA students	Yes	Can’t tell	Yes
Tummala-Narra et al. (2021)	Yes	Yes	Yes	Yes, AA students	Yes	Can’t tell	Yes
Wong et al. (2010)	Yes	Yes	Yes	Yes, AA students	Yes	Can’t tell	Yes
Wong et al. (2018)	Yes	Yes	Yes	Yes	No info about missing data	Yes	Yes
Yang et al. (2020)	Yes	Yes	Yes	Yes, Asian compared to white students	Not fully described and no psychometrics presented	Can’t tell	Yes
Yeh & Wang (2000)	Yes	Yes	Yes	Yes, AA students	No fully described	Can’t tell	Yes
Qualitative Methods study	Are there clear research questions?	Do the collected data allow addressing the research questions?	Is the qualitative appropriate to answer the research question?	Are the qualitative data collection methods adequate to address the research question?	Are the findings adequately derived from the data?	Is the interpretation of results sufficiently substantiated by data?	Is there coherence between data source, collection, analysis and interpretation?
Dong et al. (2020)	Yes	Yes	Yes	Yes	Yes, themes and subthemes	Yes, quotes fit the themes	Yes
Lee et al. (2009)	Yes	Yes	Yes	Yes	Yes, coding emergent themes	Yes, quotes fit the themes	Yes
Mixed Methods Studies	Are there clear research questions?	Do the collected data allow for addressing the research questions?	Is there an adequate rationale for using a mixed method design to address the research questions?	Are the different components of the study effectively integrated to answer the research question?	Are the results adequately brought together into overall interpretation?	Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?	Do the difference components of the study adhere to the quality criteria of each tradition of the methods involved?
Augsberger et al. (2015)	Yes	Yes	Yes, qual results gave more insight on mental health care barriers	Yes	Yes	Yes, no stigma variable in quantitative study, but stigma was mentioned in qual results	Yes, received from AWSHIP 5-year study

Therefore, after quality appraisal of the quantitative studies we considered the statistical results to determine the relevance of the findings. Following this we coded and converged these findings with the qualitative and mixed methods papers, developing themes across study designs.

Data Abstraction & Synthesis

We extracted numerical data from quantitative studies and synthesized these data narratively. We performed qualitative thematic synthesis to abstract and synthesize data from the qualitative studies (Hong et al., 2017; Thomas & Harden, 2008). To form themes, studies were read in their entirety and findings from all included studies were coded (Hong et al., 2017). Codes were then grouped together to develop themes (Pluye & Hong, 2014; Thomas & Harden, 2008). We then performed a third synthesis to compare quantitative and qualitative findings and derived additional themes from the combination of these findings.

Results

Sample

Within the forty-four included studies most of the studies (n=40) were quantitative descriptive studies. There was one randomized controlled trial, two qualitative studies, and one mixed methods study.

Themes

The following four major themes emerged from the data: acculturation, ethnic identity, stigma, and racism. Each will be discussed individually in more detail. In addition, there were three other areas that were mentioning in the included studies. The difference between AAs and international students from Asian countries was examined. Concerns of the influence of the degree of difference in level of acculturation between intergenerational family members was discussed as well as the personal stigma of accepting the model minority myth.

Acculturation

Several studies found that increase acculturation to U.S. society had more positive influence on help-seeking attitudes. In one study, students that were more highly acculturated to U.S. society were more likely to recognize a personal need for mental health services, were less affected by peer negative attitudes, and were open to talking with a psychologist (Atkinson & Gim, 1989). However, in another study even though AA students reported high acculturation to U.S. society they still held stereotypes about mental health concerns (Han & Pong, 2015). In fact, in one study AA students that reported higher adherence to Asian culture did not recognize the need for mental health services (Leong et al., 2011). AA students who were less acculturated to U.S. society were more likely to attribute the causes of depression to be of an internal factor and used disengagement as a coping strategy (Miller et al., 2011; Wong et al., 2010).

Ethnic Identity

Stronger commitment to ethnic identity was associated with less favorable help-seeking attitudes. In one study, AA students reported they experienced high levels of discrimination with people automatically assuming that their English communication would be poor. When this perceived discrimination was felt, the students reported more somatic symptoms (Chen et al., 2014). AA students that reported high levels of adhering to Asian values reported less intent to see a counselor (Kim & Omizo, 2003; Mokkarala et al., 2015). In a qualitative focus group study, AA students identified balancing between two cultures and parental pressure to succeed and maintain Asian values as stressors. Parents who have strong ethnic identities often have misunderstandings regarding mental health issues such as not believing that mental health concerns are important (Lee et al., 2009). Intergenerational conflict secondary to family members different level of acculturation was significantly associated with depressive symptoms and anxiety (Tummala-Narra et al., 2020). In students who more rigidly adhere to Asian values specifically emotional self-control reported negative attitudes toward mental health services (Shahid et al., 2021). Additionally, AA students that reported an elevated perception of burdensomeness were less likely to seek help increasing their risk for suicide (Tang & Masicampo, 2018).

Stigma

Stigma has been defined as the stereotyping of individuals supporting disrespectful and harmful beliefs about a group (Goffman, 1963). There are many types of stigma, including personal, self, and perceived stigma. Personal stigma is how someone views and treats other people (Pedersen et al., 2014). Self-stigma is how an individual views themselves. Public stigma is how a society views its members (Corrigan, 2004) and perceived stigma is how an individual believes the public views other people.

Higher reports of personal stigma are associated with less help-seeking attitudes (Arora et al., 2016; Cheng, 2015; Cheng et al., 2013; Loya et al., 2010; De Luna & Kawabata, 2020; Goodwill et al., 2020; Hampton et al., 2014; Han & Pong, 2015; Kam et al., 2019; Kim & Zane, 2016; Masuda & Boone, 2011; Masada et al., 2009; Pedersen & Paves, 2014; Sue et al., 1976; Wong et al., 2018). The personal stigma of Asian elders prevents the younger generation from seeking professional help. They feel pressure to “save face” by keeping their problems to themselves or within the family to maintain a positive reputation (Augsberger et al., 2015).

Self-stigma in general is also associated with less favorable help-seeking attitudes (Cheng et al., 2017; Eisenberg et al., 2009; Kim & Kendall, 2015). Perceived stigma predicted higher self-stigma for racial ethnic minority (REM) students as well. If they think others will stigmatize them for seeking help, they are less likely to seek help themselves (Arora et al., 2016; Cheng et al., 2013; Kim & Zane, 2016). Perceived stigma along with self-stigma is associated with lower help-seeking attitudes (Lipson et al., 2018; Loya et al., 2010).

Racism

An inverse relationship has been found between racism and help-seeking attitudes. Experiences with subtle racism and feelings of shame negatively affected favorable help-seeking attitudes (Kim et al., 2016). When Asian students were able to exhibit tolerance to stigma and racism, they had positive attitudes regarding mental health services (Ting & Hwang, 2009). Levels of depression and anxiety were positively associated with experiences of racism (Tummala-Narra et al., 2018). Racism and discrimination were correlated to perceived stigma decreasing the likelihood of seeking professional help. REM college students believe they may be more stigmatized by others due to their background, which prevents them from seeking help (Cheng et al., 2013).

Additional findings

International students

International Asian students were more likely to seek help and preferred face-to-face interactions as opposed to telehealth (Chang & Chang, 2004). In a study that compared intent on seeking mental health services between Chinese students, Chinese students from Hong Kong reported lower intent to seek mental health as compared to students from Mainland China (Chen & Mak, 2008). Findings from qualitative interviews showed that students reported that physical distance from families helped facilitate help-seeking behaviors. Barriers that these students discussed included family dysfunction, cultural factors, and stigma (Dong et al., 2020).

Model minority myth

In a study measuring the imposter phenomenon, AA students report higher feelings of insecurity as compared to African American and Latinx students (Cokley et al., 2013). In a within group study of AA college students, those who reported internalizing the model minority myth were less likely to seek mental health services (Kim & Lee, 2014). Students who reported strong commitments to traditional values had more negative attitudes about mental health help-seeking (Tummala-Narra et al., 2018).

Intergenerational conflict

Conflict between generations were more pronounced in second generation AA college students (Chang et al., 2013). Traditional values of stoicism and stigma against mental health concerns were barriers for Asian college students (Dong et al., 2020). In fact, when Asian students did not prescribe to stigma related to mental health and were less concerns about a loss of face, they were more likely to access mental health services (Gee et al., 2020).

Discussion

Design

By far, most of the studies were quantitative descriptive designs. It is important to test a model such as the proposed mid-range theory presented in Figure 2, that includes all factors found to contribute to a lack of mental health seeking behavior. This could lead to the development of intervention strategies aimed at increasing services for Asian college students.

Figure 2.

A proposed mid-range theory of mental health seeking among AA college students

Conceptual Overlap

A major finding of this review is that concepts are entangled with many aspects overlapping with each other. This makes synthesizing the findings difficult. We will discuss the conceptual overlap for two sets of concepts: concepts related to cultural identity and concept that is related to shame. These two areas of conceptual overlap will be discussed referencing both the studies included in the review as well as other studies not included in this review.

Cultural Identity

There is some overlap in the operationalization of acculturation, ethnic identity, and intergenerational conflict. Intergenerational conflict can lead to feelings of guilt and depression, especially when there is a difference in the acculturation levels between generations. This conflict is based on the older generation believing that mental illness is a personal weakness and brings shame to the family (Cho et al., 2015) as well as parental adherence to their ethnic identity and expectations of their children adhering to familial values of respect for parents (Kim & Aronowitz, 2019). The reason international Asian students were more likely to seek mental health services as compared to AA students (Chang & Chang, 2004) may be due to being away from family and being able to withhold knowledge of their care from their family. Asian older adults are less likely to be acculturated to the U.S. compared to the younger generation and significantly more likely to feel that having mental health concerns shows a sign of weakness and increases shame for the family (Yang et al., 2020). The belief that a mental health diagnosis leads to shame that affects the entire family and leads to a decrease in opportunities both professionally and personally (Yang & Rosenblatt, 2001). Believing this myth increases does affect Asian individuals from seeking mental health services (Sorkin et al., 2016).

Shame

Stigma, racism, and belief in the model minority myth also have conceptual overlap leading to self-shame. In the included studies, stigma was measured as the participant’s stigma against mental health as well as feeling stigmatized if they seek help (perceived stigma). This perceived stigma is a form of subtle racism causing interpersonal shame and decreasing the likelihood of accessing mental health services (Kim et al., 2015). When REM students think that they are stigmatized by others because of their background they did not seek mental health services (Cheng et al., 2013). However, it may be that these students then turn to informal sources of support such as friends.

The model minority myth is a belief (Kim, 1973; Lim, 2015) that stems from Asian Americans’ tendency to isolate themselves as a means of adaptation. They are less likely to appear different from mainstream white society, therefore less threatening (Chow, 2017). However, they may be vulnerable to discrimination due to higher social expectations placed upon them and stigmatization if they don’t meet these expectations (Chen et al., 2014). Internalization of the model minority myth increases Asian students’ personal pressure to excel, increasing their feelings of insecurity, and decreasing their help seeking behaviors (Cokley et al., 2012; Tummala-Narra et al., 2018). Historically the model minority myth has affected the number of empirical studies that focus on AA mental health utilization (Yamashiro & Mtsuoka, 1997) and this bias continues to the present time.

Future Implications

The proposed mid-range theory (Figure 2) suggests the concepts that should be measured within a study to explore how these concepts are intertwined and how they affect mental health seeking behaviors in AA college students. Exploring the level of multicollinearity between the concepts could help clarify the overlap related to cultural identity and shame. Clarification of these concepts is the first step in understanding the intersectionality of their effect on mental health help seeking behavior.

Clinical implications for nurses include understanding of the potential overlap in level of acculturation to the United States, ethnic identity, and the potential of intergenerational conflict related to both emerging adults’ level of acculturation and their ethnic identity. The more AA students accept the model minority myth and reject traditional Asian customs the greater potential of intergenerational conflict. These students may have to present themselves quite differently depending on their environment. For example, as a college student with a diverse group of emerging adults to a home environment where parents follow traditional cultural norms. Nurses in all settings should be aware of the possibility of AA students living as multiple selves within multiple worlds (Cooper, et al., 1998) and that AA college students are more likely to seek counseling for academic and vocational problems but not emotional or interpersonal concerns (Kim, 2007).

Summary

Concepts used to define culture were found to have overlapping aspects of how researchers operationally define them in the various studies. Few studies examined a combination of these concepts as a means of examining interactions between the concepts. Asian students did not use mental health services because they are balancing their desire to be part of the two cultures. From this review a proposed mid-range theory is presented (see Figure 2), which needs to be tested to further understand the relationship between the factors and mental health seeking behaviors among AA college students.

Limitation

Due to the limited research focusing specifically on the Asian population, some of the references are old. The lack of studies of AAs and help-seeking required us to broaden the search to include studies with a comparison of ethnic/racial comparisons as well as extending the search timeframe. Additionally, most of the studies had samples that included all Asian groups, thereby limiting the ability to look at the individual cultural experiences between different Asian groups. Differences between South Asian and East Asian philosophical and cultural perspectives could influence access to mental health services.

Conclusion & Implications

It is critical to understand the barriers to mental health services among AA college students. Addressing stigma regarding mental health issues that are perceived from others as well as those from cultural beliefs is key to preventing delay in access to care. The overlap of conceptual definitions to understand cultural beliefs and values affecting measurement have complicated the interpretation of the research. Future research should include a multidimensional operationalization of culture that includes acculturation, ethnic identity, personal stigma, and their effect on mental health help-seeking attitudes. A study testing the effect of the factors found from the descriptive studies on help seeking within one study is needed. This could lead to a better understand of how these concepts effect mental health seeking and contribute to intervention development.

Accessible Summary.

What is known on the subject?

• Only 8.6% Asian Americans (AAs) report seeking mental health services compared to nearly 18% of the general population.

• There is a stigma against seeking mental health services among AAs.

• Mental illness is thought to be caused by a lack of harmony of emotions or evil spirits leading to delay in treatment among AAs.

What the paper adds to existing knowledge?

• Asian students are hesitant to use mental health services because they are balancing their desire to be part of the two cultures.

• Concepts used to define culture were found to have overlapping aspects of how researchers operationally define them, and few studies examined a combination of these concepts as a means of examining interactions between the concepts.

• AA emerging adults feel pressure through personal stigma from elders to “save face” by keeping their problems to themselves or within the family to maintain a positive reputation for the family.

What are the implications for practice?

• The overlap of conceptual definitions to understand cultural beliefs and values affecting measurement have complicated the interpretation of the research.

• Future research should include a multidimensional operationalization of culture that includes acculturation, ethnic identity, personal stigma, and their effect on mental health help-seeking attitudes.

• Differences between South Asian and East Asian philosophical and cultural perspectives could influence access to mental health services, therefore future studies should consider sampling that would allow for comparison of the groups.

• Understanding the factors that influence mental health help-seeking behaviors can determine intervention strategies to improve AA emerging adult mental health.

Relevance Statement:

Understanding the factors that contribute to mental health seeking behaviors can help nurses develop innovative interventions to improve the mental health of Asian American emerging adults.