#91943: Providing Culturally Responsive Care to Asian Immigrants

Culture is a complex concept, and its common conflation with race and national origin can be confusing [160]. Culture refers to the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems [64,112]. Culture involves attitudes and beliefs that are passed from generation to generation within a group. These patterns include language, religious beliefs, institutions, artistic expressions, ways of thinking, and patterns of social and interpersonal relations [74]. Culture can also represent worldviews, encompassing assumptions and perceptions about the world and how it works [158]. Some have defined culture as "the growth, development, and expressions of a client system's worldview through an interaction with its biopsychosocial and spiritual environments" [160]. Culture helps to elucidate why groups of people act and respond to the environment as they do [84]. Culture has been conceptualized as a diversity domain characterized by different value systems, norms, and social and behavioral patterns [277]. Kluckhohn and Strodtbeck proposed five different dimensions that comprise a worldview [97]:

Experts have asserted that culture has two components: the observable and the unobservable [285]. The observable include language, customs, and specific practices, while the unobservable include beliefs, norms, and value systems.

Some experts argue it is also necessary to understand epistemological bases of groups' knowledge when defining culture [191]. In other words, it is important to ask: what is knowledge and where is it derived from? For example, some cultural groups' beliefs or knowledge about health and mental health are derived from shamanistic traditions or religious orientations, such as Buddhism or Taoism. This knowledge is therefore rooted in cultural beliefs, which dictate behaviors [191]. Therefore, culture is deeply tied to epistemology.

Current perspectives note that culture is not static; it is not merely inherited nor are groups of people passive recipients of culture. Rather, "culture and people negotiate and interact, thus transforming and developing each other. It is a process of continuous modification" [35].

On the other hand, race is linked to biology. Race is partially defined by physical markers such as skin or hair color [94]. It does not refer to cultural institutions or patterns, but it is generally utilized as a mechanism for classification. In modern history, skin color has been used to classify people and to imply that there are distinct biologic differences within populations [134]. Historically, the census in the United States defined race according to ancestry and blood quantum; today, it is based on self-classification [134]. However, some assert that race is socially constructed, without any biologic component [189]. For example, racial characteristics are also assigned differential power and privilege, lending to different statuses among groups [181]. The American Anthropological Association has described race as "an ideology of human differences," which then "became a strategy for dividing, ranking, and controlling colonized people used by colonial powers everywhere" [288].

Ethnicity is also a complex phenomenon and has been defined in many different ways. Alba categorized ethnicity into four groups [5]:

When ethnicity is viewed as social class, the individual's ethnicity is compared or equated with their socioeconomic class (e.g., working class or lower class). This is most clear in ethnic enclaves, the residents of which have strong cultural and familial ties [66].

Ethnicity may also be associated with persecution, both political and social. Ethnic unity may serve as a tool for social change and political reform [66]. Several famous ethnic movements took place in the 1960s, such as the unification of farm workers headed by César Chávez [66]. Ethnicity has also been viewed as a return to traditions, characterized by a renewed interest in ethnic foods, traditional religious practices, native language, and folklore [66]. Finally, ethnicity is also acknowledged as being a symbolic token, a way for individuals to maintain a nostalgic connection to their homeland [66].

Although these three terms are often employed interchangeably, it is important to consider the impact of the words chosen. Gregory writes the following, which should cause us to reflect on how practitioners use various terminology and its effect [171]:

Acculturation refers to a dynamic process that involves cultural change triggered when two cultural groups come in direct contact [4,9,19]. For example, when immigrants come to the host country, they may adapt to the values, behaviors, and belief systems of the dominant group. According to Berry, ethnic minority immigrants culturally adapt utilizing one of four different strategies: integration, assimilation, separation, or marginalization [19]. An individual can opt to integrate, adopting part of the values, beliefs, and behaviors of the dominant culture while retaining his/her own cultural identity [4]. Assimilation, on the other hand, is defined as an individual choosing to abandon his/her own cultural identity in favor of completely incorporating the value systems of the dominant culture. An individual can select to separate completely from the dominant culture and decide not to adopt any of the cultural values of the dominant culture. This is known as cultural assimilation [251]. The other dimension of assimilation is structural, specifically the process by which immigrants become fully integrated and incorporated into the host country's social institutions [251]. Finally, an immigrant can be marginalized, a process by which he/she loses both his/her cultural identity as well as that of the dominant culture. When this is the case, alienation and isolation ensue [4,19].

For the most part, scholars assume acculturation is linear or unidirectional. With a unidirectional or unidimensional model of acculturation, immigrants either remain ensconced in their cultural traditions or are integrated into the host country [187]. The concern with unidirectional acculturation theories is that they assume that equal opportunity can be accessed by all. Furthermore, they tend to rely on a Eurocentric benchmark that should be achieved by all immigrants; those who do not achieve this level are viewed inferior, lazy, or inassimilable [289]. In other words, unidirectional acculturation theories are reductionistic, assuming dichotomous outcomes (pathological vs. normal) [291].

There is also some research that indicates the acculturation process is not linear but multidimensional [187]. Immigrants may retain elements of both cultures and move back and forth. In one study with Korean American youths and their parents, Korean American youths who spent most of their time in the United States displayed an integrated bicultural strategy [254]. They were integrating well into the United States but still professed a strong allegiance to their Korean heritage. No participants in the study identified as completely assimilated. A study of Filipinos in the Philippines, Filipino immigrants in the United States, and American-born Filipinos compared gender role beliefs among the three groups [192]. If acculturation always occurred in a linear pattern, then one would assume that American-born Filipinos would hold more egalitarian or liberal attitudes toward women. However, immigrant Filipinos in the study indicated more liberal attitudes toward women than native Filipinos in the Philippines but similar attitudes to American-born Filipinos. Interestingly, American-born Filipino men appeared to have returned to more conservative or traditional attitudes, similar to those of Filipinos in the Philippines. The researchers speculated that cultural attitudes are not static; rather, the process is dynamic, and immigrants may feel they have to adapt their attitudes in order to survive. In a study of Chinese immigrant adolescents, researchers found that Chinese immigrant adolescents who had low proficiency in English were concerned with learning to relate to others within their own ethnic group and other racial groups [193]. Adolescents who had more family obligations also expressed more acculturative concerns. It was deduced that adolescents with more family chores and obligations to fulfill are more immersed in the traditional environment and have less time to learn and engage in new situations.

Acculturation is an ongoing process involving continuous learning about the environment [9]. Certainly, it is not linear nor does it occur on a single level. At the macrolevel, acculturation processes influence value systems, arts, and language [9]. At the exosystem, informal and formal social structures (e.g., communities, neighborhoods, schools, peer groups) can affect individual behavior [188]. At the mesolevel, acculturation impacts families and social interactions. Finally, at the microlevel, acculturation affects individuals' emotions, mental health, health, beliefs, and other human functioning [9].

There have been criticisms of bidirectional acculturation theories as well. These approaches do not take into account social injustices and how cultural identity is a continual process that requires constant negotiation, construction, and redefinition. It would also benefit these theories to consider the effect of the new immigrant(s) on the host country [289].

Assimilation was a term first conceptualized by Robert Park as a linear process, whereby immigrants slowly adopt an American way of life [32]. "Melting pot" is another term frequently heard, and it is often equated with assimilation. The term surfaced in the early 1900s. The melting pot concept was an idealistic goal whereby people of all races would peacefully unite, ultimately integrating, intermarrying, and blending—yielding a new people called "Americans" [94]. The traditional model of assimilation assumed that immigrants would discard their cultural values for the traditions of the host country, the ultimate goal being complete incorporation into the host culture [32]. The traditional hypothesis was based on the belief that as immigrants become more educated and more economically mobile, they would eventually assimilate. However, over time, scholars realized that assimilation was not unilinear. Immigrants can retain their ethnic identity and cultural traditions and still adjust to the norms of the host country [56]. Other scholars noted that some immigrant groups achieved upward mobility without completely assimilating to the dominant culture [142]. Consequently, there is no one simple assimilation trajectory; each ethnic immigrant group is very diverse.

In addition, the segmented assimilation theory has been used to describe immigrants who do not easily adapt to their new country [198]. According to this theory, immigrants do not follow a linear path to assimilation. There are a host of factors that contribute to different rates of assimilation, including age, gender, and socioeconomic status [198]. For example, poorer immigrants experience more obstacles to social mobility. They may only be able to obtain low-wage employment with no benefits, which could then have a series of ripple effects such as poor health and lack of access to transportation [198,199].

In another study using segmented assimilation theory and using an archival dataset, researchers found that migrant children from rural areas who moved to an urban area in China performed better in terms of adjustment and academic outcomes when they entered formal urban schools compared to children who were segregated into informal migrant schools [250]. The latter group had more challenges in adjusting to the urban area and experienced more prejudice and discrimination.

Racism is the "systematic subordination of members of targeted racial groups who have relatively little social power…by members of the agent racial group who have relatively more social power" [178]. Racism is perpetuated and reinforced by social values, norms, and institutions. There is also controversy regarding whether unconscious (implicit) racism exists. Quillian argues that images that are embedded in our unconscious are the result of socializations and personal observations, and negative attributes may be unconsciously applied to racial minority groups [194]. These unconscious attributes affect individuals' thoughts and behaviors without a conscious awareness.

Prejudice, on the other hand, is a general negative feeling, attitude, or stereotype against members of another group [46]. Personality theory (i.e., authoritarian personality facilitates higher levels of prejudice) and cognitive theory (i.e., prejudice is a type of bias stemming from stereotypical thinking) are common theoretical frameworks for understanding prejudice [251]. All humans have prejudices, but not all individuals adhere to racist attitudes. The following equation helps to distinguish between racism and prejudice: "prejudice plus power equals racism" [46]. Gordon argues that prejudice stems from the process of ascribing every member of a racial group with the same attribute, which is the Principle of Least Effort [252]. Furthermore, Gordon's principle of Belief in Essence asserts that whatever good or bad that resides in the group is also attributed to the individual, allowing for rapid negative judgments.

Discrimination has traditionally been viewed as the outcome of prejudice [6]. Discrimination encompasses overt or hidden actions, behaviors, or practices that are executed by members in a dominant group against members of a subordinate group [49]. The perpetrator of discrimination may be an individual, organization, or group, and similarly, the victim of discrimination may fall under the same categories [49]. Discrimination has also been categorized into two groups: everyday discrimination, which is subtle, continual, and part of day-to-day life and can have a cumulate effect on individuals, and lifetime discrimination, which consists of major discreet discriminatory events [195]. Discrimination is believed to be a stress-mediated pathway, and there may be a relationship between discrimination and negative health effects, such as cardiovascular and respiratory problems [196]. Furthermore, discrimination adversely affects access to healthcare services [259].

Experiences of Asian Americans and immigrants are rooted in a long historical backdrop of racism, prejudice, and discrimination in the United States. Asian Americans and immigrants have long been viewed as "perpetual foreigners," and in the 1800s, the term "Yellow Peril" was coined to describe the perceived danger associated with these individuals [310,362]. During this period, and continuing to today, stereotypes persisted that Asian individuals were diseased, unclean, and/or depraved [362]. These prejudices were codified in law with the Chinese Exclusion Act of 1882 and the Immigration Act of 1924, which restricted Asians from entering the United States and reinforced the view of Asian Americans being perpetual foreigners [362].

In 2020–2021, there was a documented rise in anti-Asian sentiment, coinciding with the COVID-19 pandemic, with similar sentiments to historical stereotypes and discrimination. According to a 2020 study conducted by the Pew Research Center, 31% of Asian adults reported experiencing slurs or jokes because of their ethnicity during the pandemic [363]. In a survey of 211 Asian and Asian American respondents, half indicated they had heard a comment about Chinese people being the source of the virus, almost one-quarter heard comments about Chinese people being "dirty," and one-third reported hearing comments regarding avoidance of Chinese or Asian food as a means to prevent infection [364].

The term "cultural competence" is utilized so frequently that the definition of this term is a bit nebulous. Consequently, it is vital to look at some definitions framed within various theoretical paradigms.

A modernist or positivist perspective maintains that concepts of culture and cultural characteristics of a specific group are stable and can be observed and measured because they endure over time [43]. Therefore, practitioners can learn about the specific sets of beliefs, value systems, behaviors, and norms of particular cultural or ethnic groups and apply them to their clients/patients. Inventories that measure individuals' belief systems and values and instruments or tools that evaluate one's own cultural competence or an organization's level of cultural competence reflect this positivistic philosophy.

On the other hand, a postmodernist perspective argues that culture is dynamic and continually changing [43]. Because there are multiple realities that cannot be easily grasped and understood, it is not possible to measure concepts of culture. In other words, culture is socially constructed [43]. They also reject binary classifications of culture. These dichotomies are believed to perpetuate the marginalization of Asian Americans [181]. As a result, when working with diverse clients/patients, practitioners must come into the clinical process with a "not-knowing" position [43]. Laird further asserts that practitioners must be "informed not-knowers" [43].

A psychoanalytic perspective takes cultural competence and focuses on the practitioner's own journey exploring his/her self-knowledge or self-awareness. The practitioner's feelings, values, knowledge, beliefs, and biases are inextricably tied into the clinical process, which ultimately affects the client/patient [43]. The psychoanalytic perspective focuses on the practitioner's transference of cultural experiences [53]. Practitioners are asked to be aware of their cultural baggage, notions, and biases. Consequently, self-awareness is a preintervention task that practitioners must be willing to undertake, in which they examine their own cultural biases and perceptions of their client's/patient's cultural background [112].

A developmental perspective maintains that various disciplines should move towards cultural competence. It assumes that practitioners and the field can move in a stage-like fashion, where the end point is the achievement of cultural competency. McPhatter conceptualized the Cultural Competence Attainment Model as an ongoing process of developmental learning involving [122,278]:

Regardless of the theoretical model, cultural competence does not necessarily mean that practitioners will move toward an integration of beliefs and values from non-Western contexts. Rather, cultural competence involves the ability to identify the ways in which Western and American culture influence individual belief and value systems and how these norms influence practitioners' worldviews and interactions with clients [191].

Cultural competence exists on many different levels—on the individual level (practitioner's self-awareness) and on the practitioner-client/patient relationship level. On an individual level, cultural competence training might focus on what culturally diverse clients expect, prefer, and desire or on practitioners' worldviews and experiences [201]. However, to focus on just the individual or micro level would neglect the macro level, the community level, and organizational levels. Training that addresses the macro level would focus on how social, economic, and political forces influence client/provider relationships and clients' access to resources [201].

Definitions and orientations toward cultural competence remain complex, multifaceted, and contradictory at times. To illustrate this, researchers identified four contradictions with this notion of cultural competence [197]. First, there is conflict regarding whether knowledge about traditions, cultural beliefs, norms, and values of any particular group can ever be obtained. Practitioners may have pieces of information but true knowledge may not be possible; the client is the expert. Furthermore, much of the knowledge gleaned about cultural groups is not necessarily "empirical," and practitioners may have broad anecdotal information, which, if misapplied, can lead to stereotyping [197]. Second, categorizations are not able to capture the multifaceted and multilayered complexities of culture. When a particular cultural group is referred to as being collectivistic rather than individualistic, these categorizations may end up obscuring individual differences of clients. Third, the emphasis on privileging group differences may be dissonant with many of the helping professions' ethical mandates to promote self-determination and autonomy. Fourth, it is unclear if cultural competence is truly a goal that can be attained due to lack of empirical measurement. Furthermore, it is unclear what the benefit would be to the patient/client if cultural competence was able to be measured within subgroups [197]. The final consideration is how a practitioner is able to assess mastery of cultural competence [365].

Despite more than 40 years of multicultural counseling competence and associated research, questions remain [231]. For example, how does demonstrating cultural competence affect therapeutic change? How is cultural competence actually manifested in clinical practice? Is multicultural counseling competence culturally specific or culturally general?

However, it is clear that clients need to feel safe. Studies indicate that minority and immigrant clients feel their cultural differences are pathologized, which then ultimately leads them to feel unsafe in the therapeutic environment [282]. Counselors should be able to determine when culture is or is not impacting a presenting issue [282]. The term cultural competence may not be totally appropriate; "competence" implies an endpoint, while in reality it is a lifelong journey of learning [366]. Instead, the terms "cultural humility," "cultural respect," and "cultural safety" may be more suitable. Cultural humility conveys the need for ongoing reflection, learning, and self-critique; cultural respect involves a commitment to hearing patients'/clients' stories, and cultural safety entails practitioners recognizing the power differentials and making the environment safe for patients and clients.

Chinese Americans are the largest Asian American group in the United States. Their immigration history is long and can be distinguished by five different waves. The first wave of Chinese immigration dates back to 1785 [104]. It was only between the period of 1850 and 1919, with the discovery of gold in California, that a large influx of Chinese immigrants to the United States was triggered—primarily Chinese male peasant farmers who left their homelands with dreams of finding a new fortune [104]. In 1864, the building of the transcontinental railroad triggered further recruitment of Chinese immigrants from Canton [104]. The railroad construction promoted an open immigration policy, which gave unrestricted access of Chinese immigrants to the United States, spurred primarily for reasons of cheap labor [104].

In 1882, the United States implemented the Chinese Exclusion Act, as a result of racial conflict and anti-Chinese sentiment. Due to a general lack of understanding, the Chinese were categorized as Mongolians, and there was a concern about the amount of cheap labor and the fact that there were so many Chinese men who came to the United States without families, relying on prostitution for companionship [73,78]. The U.S. government felt that this antifamily tendency would adversely affect the United States [73]. With the implementation of the Chinese Exclusion Act, Chinese laborers were barred from entering the United States. Furthermore, the Act prohibited Chinese immigrants who were already residing in the United States from being naturalized [104]. Despite these restrictions, many Chinese immigrants found loopholes to enter; one major strategy was utilizing the "paper son" system [78]. Despite these new restrictions, U.S. immigration laws did allow relatives of American citizens of Chinese descent to enter the country. In 1906, in San Francisco, a major earthquake and fire destroyed much of the city's legal documents. Many Chinese immigrants used these circumstances to their advantage. Chinese who were born in the United States, or who claimed they were, visited China and came back reporting the birth of a son [104]. Due to the fire, there were no records to prove otherwise. This created an opportunity for an individual to come to the United States, implementing a system known as "paper sons" [78].

The second wave of Chinese immigrants came after the implementation of the Immigration and Naturalization Act. This act imposed a numerical limit on immigration and favored northern and western European immigration. However, in 1930, this law was changed to permit wives of Chinese merchants and Asian wives of American citizens married before 1924 to immigrate to the United States [104]. Therefore, during the periods of 1930 and 1942, as more Chinese women entered the United States, stable family units emerged in Chinatowns [104].

The third wave of Chinese immigration took place between 1943 and 1964. This was strengthened by passage of the War Brides Act in 1945, which allowed Chinese women to immigrate as brides of men in the U.S. military. In 1953, the Refugee Relief Act permitted educated Chinese into the United States as refugees. In 1965, the immigration quota laws were repealed, which spurred a large influx of Chinese women to the United States and reunited many Chinese families that had been separated for decades [104].

During the period between 1965 and 1977, the fourth wave brought Chinese immigrants to the United States under the Immigration Act of 1965. These immigrants were primarily working-class families who settled in large urban areas, primarily in cities with Chinatowns. Immigrants who arrived during this period worked long hours trying to achieve the American dream.

Finally, the fifth wave began in 1978, after three decades of the closed-door policy, and immigrants from China were allowed to join their relatives. A large number of students and professionals also immigrated to the United States to pursue their education. Furthermore, there was a large group of Chinese ethnics from Cambodia, Laos, and Vietnam who fled Southeast Asia to escape torture during the Khmer Rouge regime in the 1970s [104]. In 1989, with the student protests in Tiananmen Square and subsequent public outrage at the military force used, Congress was concerned for the safety of students from China studying in the United States who would have to eventually return back to their homeland. In 1992, Congress enacted the Chinese Student Protection Act, which offered permanent residency status to student immigrants from China [200].

Immigration is influenced by the economic forces occurring in the receiving country. With industries in the United States moving more and more to high technology, there was a demand for professional and technical workers with postgraduate degrees. As a result, the Immigration Act of 1990 was passed, which revised the definitions of the H-1B visa, a non-immigrant visa category that allows American employers to hire skilled immigrants who have at least a bachelor's degree in areas where there is a shortage in the U.S. labor market [200]. Many highly educated Chinese immigrants came into the United States under this act in the early 1990s. In 2017, China accounted for 32.5% of the 1,079,000 international students who came to the United States to study. In 2019, China accounted for 13% of the H-1B petitions for skilled workers in specialized occupational sections to receive approval to reside in the United States to work [370]. Furthermore, some Chinese nationals have established households in the United States, from which their children may be educated, and maintain a home in China, where the adults continue to work [104]. Today, Chinese immigrants who are educated, hard-working, and ambitious tend to be considered "model minorities" and are viewed positively by the governments of United States and Canada as they help to fill gaps in the skilled labor market [200]. In 2019, China and Hong Kong represented 18% of Asian immigrants to the United States [371].

As a result of differences among the various immigration waves, Chinese immigrants in the United States are tremendously diverse in terms of a variety of social factors, including educational level, English proficiency, socioeconomic status, and acculturation. For example, there are many Chinese immigrants who originated from rural areas in Canton who came to the United States in the early 20th century, but who remain in Chinese enclaves and speak minimal English [180]. They differ tremendously from more recent Chinese immigrants from Hong Kong or Singapore who are very westernized and highly proficient in English [180].

In 2019, there were 5.4 million Chinese Americans (excluding those of Taiwanese descent) in the United States, making them the largest Asian subgroup in the United States [372]. If language is an indicator to level of acculturation, Chinese Americans are diverse in their level of acculturation. An estimated 14.6% of Chinese American households speak primarily English at home, while almost 50% do not speak English at home and speak minimal English outside of the home [168]. They have high labor force participation at 61% for Chinese individuals 16 years of age and older [372].

In 2019, there were 4.2 million Filipinos living in the United States, residing primarily in California [373,374]. They, too, are a very diverse group. Approximately half of Filipino Americans and immigrants have at least an undergraduate college degree, which is higher than the rate for all Americans in the United States (38%) and all Asian Americans (31%) [373]. The three main Filipino cultural subgroups are Tagalogs, Ilocanos, and Visayans, and their diversity reflects their immigration patterns [180].

Emigration from the Philippines to the United States is marked by four waves [104]. The first wave was triggered in 1763, when Spain started trade between Manila and Cebu. Filipino slaves and laborers were said to have jumped off the vessels on the way back to Spain, ending up in Louisiana [104]. The second wave began in the early 1900s and ended in 1934 [104]. This group was comprised of nonmarried male farmers who were recruited to work on pineapple plantations in Hawaii and various parts of California, where they experienced much discrimination [7,104]. Between 1945 and 1965, the third wave included Filipino service men and their brides, as the United States granted citizenship for Filipinos who fought in World War II [180]. This group had difficulty adjusting to the United States and generally ended up with menial jobs [7]. The fourth wave of Filipino immigrants came after 1965, when the Immigration and Nationality Act was modified to ease its original immigration quotas [180]. During the 1960s, the United States witnessed a large influx of well-educated, professional Filipino immigrants, especially healthcare professionals, who left the Philippines due to displeasure with the government [94,180]. This period has been called the "brain drain" because many doctors, nurses, and engineers came to the United States to further their training and/or obtain better employment opportunities [104]. Today, the majority of Filipinos in the United States have lawful permanent residence primarily through family reunification and employment-sponsored visas [374]. The Philippines ranked second for these two immigration entry vehicles [370]. Documented residents in the United States can sponsor their spouses and unmarried children for permanent residency, and U.S. citizens scan sponsor parents, married children, and adult siblings [375].

Japanese Americans have a long history in the United States, dating back more than 100 years. Japanese immigration was at its highest during the years between 1880 and 1920 [104]. Because Chinese laborers were viewed as a threat by many, the Japanese government made agreements with the United States to allow Japanese workers to work on sugar plantations in Hawaii [26,104]. As Japanese laborers continued to immigrate to Hawaii, and as they gradually moved to the mainland, anti-Japanese sentiment mounted, and eventually, in 1907, President Theodore Roosevelt issued the Gentleman's Agreement to curtail Japanese immigration [26]. The Gentleman's Agreement stated that only those Japanese who had a parent, husband, or child already living in the United States were allowed to come to join their relative [85]. Therefore, the Japanese government actively encouraged Japanese women to immigrate to the United States, hoping to promote marriage and families of these laborers. They believed that the presence of these women would serve to prevent gambling, prostitution, and various vices among the Japanese laborers [104]. As a result, Japanese women started coming to the United States as "picture brides." Brides were matched based upon family background, and once the initial match was made, a photograph was mailed to the potential groom [26]. In Japan, merely entering a woman's name in the groom's family registry constituted legal marriage [127]. Therefore, Japanese women often came to the United States to join their new husbands without knowing anything about the man they had married [104]. Despite the implementation of the Gentleman's Agreement, Japanese immigration continued to flourish as a result of these so-called "picture brides." Consequently, a movement to completely prohibit Japanese immigration resulted in the Immigration Act of 1924 [127].

When World War II began, the Japanese in the United States experienced great discrimination. When President Roosevelt signed an executive order in 1942 to permit military authorities to remove any persons from any location without a trial, many of the Japanese who remained in the United States were moved to internment camps in remote areas of California, Arizona, Idaho, Utah, Wyoming, Colorado, and Arkansas [7,104]. Within six months, more than 120,000 Japanese Americans were sent to relocation camps [7]. After World War II, Japanese immigration resumed, the majority of which consisted of Japanese war brides who married American servicemen stationed in Japan [104].

As of 2019, Japanese Americans are the sixth largest Asian American group, numbering 1.5 million [367,376]. According to the U.S. Census, they constitute 7.8% of the Asian American population [168]. This group tends to be highly educated, with 52% Japanese Americans and immigrants 25 years and older having a Bachelor's degree or higher [376]. In 2019, 63% of foreign-born Japanese Americans had lived in the country for more than 10 years [376].

The Japanese have coined terms to describe different generations. Issei are first generation immigrants, the majority of which having immigrated between 1870 and 1924. Most Issei are not very acculturated or assimilated into the United States, preferring to let their American-born children become more acculturated [94]. Nisei are the American-born children of the Issei, born between 1910 and 1924, making them now senior citizens [94]. This group experienced tremendous discrimination and prejudice growing up in the United States. Sansei are the third generation, or children of the Nisei. With each generation, they become more acculturated, and each generation becomes more assimilated to the norms of the region in which they were raised [94].

Korean immigration to the United States occurred in three distinct waves [7,104]. As with the Japanese and Filipinos, Korean immigrants were initially introduced to Hawaii as laborers. The first wave of immigration occurred between 1903 and 1905, during which time poverty-stricken Korean farmers came to Hawaii as contracted laborers [7]. Similar to the Japanese, "picture brides" eventually joined the laborers [104]. Many of these Korean immigrants came to the United States to seek a haven from the Japanese occupation of Korea [33]. Until 1945, other Korean immigrants included students, exiles, and intellectuals [104]. During this time, immigration to the United States was allotted for only 100 students at any given year [152]. The Immigration Act of 1924 halted much of Korean immigration to the United States.

When the Immigration Act was lifted, the second wave of immigration began between 1951 and 1964 and consisted of Korean War orphans and children adopted by Americans [7]. Additionally, a large number of Korean women married American service men who were stationed in Korea and came to the United States with their new husbands [104]. The third wave coincided with the 1965 Amendment to the Immigration and Naturalization Service Act of 1955. This opened the gates to Korean immigrants, and between 1970 and 1990, the United States witnessed more than 30,000 Koreans immigrating annually [7]. In 1975, Korea was among the top five nations in the world in terms of immigrants coming to the United States [152]. Today, the majority of Koreans living in the United States are from South Korea [248]. In 2012, the Deferred Action for Childhood Arrivals Program (DACA) was implemented. It allows some individuals who entered the United States as children to defer deportation and become eligible for a work permit. There were 29,000 Korean immigrant youths who were eligible for the DACA program in 2018 [377].

Korean Americans are the fifth largest Asian group in the United States, and as of 2019, they numbered 1.8 million [367,378]. Because the third wave of immigration was the largest, the Korean American population primarily consists of those who are foreign born [168]. It is estimated that approximately one of every four Korean immigrants arrived in the United States in 2000 or later [248]. Korean children who came with their families to the United States are referred to as "1.5 generation," as they will have been predominantly socialized in the United States [94]. Approximately half of Korean Americans live in California, New York, or New Jersey. An estimated 57% of all Korean Americans and immigrants 25 years and older have attained a Bachelor's degree or higher [378].

Korean immigrants are unique in the sense that they quickly established economic stability in the United States. They are referred to as the "middleman minorities," meaning a group serving as the buffer between a dominant and a subordinate group (e.g., White and Black Americans in the United States) [94]. Upon coming to the United States, Koreans, as middleman minorities, brought with them a high level of education, capital, and skills. They found a niche in small business sectors such as retail shops, serving Korean clientele and other ethnic minority groups [94]. They often rely on family members for labor and financially support new Korean immigrants so they, too, can start small businesses [94]. According to the Pew Research Center, they have the highest rate of self-employment among Asian Americans in the United States. The number of Korean immigrants has not increased in recent years, partially due to the fact that economic conditions in South Korea have improved [290].

Thailand, Cambodia, Vietnam, Laos, Indonesia, Malaysia, Singapore, and Burma (Myanmar) make up most of Southeast Asia. Southeast Asians are the most recent immigrant Asian group to the United States. Each Southeast Asian immigrant subgroup's immigration experience is diverse and is influenced by their homeland's unique sociopolitical factors. This section will focus primarily on Vietnamese, Cambodian, and Laotian immigrants and refugees. These groups share the common experience of leaving their homelands due to repressive political regimes [33]. They are assigned the status of refugees because they fled their homeland for reasons of survival and safety during a politically unstable and corrupt government, and to return to their homeland would mean persecution [94].

Asian Indian immigration can be traced back to the mid-1800s, when they came and settled in California. These immigrants were primarily farmers [7,104]. Due to open hostility and discrimination, many left to return to India. Some of those who did stay married local Mexican immigrants [104]. There was minimal Asian Indian immigration between 1917 and 1965 due to the Immigration and Naturalization Act, which placed quotas on the amount of Asian immigrants coming into the United States. In 1965, when an amendment altered immigration policy, race was less of a determinant for entering the United States. Instead, immigrants' skill sets and potential to contribute to the economy became the primary criteria for entrance [104]. Therefore, the second wave of Asian Indian immigration was comprised largely of professionals such as engineers, technicians, and physicians. The third wave occurred after the Family Reunification Act of 1990, which served to reunite family members and relatives of those immigrants who had already come to the United States. This third wave of Asian Indian immigrants was sponsored by family members who had already immigrated to the United States. Unlike their family members who came in the second wave, this third wave of immigrants were generally not as highly educated, had lower English proficiency, and lacked highly technical or professional skills [104]. Upon settling in the United States, many opened small businesses or entered vocational trades [104].

As of 2019, Asian Indians are the second largest Asian American group in the United States, with a population of 4.6 million [382]. The majority (54%) are relatively recent immigrants, having come to the United States between 1990 and 2000. Asian Indians are one of the largest groups to obtain H-1B temporary visas, which allow employers to hire workers from outside the country to enter the United States for highly skilled and specialized jobs [311]. They account for 71.7% of H-1B visas [370]. In 2019, 75% of Asian Indian Americans and immigrants 25 years of age and older had a Bachelor's degree or higher [382].

Only a handful of large-scale, federally funded epidemiological studies have been completed using the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) to establish prevalence rates of psychiatric disorders. Smaller scale studies using nonprobability sampling designs do not provide overall prevalence or incidence rates. However, they do provide a glimpse of a phenomenon at any given point in time within a specific population. In the following sections, some major psychiatric disorders among the different Asian American subgroups will be reviewed. It is impossible to cover every psychiatric diagnosis and every configuration of Asian American subgroups. The goal of this section is to provide a brief overview.

Mood Disorders

Depression is a common psychiatric disorder. It is estimated that between 5% and 10% of adults in the United States experience severe depression in any given year, and an additional 3% to 5% suffer from mild forms of depression [88]. The Epidemiologic Catchment Area (ECA) study and the National Comorbidity Study (NCS) examined mental health needs and prevalence rates of psychiatric disorders in the United States [172]. Both research studies placed all Asian American/Pacific Islander subgroups together into one large category, and the final sample sizes were small. As a result, it was difficult to discern with more specificity who actually participated in the study [172]. However, researchers have begun to acknowledge the role of culture in mental health and recognize that there is tremendous diversity within Asian subgroups.

In the United States, prevalence estimates for depression among Asian Americans and immigrants have varied. A meta-analysis of 58 studies found that the prevalence rates ranged from 4.5% to 11.3% among adults [292]. In a large-scale study conducted in Los Angeles focusing on 1,700 Chinese Americans and immigrants, the researchers found that approximately 7% of the respondents disclosed experiencing depression during their lifetime, and about 3% stated they were depressed in the past year [163]. These prevalence rates are much lower compared to the rates of depression in a national epidemiological study, which found a lifetime prevalence rate for the general population of 16.2% and 6.6% for the last 12-month period [87]. A study with 487 Chinese American adults found a lifetime prevalence rate of 18.3% for major depression disorder and a past-year rate of 7.2% [293].

Other studies have utilized self-reported measures such as the Center for Epidemiologic Studies Depression Scale (CES-D). The CES-D is a popular and well-validated 20-item instrument measuring depressive symptoms. Typically, the clinical cutoff score of 16 or greater signifies clinical depression [144]. One study found that 19% of the study sample of Asian Americans reported depression [100]. Oh, Koeske, and Sales found a 40% rate of depression in a Korean immigrant sample in the United States [131]. They also found that those who were more acculturated experienced less acculturative stress, which in turn was associated with lower levels of depression. In another study of 121 Vietnamese American college students, 34% of the sample reportedly experienced depression [133]. A 2017 study found that among a sample of 1,639 Asian immigrants, about 8% of women and men reported experiencing major depression during their lifetimes [312]. Acculturative stress stemming from legal issues and discrimination was correlated with depression, even after controlling for demographic variables. Specifically, acculturative stress stemming from discrimination, seeking employment, having an accent, and feeling isolated and disrespected contributed to poorer mental health. Depression is also correlated with lack of health insurance, lower neighborhood cohesion, and having a language-discordant healthcare provider, and these variables may also be related to acculturative stress [383]. In general, southeast Asian Americans have the highest levels of depression (19%); specifically, Cambodians reported the highest prevalence (39.1%). Conversely, east Asian Americans report the lowest rates (9.3%), with Japanese Americans being the least affected (3.3%) [383].

According to the American Academy of Child and Adolescent Psychiatry, common patterns of symptomatology displayed by children from diverse populations can differ significantly from those in Euro-Americans due in part to the influence of their culture. For example, emotional reactivity during depression is greater in Asian-origin individuals than in whites.

(https://www.jaacap.org/article/S0890-8567(13)00479-6/fulltext Last Accessed: November 8, 2021)

Strength of Recommendation: Expert Opinion/Consensus Statement

A 2010 study examined the 12-month antidepressant use for major depression among Asian Americans [253]. Asian Americans had an antidepressant usage of 10.9%, compared with 32.4% of non-Hispanic Whites. The percentage varied by ethnic subgroup, with 8.7% of Vietnamese Americans and 17% of Chinese Americans reporting previous year antidepressant use.

A meta-analysis study found that how one measures acculturation is crucial [294]. When acculturation is defined as adopting the values of the new culture, depression is less likely. Asian Americans who were more acculturated to their host country's values experienced less depression than those with lower levels of acculturation. Situational factors will contribute to depression as well.

A large-scale study of 1.3 million participating adults was conducted by the U.S. Census Bureau to screen for depression and anxiety during the COVID-19 pandemic and related isolation and lockdowns [384]. Adults were four times more likely to screen positive for depression and anxiety in 2020 compared with 2019 [384]. By summer 2020, depression and anxiety had increased the most for Asian Americans, which corresponded to COVID-19 cases rising, increasing instances of violence against Asian Americans, and the racial protests [384].

Typically, many immigrants leave their familiar surroundings and family in hopes of a better life. Yet, on a short-term basis, the immigration and adjustment processes are very stressful and often have ramifications on overall family dynamics and individual well-being. Immigration is associated with numerous life changes and adjustments for the immigrant, including economic changes (e.g., unemployment or underemployment); changes in social supports and networks; adjustment to new customs, the environment, and nutrition differences; and acquiring new language competencies and life skills [18]. Typically, those immigrants coming to a more developed country will experience a more difficult adjustment process [157]. Immigrants with children experience a more pronounced need to navigate between two cultures. Children will often be the first to experience the contrast in norms, values, and behaviors in school settings and with peers. They may acculturate more quickly than their parents, which could produce family stress and feelings of isolation between parents and children [208]. A focus group of 22 Chinese immigrant parents found that differences in Western and Chinese cultural practices at home and at school were predominant stressors [320]. Discrepancies in English language skills among Chinese immigrant parents and children can also promote stress [320]. Parents may also rely on children to help them navigate their new environment and to interpret. This can unwittingly produce challenges in role boundaries.

Obtaining employment upon arrival is vital to survival, but it is difficult for many immigrants due to lack of training, limited English proficiency, different licensing requirements, discrimination, and lower educational level [260]. In a study conducted by Mangiafico, unemployment and underemployment were pronounced in a Chinese immigrant sample [116]. Despite their high levels of education, Chinese immigrants found that securing employment was difficult upon arrival in their new host country. More than half (65.3%) of the Taiwanese immigrants in the sample, 25% of the Hong Kong immigrants, and 17.6% of the immigrants from mainland China had four or more years in college. However, during the period of the survey, one-third (33.8%) of the immigrants from mainland China were unemployed although only 3.4% were unemployed in their homeland. Though not as drastic, Taiwanese immigrants showed similar trends; one-fifth (20.4%) were unemployed in Taiwan, but approximately one-third (32.7%) were unemployed in the United States [116]. In a 2014 ethnographic study with 15 Korean immigrant women who immigrated to Canada, the participants discussed the challenges with employment upon settling into their host country [301]. Most were professionals in Korea but found themselves in low-skilled jobs such as cleaners, kitchen helpers, and cashiers in Canada. Despite the challenges of underemployment, their jobs helped them to improve their English, which they believed was vital to their survival [301]. Not only is employment essential for survival, but employment is tied to sense of self. For immigrants, this is even more significant because many left everything familiar in order to improve their socioeconomic status [260]. Ultimately, this has negative health and mental health effects.

Shifts in family dynamics and gender role reversals often result upon immigration. It has been noted that many rules and values that were once endorsed and deemed effective in an immigrant's homeland are no longer effective in the new host country [155]. Family rules dictate the overall functioning of the household, behaviors and dynamics between family members, and family roles. Family rules can implicitly prescribe and sanction gender roles; that is, which family member assumes the breadwinner position and which family member fulfills nurturing responsibilities. In many cases, unskilled jobs are more readily accessible to immigrant women than to immigrant men, thereby challenging family structure and roles [155]. Consequently, female immigrants' private and public statures are often enhanced due to immigration [153]. Many female immigrants, for example, join the labor force more quickly than male immigrants, and female immigrants earn more than men in the early years of immigration [153]. As a result, many female immigrants experience elevated status and greater visibility in their new host country compared to that in their homeland [153]. For some, these drastic changes produce family conflict [155].

In a 2011 interview study with 30 Iranian immigrants to Canada, men discussed difficulties adjusting to their wives' new freedoms in their new country. They also reported feeling their identities of being "good husbands" were threatened because they could no longer provide for their families adequately [261]. In a study of Asian Indian women who came to study in the United States, participants reported having an expectation of greater freedom. However, they often found themselves under the supervision of distant relatives in order to maintain traditional gender role expectations [321]. In Vietnamese families, women often were required to enter the labor force to ensure economic survival. In many cases, it was the women who became the primary breadwinners, because low-skill jobs such as maids, food service workers, and housecleaners were more readily available for women. However, the logistics of caring for a household can also impede Asian American women from entering the labor market. Based on data from the 2009–2011 American Community Survey, Asian immigrant women who lived in extended households (e.g., with a mother or mother-in-law) were more likely to work outside the home [391].

There can be negative family consequences as a result of women's paid labor participation. Service providers, for example, revealed that extreme family problems such as violence tended to occur when men felt they were unable to fulfill their traditional responsibilities in caring for their families. These men were often reluctant to accept menial jobs because it signaled a status loss, and with no other recourse, their wives often had to assume the role of breadwinners [60]. Asian men who immigrate later in life often report difficulties obtaining employment as a result of lower English proficiency. This affects social position and is counter to traditional Asian values and is correlated with higher levels of acculturative stress [392].

The American Academy of Child and Adolescent Psychiatry notes that differential acculturation is a predictor of negative mental health consequences for youth, such as school difficulties, gang involvement, depression, and suicidality, in some Asian-American families.

(https://www.jaacap.org/article/S0890-8567(13)00479-6/fulltext Last Accessed: November 8, 2021)

Strength of Recommendation: Expert Opinion/Consensus Statement

Another ethnographic study with Vietnamese immigrant families found similar patterns of redefinitions of patriarchal gender relations [89]. In order to ensure economic survival, patchworking was a strategy employed by many Vietnamese families. This strategy involved combining resources from all family members, and the "patchwork" of these collective resources promised a greater likelihood of economic survival in a new country. According to Kibria, the process of immigrating to the United States and the strategy of patchworking resulted in families negotiating new family rules such as gender roles and relations [89]. Because Vietnamese men were periodically or chronically unemployed, women had to step in to contribute to the household's income. This resulted in a shift in power, which challenged traditional authority, an integral characteristic of Asian family structure. Family conflict is often a direct consequence [89]. Any time established family hierarchies are disrupted due to one family member (e.g., child or wife) being perceived to have more power (e.g., access to language or resources), it is inevitable that the boundaries in a family will change. These changes could produce conflict, resulting in mental health and behavioral changes [208]. Acculturative stress often stems from culture conflict [393]. For example, South Asian women who lived in Canada for at least two years often reported acculturative stress due to intergenerational conflict at home [393].

The DSM is the most commonly used reference to define and establish psychiatric disorders. However, one of the major questions about the DSM is whether its diagnostic categories are valid across cultures [31]. PTSD as a diagnostic category, for example, has been quite controversial. In part, this stems from measurement issues. In order to accurately capture the amount of stress experienced, it is first necessary to inquire regarding the culturally appropriate traumatic precipitators. Terheggen, Stroebe, and Kleber, for example, noted that in Tibet, the destruction of temples and other religious symbols were regarded as extremely traumatic [165]. It would be necessary to inquire about these events in order to fully capture the traumatic stress experienced. Another aspect of the controversy regarding PTSD as a valid cross-cultural category revolves around how symptoms are displayed within cultures. Guilt, for example, is characteristic of survivors of trauma; yet, in many Asian cultures, shame is expressed rather than guilt. In the Tibetan language, for example, there is no word for guilt. Furthermore, somatic symptoms are also more frequently exhibited in Asian cultures. In Terheggen, Stroebe, and Kleber's study, Tibetans were more likely to endorse the somatically phrased items for depression and anxiety as opposed to psychologically phrased question items for these symptoms [165]. An earlier study conducted by Matkin, Nickles, and Demos found some evidence to suggest that at least some PTSD diagnostic criteria appear to have cross-cultural validity with Cambodians, who tended to manifest more somatic symptoms than some of the other PTSD criteria, such as flashbacks, hypervigilance, and emotional attachment [117]. Similarly, Vietnamese refugees expressed more somatic presentations of PTSD as opposed to the general symptoms typically associated with the disorder [117]. This controversy continues, and it raises questions about the applicability of all DSM-defined entities in all cultural contexts.

It has also been questioned whether psychiatric symptoms expressed in ethnic minority patients or patients from other cultural groups are similar to individuals in Western societies and whether the DSM can detect any cultural variations in the manifestation of symptoms [172]. It is possible that culture-based idioms of distress, or "socially and culturally resonant means of experiencing and expressing distress in local worlds," may not be captured by Western definitions of various psychiatric disorders [265]. In other words, idioms of distress can be mechanisms by which groups express symptoms in a culturally and socially sanctioned manner [397].

These behaviors or symptoms can include different mannerisms, figures of speech, and emphases on certain symptoms while ignoring others [31]. The most common culture-based idioms of distress are somatic symptoms. Some groups tend not to psychologize emotional problems; instead, they experience psychological conflicts as bodily sensations (e.g., headaches, bodily aches, gastrointestinal problems, and dizziness) [136]. It has been argued that the presentation of somatic symptoms for many psychiatric conditions is less stigmatizing and more culturally congruent in cultures that value or emphasize inhibition of emotions. Many Asian groups are encouraged to keep silent and not verbally communicate emotions so as to preserve harmony in interpersonal relationships [136]. Pang, for example, notes that some Koreans may even consider it unfilial to emotionally express conflict with parents, children, and elders [136].

It would be simple to state the somatization of emotional problems is straightforward and clearly exhibits physical symptoms. According to Pang's study of Korean elders in the United States, their somatic expressions of distress are interspersed with not only physical, but also emotional, spiritual, cognitive, affective, behavioral, and supernatural components [136]. Somatization is not simply about the denial of psychologic complaints, because emotions are not the root of mental illness [327]. The language utilized to describe their feelings is somatically oriented, but the physical symptoms are merely metaphors. For example, to describe jealousy, they may say that they have a stomach ache. To describe how they feel when they are affronted, they might say, "I have been injured and wounded all over my body" [136]. In other words, they may not necessarily be presenting somatic symptoms; rather, they are merely metaphorically describing their emotions [136].

While it is not feasible for the DSM to address every culture for every diagnosis, the fifth edition of the DSM (DSM-5), published in 2013, includes an expanded outline for cultural formulation and a newly added assessment tool, the Cultural Formulation Interview (CFI). The CFI is a set of 16 questions addressing cultural definition of the problem; cultural perceptions of cause, context, and support; cultural factors affecting self-coping and past help seeking; and cultural factors affecting current help seeking. This assessment has been field-tested for usefulness among clinicians and acceptability among patients [8].

It is important to consider that the existence of cultural idioms of distress remains a topic of debate. Experts continue to question whether these idioms are linguistic expressions or actual behaviors, if they reflect broader social structures, and if there are boundaries dictating their appropriate use [398].

The process of help-seeking is not linear; rather, it is a complex web of factors that influence whether an individual will seek formal or informal assistance for their problem [330]. This includes demographic factors, cultural beliefs and norms, perceptions of barriers to help-seeking, individual and family appraisals of the problem, and constellation of ecologic factors [330].

Understanding individuals' patterns of help-seeking also provides a window to understanding attitudes toward mental health and the role of cultural schemas. Asking for either formal or informal assistance implies different meanings in different cultures. Although Western societies pride themselves on individualism and self-sufficiency, there is also less of a stigma in obtaining psychological or therapeutic help. Particularly in the United States, obtaining counseling or therapy is viewed positively, as it is regarded as a mechanism to promote insight and personal growth. However, in many Asian cultures, emotional and psychological problems are in part attributed to bad luck, misfortunes from displeased ancestors, and/or a lack of personal willpower, self-control, or maturity [167]. Furthermore, personal problems are viewed as private and are not to be expressed to outsiders; these problems should be kept within the family. This ultimately serves to prevent loss of face not only for the individual experiencing the problem, but for the entire family system [104]. Religious beliefs about fate, acceptance, and perseverance can also impede Asian immigrants from seeking formal assistance. Help-seeking is very complicated, as there are a host of variables that can affect the process.

Demographic factors are an important predictor to help-seeking. In Kung's study of 1,747 Chinese Americans and immigrants in Los Angeles County, the majority (75%) stated they had never sought formal help for emotional problems, but 25% stated they had sought help from family and friends [99]. Gender and age were good predictors of seeking formal help. Women and younger Chinese Americans and immigrants, for example, were more likely to seek mental health services [99]. Not surprisingly, higher levels of English proficiency predict mental health treatment receipt [399].

Acculturation is another key variable in influencing help-seeking. Because mental health theories and counseling techniques are primarily rooted in Western ideologies (e.g., values emphasizing verbal and emotional expressiveness and direct communication), it would make sense that those ethnic minority immigrants who are more acculturated would be more likely to seek mental health services. DeVitre and Pan examined the role of enculturation (defined as degree of adherence to Asian cultural norms such as collectivism, emotional self-control, humility, and family orientation around achievement) and acculturation in attitudes toward seeking mental health treatment among 75 Asian American adults [400]. In this study, higher levels of enculturation negatively correlated with positive attitudes toward seeking mental health treatment; acculturation only partially predicted help-seeking attitudes. In a study of Asian Indian university students in the United States, higher levels of personal stigma were correlated with more negative views about seeking psychologic help [331]. The need for achievement and honoring family were paramount and may override perceptions about help-seeking. However, another study found that Asian American college students who are more acculturated were more tolerant of the stigma of seeking formal help, more likely to recognize a personal need for counseling, and more receptive to talking about personal problems with counselors than their less acculturated counterparts [16]. Similarly, a study of 107 Asian American college students found that Asian American students who were more tolerant of the stigma were more likely to seek formal mental health assistance [218]. The researchers point out that personally feeling stigmatized may not be the sole reason for not seeking mental health services; rather, it is the concern that close family members will be stigmatized. Yet, there has been some debate about the role of acculturation in help-seeking, as it is possible that those who are more acculturated have more psychosocial problems and, by extension, are more receptive to seeking formal assistance [99]. However, Kung found that those who were more acculturated and who had a diagnosable mental disorder were less likely to seek informal help from family and friends [99]. A 2014 study found that Asian Americans employed less family support than White Americans and Latinos and relied less on friends than White individuals [307]. Although Asian cultures are collectivistic and family oriented, it is possible that individuals avoid seeking help from family in order to preserve group harmony and reduce conflicts [307].

However, acculturation is not the only factor. It has been speculated that level of family cohesion could affect help-seeking of mental health services. For example, those with high levels of family cohesion might not turn to mainstream mental health services, relying instead on family. In one study, for each point increase in family cohesion, there was a lower odds ratio of receiving mental health services [268]. The researchers found the variable that influenced help-seeking was generational status. Second-generation and third-generation Asian Americans who had similar levels of family cohesion to first-generation individuals were 1.7 and 2.67 times more likely to receive mental health services, respectively [268]. Other research has found that stronger identification and commitment to one's ethnic group are related to less favorable attitudes toward formal help-seeking [332]. It has been posited that adhering to an Asian cultural orientation creates dissonance with perceived notions of Western values of seeking help with mental health professionals. It is clear that the complexities of the phenomenon of acculturation should be studied further.

Religiosity and spirituality also affect help-seeking patterns. It can be argued that those who are religious or spiritual are more likely to seek help from the clergy than mental health professionals because their worldviews are more congruent with those of clergy. One study with 2,285 Filipino Americans examined the role of religiosity and spirituality [2]. Given the fact that many Filipinos are Catholic and the literature demonstrates that this population underutilizes mental health services, it was speculated that they would be more likely to seek help from religious leaders [2,108,167]. Findings showed that their rates of help-seeking from clergy and mental health professionals were comparable. Not surprisingly, those who exhibited higher levels of religiosity were more likely to seek assistance from clergy when emotionally distressed. However, level of religiosity did not only affect seeking help from mental health professionals; those with higher levels of spirituality were less likely to get assistance from both mental health professionals and clergy [2].

Among some Southeast Asian groups, including Cambodians, sleep paralysis or "ghost oppression phenomenon" is common [219]. This sleep paralysis consists of hallucinations and panic attacks and is believed to be caused by a ghost who is discontent with the individual. Therefore, a monk will splash holy water or offer food to the ancestors to appease the ghost [219]. Seeking assistance from a monk, shaman, fortune-teller, acupuncturists, or herbalist is more religiously and culturally aligned with the belief systems than seeking help from a professional health or mental healthcare provider [269]. More research is needed to flesh out the interaction of religiosity and spirituality and its influence in help-seeking patterns in the Asian American communities.

Stigma and the fear of losing face also affect help-seeking [269]. As discussed earlier, the terms used for mental illness are often pejorative and stigmatizing, and therefore, seeking mental health services may be regarded as negative with long-lasting adverse repercussions. Pakistani women stated that the word "mental" meant "crazy" and to seek mental health services had extreme aversive ramifications [176]. In this community, a husband may use the stigmatization as grounds for divorce, making the argument that he must seek a wife and mother who is more stable and fit [176]. It also has marginalizing day-to-day effects within the family. Women who have been diagnosed with psychiatric conditions are made to feel as if their opinions do not matter; they have difficulty disciplining their children as respect is lost. Overall, they experience loss of status within the family [176]. These outcomes are inextricably tied to the cornerstone of Pakistani value systems that emphasizes the importance of family, with women's identities rooted to their core values of being a wife and mother [176]. Therefore, it is not uncommon among Asian Indian women to reframe any feelings of sadness or depression to a discussion about physical symptoms of weakness (kamzori) [264]. This is research indicating that individuals who view mental health conditions as physical disorders with recognizable symptoms are more likely to seek formal services [333].

The Chinese concept of "face" has two components: mianzi and lian [62]. Mianzi is one's worth as can be claimed within a social network. Lian has to do with internal and external moral sanctions [62]. Therefore, mianzi is lost when one's performance fails to live up to the standards one has claimed within the social network, and lian is lost when one transgresses moral boundaries leading to guilt and shame [62]. Both lian and mianzi work together to create the concept of "face." It has been speculated that fear of losing face is one reason why Asians underutilize mental health services. Gong, Gage, and Tacata's study examined the role of concern with face and language use with help-seeking among various sectors of care among Filipino Americans [62]. Their findings are interesting. First, Filipinos who speak primarily the Filipino language and who are concerned with issues of face are more likely to use the lay system (e.g., family and friends) and less likely to use general medical services. The authors speculated that because they are concerned with losing face and seeking outside help is stigmatizing, they would prefer to keep their personal problems at home. The opposite occurred for bilingual Filipinos. Those who were more concerned with face were less likely to seek help from family and friends but were more likely to utilize the general medical system. The authors posited that bilingual Filipinos are more familiar with both Western and traditional Asian sectors of care and have access to formal systems of care without having to worry about language barriers. Furthermore, seeking help from family and friends would ultimately expose their families to shame. Consequently, it is easier to hide their problems by seeking outside assistance [62].

The concept of "face" may also be linked to the internalized model minority myth. This myth is the societal perception that Asian Americans have achieved the American dream that hard work leads to success. Those who have internalized this myth may not seek professional help for fear of losing face, stigmatizing their family, and failing to live up to the attainable dream. In a study with 106 Asian American college students, those who scored higher on measures of internalizing the model minority myth had less favorable help-seeking attitudes [308]. Those who adhered to internalized model minority were more likely to value emotional self-control as opposed to seeking outside help [308].

Help-seeking is a complex social phenomenon. It is not simply a rational decision whereby individuals respond to a given personal problem, evaluate their resources and options, and then make a decision [88]. Rather, help-seeking is embedded within a larger sociocultural context including a host of factors ranging from personal variables (e.g., religiosity) to family variables (e.g., perception of loss of face), environmental (e.g., lack of culturally sensitive services, transportation issues, finance/cost, insurance status, etc.) and structural variables (e.g., racism and discrimination).

Asian Americans and immigrants have traditionally been an invisible group in relation to studies on health. This invisibility stems from several factors. First, care frequently takes place within families and communities. In part, this stems from a collectivistic orientation and general reluctance to seek outside help in order to keep private matters within the family. Second, national data examining health conditions pool or aggregate findings of ethnic minorities; that is, the data is not analyzed by specific ethnic subgroups [173]. The National Center for Health Statistics, for example, reported that the incidence of breast cancer among minority women are lower than White women, and one might conclude from this statement that this holds true for all ethnic minority women, which is not necessarily the case [173]. Even when data are analyzed for specific ethnic groups, it is not broken down into their subgroups. Therefore, it is not possible to extrapolate incidences and risk factors for specific Asian subgroups in most health data [61].

Yet, it is imperative to specifically focus on the health needs of Asian Americans and immigrants. This group is less likely to have a primary care provider compared with White Americans (68% compared with 77%), with level of acculturation a predictor of using a usual care provider [55]. Specifically, lower levels of acculturation (as measured by proficiency of English and length of time in the United States) were predictive of both Asian and White Americans not having a health provider for consistent care and seeking usual care in the emergency department. This was reinforced by a 2019 study that found the likelihood of seeking help decreased twofold in those without a usual place of care and fivefold in those with communication issues in healthcare settings [401].

Variations in acculturation and foreign-born status also significantly impact health concerns. Immigrants who enter the United States can potentially bring illnesses native to their homeland; acculturative stress can exacerbate pre-existing conditions and/or trigger illnesses and vulnerability to new diseases can be heightened [44]. Tuberculosis (TB), for example, is disproportionately high in foreign populations in the United States and Canada [270]. This is complicated by a general reluctance to seek medical attention due to language issues, traditional health beliefs and practices being incongruent with Western medicine, and lack of insurance [44]. Asian Americans, Native Hawaiians, and Pacific Islanders are more likely to be uninsured compared with non-Hispanic White individuals [271]. Much of this is due to the fact that they tend to be employed in small businesses that do not offer health insurance.

There are also erroneous health beliefs that could place groups at risk. In the past, prior to increased community education about human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), some Asian American groups believed that HIV was a culturally foreign disease and that they were genetically immune to it [44]. It will not be possible to cover every medical condition and examine every Asian group. Instead, this section is meant to provide an overview, which will hopefully stimulate readers to do more in-depth study.

Over the last decade, diabetes and the issue of obesity, particularly among children, have been much publicized in educational awareness campaigns. In general, Asian Americans and immigrants tend to have lower body mass index (BMI) [402]. For example, non-Hispanic White Americans are 60% more likely to be obese than their Asian American counterparts [402]. Therefore, one might speculate that this population has lower rates of diabetes, but it is important to consider within-group diversity among Asian Americans. While Asian Americans overall are less likely to be obese, some subpopulations (e.g., Filipinos) are more likely to be obese [402].

The prevalence rate of diagnosed diabetes among Asian Americans was 11.2% in 2013–2016; the rate among White Americans was 9.4% [403]. Some subgroups, such as Native Hawaiians and Japanese Americans, are two times more likely to have diabetes compared with their White counterparts [272]. Among Cambodian refugees, the rate of diabetes is more than twice the national average (27.6% vs. 12.4%) [334]. In the Asian Indian population in the United States, type 2 diabetes prevalence rates range from 17.4% to 29% [335].

According to the Racial and Ethnic Approaches to Community Health (REACH) Risk Factor Survey data, the prevalence of diabetes is 19% among Asian Indians, 10.8% among Koreans, and 9.3% among Chinese [41]. In general, Asian Americans have poor diabetes management practices compared to other groups (e.g., less likely to do weekly self-glucose checks). Korean Americans were less likely to have had a physical exam within the last year compared with Chinese and Asian Indian Americans [41].

There also seems to be an intergenerational effect of diabetes. Second- and third-generation Japanese Americans, for example, have higher prevalence of diabetes compared with their counterparts residing in Japan [75]. It is possible that as immigrants become more westernized, they also adopt a more sedentary lifestyle and consume foods higher in fat [75]. However, in another study, acculturation was positively correlated with reaching blood glucose level goals among Asian Americans [404]. In a study using data from the National Health Interview Survey, researchers found that Asian Indians in the United States had lower BMIs than non-Hispanic Whites, but that they were also less physically active [220]. However, Asian Indians have a higher likelihood of becoming diabetic despite their lower rates of obesity compared to their non-Hispanic White counterparts [220].

Risks of coronary heart and cardiovascular diseases have become a pressing issue in many developing countries. In 2015, there were an estimated 422 million cases of cardiovascular disease worldwide, and one-third of all deaths were attributed to cardiovascular disease [405]. Countries in South Asia represent at least one-quarter of developing countries worldwide, and among all Asian subgroups, Asian Indian immigrants and those born in the United States reported the highest rates of ischemic disease [52,68]. Smoking is a risk factor for all groups, and it is actually lower among South Asian Indians compared to their European counterparts [68]. Yet, because tobacco is used for both smoking and chewing in South Asia, many public health advocates maintain the importance of education that teaches the adverse effects of smoking and chewing tobacco and their correlation to cardiovascular conditions [129]. Socioeconomic status also appears to be a risk factor for South Asian Indians. In a study conducted in a semi-urban area in India examining the role of social class and coronary heart disease, Reddy, Rao, and Reddy found that as social class increased so did levels of sedentary life styles, cholesterol, hypertension, and obesity, all of which are risk factors for coronary heart disease [148]. There is also data that shows that Asian Indians tend to have lower high-density lipoprotein (HDL) cholesterol and high triglyceride levels [68]. Others have concluded that coronary heart disease may also be genetically influenced [129]. Unfortunately, it is not yet clear which risk factors significantly contribute to this disease among Asian Indians. There is some indication that psychosocial risk factors may heighten Asian Indians' vulnerability to cardiovascular issues. In the United Kingdom, Asian Indians have higher coronary heart disease mortality compared to White Europeans [221]. A study of 105 Asian Indian men in the United Kingdom found that, compared to White Europeans, Asian Indians experienced more chronic stress in the areas of work, finances, and residential overcrowding. Findings also showed that these stressors were not necessarily buffered by social support, despite the common myth that large extended family structures serve as that social support [221].

According to the Office of Minority Health, Asian Americans are 50% less likely to die from heart disease compared with White Americans [406]. However, specific Asian American subgroups are affected disproportionately. According to 2009 data, Native Hawaiians and Pacific Islanders are three times more likely to be diagnosed with coronary heart disease than their non-Hispanic White counterparts [273]. Filipino Americans are one of the highest risk groups among Asian Americans for hypertension [223]. South Asians are also at high risk of cardiovascular disease in part because of the increased prevalence of risk factors, such as hypertension, high cholesterol, diabetes, and hyperglycemia [407]. In California, Filipino Americans had a prevalence rate of 26.6% for hypertension, compared to 24.4% for Whites, and Filipino Americans are the ethnic group at greatest risk for hypertension following African Americans [223]. In a study of Filipino Americans in Philadelphia, 67.5% self-reported high blood pressure and 57.1% reported high cholesterol levels [336]. Cambodian refugees also have high rates of hypertension compared with national averages (47.9% vs. 20%) [334]. Experienced trauma and acculturative stress may contribute to the risk of hypertension. The risk of hemorrhagic stroke is higher in every Asian American subgroup compared to non-Hispanic White Americans [52]. There is also some evidence that immigrants' longer residence in the United States increases the odds for obesity and hyperlipidemia (high cholesterol) [274]. This trend seemingly applies to Chinese Australian immigrants as well. A study found that those who immigrated to Australia before 18 years of age were more likely to experience cardiovascular disease, obesity, and diabetes than those who immigrated later in life [337].

There are some trends indicating a decrease in physical activity among Asian Americans, with 32.4% reporting no physical activity in 2015–2016, compared with 21.5% in 2011–2012 [408]. In some cases, cultural factors may impede physical activity. For example, South Asian immigrants may view exercise as leisure activity—as putting oneself first over the family unit and their needs [407]. Cultural norms regarding modesty and going out alone may further hinder some immigrant women from engaging in physical activity outside the home [407].

Cancer is a dreaded disease regardless of an individual's cultural background. However, culture does shape the meaning of the diagnosis, help-seeking patterns, and coping strategies. In general, Asian Americans have the lowest rate of cancers (3.9 per 100,000 population) compared with other racial groups (e.g., 9.9 per 100,000 population among White Americans) [417]. However, it remains the leading cause of death for this group in part due to disparities in seeking preventive care [280]. In 2016, there were 57,740 new cancer cases among Asian Americans, Native Hawaiians, and Pacific Islanders in the United States [344]. Asian and Pacific Islander men are 50% less likely to have prostate cancer but are twice as likely as their non-Hispanic White counterparts to have stomach cancer [417]. Asian American men are 1.7 times more likely than White men to die from liver cancer [417]. Liver cancer accounted for 22% of cancer deaths among Vietnamese-American men [345]. In the Filipino community, colorectal cancer is the leading cause of cancer death. Mortality rates from liver and stomach cancers are also high in this population [346]. Hmong have the highest cancer rates even compared with their Asian American counterparts; specifically, they have the highest incidence of cancers of the liver, stomach, pancreas, and nasopharynx compared to all races [281]. This trend was reproduced in a study that compared adjusted cancer rates for Hmong residents of Minnesota to the general population in Minnesota [347].

In general, Asian American women are more likely to survive cervical cancer compared with their White counterparts, with the exception of Korean and Japanese American women [348]. However, Asian American women tend to avoid screenings and be diagnosed at an older age. Possible barriers to help seeking include low English proficiency, preference for health providers from the same ethnic group, adherence to a cultural value of modesty, and a general mistrust of Western health systems [281].

Overall, Asian and Pacific Islander women are 30% less likely to have breast cancer than non-Hispanic White women [230]. However, Asian immigrant women who have lived in the United States for more than half of their lives are three times more likely to be diagnosed with breast cancer than those born in the United States [418]. A landmark study of Asian Americans in California found that Asian American women (except Japanese women) had experienced an increase in breast cancer diagnoses, with Korean women experiencing the largest increase [349]. Breast cancer also accounts for about 19.5% of all cancer deaths among Asian Indian women and Filipino women [345].

In a study of 196 Korean American women, 54% had obtained a mammogram in the past two years. Women who reported knowing where to get a mammogram, having a regular doctor, and greater trust in healthcare providers and healthcare system were more likely to adhere to breast cancer screening recommendations [350]. In a study of Asian American college women, women who were sexually active were nine times more likely to have had a clinical breast examination than non-sexually experienced women [232]. The researchers speculate that Asian college women who are sexually active are more likely to visit a gynecologist and therefore will receive such screenings. In addition, culturally appropriate education material about mammograms should be developed and should target Asian women and their spouses and family members, who can be influential in supporting healthy behaviors [107].

Illness is not just an event; it also encompasses the client's/patient's subjective experience, cultural beliefs, and expectations regarding the illness. The term "illness" is different from "disease," as the term "illness" refers to the client's/patient's subjective experience of the disease and its effects on different arenas of his/her life [177]. The biomedical model usually does not focus on the client's/patient's expressions of the illness concept and how culture might impact disease presentation [47]. Level of acculturation, education, and socioeconomic class also influence illness beliefs [47]. Baki-Miri, Gogi, and Baki observe that there are three major categories for health belief systems regarding etiology of illnesses: occult, holistic, and scientific traditions [283].

Communication, the process of sending a message from one party to another, consists of both verbal and nonverbal components. Verbal and nonverbal communications are embedded within the culture of the parties disseminating the information and within the culture of the parties receiving the information. Communication is complex and multilayered because it involves unstated, implicit rules about a variety of factors, including physical distance between parties, tone of voice, acceptable topics of discussion, physical contact, and amount of eye contact [132]. Each of these variables is influenced by the perception of the level of formality/informality of the situation. Frequently, misunderstandings occur because the decoding and interpretation of these nonverbal cues are not accurate.

The verbal component of communication is just as complicated. Certainly, similarity in language shared by both parties enhances communication, but assuming that both parties in a conversation speak the same language, how the information is interpreted is still influenced by a host of factors. Linguists have posited that approximately 14,000 different meanings and interpretations can be extracted from the 500 most common English words [33]. Consequently, practitioners must be aware of the different communication styles held by diverse ethnic minority clients/patients, as the clinical communication process is the primary vehicle by which problems and solutions are identified and conveyed [17].

Styles of communication can be classified from high- to low-context [154]. High-context cultures are those cultures that disseminate information relying on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties [33,421]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [132,154]. On the other hand, low-context cultures rely on verbal communication or what is explicitly stated in the conversation [33]. Consequently, low-context communicators listen with their ears and focus on what is being said [132,154,421]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islanders, Hispanics, Native Americans, and African Americans, are from high-context cultures [154]. A study of Asian American and White college students found that Asian American students reported using indirect styles of communication more frequently compared to their White counterparts [236]. The researchers also found a relationship between adhering to Asian cultural values of emotional self-control and higher usage of indirect communication styles among the Asian American students. Clearly, adherence to cultural values influences communication styles.

Communicators from high-context cultures generally display the following characteristics [33,132,237,421]:

On the other hand, low-context communicators can typically be described as [33,132,421]:

Understanding the distinctions between individuals who come from high- and low-context cultures can promote cultural sensitivity. However, it is vital that practitioners take heed of several words of caution. First, it is important not to assume that two individuals sharing the same culture (e.g., low-context culture) will automatically have a shared script for communicating. Second, it is important to not immediately classify an individual into a low- or high-context culture because of their ethnicity. A Chinese American man may not necessarily be a high-context communicator because he is Asian. A host of factors, such as level of acculturation, upbringing and socialization, education, and family immigration history, will all play a role in how one learns to communicate. Third, a major criticism of the discussion of low-/high-context cultures is that they reinforce dualism and ultimately oversimplify the complexities and nuances of communication [113].

Some use the terms "passive" or "indirect" to describe the communication styles of persons from high-context cultures, but this connotes a deficit and should be avoided [353,354]. It is also important not to assume that Asian American clients/patients desire practitioners to communicate in the same ways that they do [355]. People often expect mental health and healthcare communication to be rooted in Western values and principles and for communication patterns to be consistent with these values [355].

Learning to communicate effectively also requires an understanding of how different conversational traits influence the communication process, or how information is conveyed and interpreted. Again, the goal of this section is not to simply dichotomize individuals' conversational styles into categories, but rather to understand the factors that play a role in how someone makes a decision on how to communicate [132]. Readers should not merely stereotype Asians with certain conversational traits and assume these overarching observations apply to all Asians.

There are five different conversational traits: formality, intimacy, directness, acknowledgment, and tolerance of conflict [132]. Formality involves the degree of hierarchy acknowledged in the relationship during the communication. For example, are titles employed? Who is addressed first? Most high-context cultures are influenced by the social status and the expertise of the person. The background of the person informs perception of authority and hierarchy [421]. Furthermore, most Asian groups are patriarchal and hierarchal. For example, in Chinese, Korean, Cambodian, and Japanese cultures, men and elders are placed on the top of the authority structure. Therefore, when working with Asian American and immigrant individuals, particularly those who may be less acculturated, practitioners should convey authority, credibility, and legitimacy [104]. For example, when working with Hmong immigrants, practitioners should avoid using overly casual language because Hmong respect professionals and believe they deserve honor and deference [238]. Therefore, any unprofessional behavior on the part of the professional could jeopardize their credibility. Many Asian American or immigrant clients/patients come into counseling believing that the practitioner will quickly identify the problem and provide a solution [104]. When the practitioner does not do so, he/she loses legitimacy in the eyes of the client/patient. Therefore, the practitioner must overtly establish authority. Employing professional titles and displaying diplomas and professional licenses are some examples of overtly establishing legitimacy. Furthermore, by obtaining sufficient information about the client/patient and family, and offering some explanation to the cause of the client's/patient's problems can assist in facilitating credibility. It may also be important to bring in family members, particularly an elder who is considered to be the authority figure, as a sign of respect.

Intimacy refers to the amount of personal information that is disclosed [132]. Asian Americans and immigrants generally believe that family matters are highly private. Therefore, discussions regarding certain health and mental health issues are strictly limited to the family system and should not be aired to the public. Directness refers to the extent the message or content is explicit without any assumption that the party receiving the communication will understand any hidden meanings. Asian cultures, as discussed, tend to be high-context cultures. Furthermore, Asian cultures tend to emphasize the prohibition of direct disclosures of emotional expression [104]. As a result, Asian clients/patients may not have the skills to discuss problems and to express themselves openly. The practitioner will have to learn to become attuned to indirect forms of communication.

Acknowledgment and tolerance of conflict is another conversational trait [132]. It refers to the extent to which conflict is openly dealt with and the extent to which one is comfortable with conflict. Asian cultures emphasize harmony, which is an underlying value influencing much of the belief systems. The yin/yang theory is not only applied to health, but also personal relationships. It promotes the notion that when harmony is at the heart of all relationships and different components of one's social environment, personal development, satisfaction, and growth are the end results [36]. Consequently, Asians tend to avoid conflict and any self-expressions that are confrontational [36].

As long as there are two parties involved in a conversation, nonverbal communication is inevitable, and it becomes salient particularly when it is processed from one culture to another. Nonverbal communication is any behavior (including gestures, posture, eye contact, facial expressions, and body positions) that transcends verbal or written forms of communication [71]. Nonverbal communication can enhance or reinforce what is said verbally, and conversely, it can completely contradict the message communicated verbally. It can also end up replacing what was verbally communicated if both parties do not share a native language [103].

In Western culture, communication is more direct and eye contact is highly valued. When eye contact is not maintained, many Westerners assume that the party is hiding pertinent information. However, in some cultures, including Asian cultures, reducing eye contact is a sign of respect [17]. In Asian culture, the practitioner is viewed as an authority figure, and avoiding eye contact is a symbol of respect, not dishonesty or lack of confidence [36]. Conversely, clients may interpret direct and indirect gazes differently. For example, in one study, Japanese individuals tended to rate faces with a direct gaze as angry and less pleasant compared with Finnish participants [118].

The amount of social space or distance between two communicating parties is culturally charged as well. Depending upon the social context, Westerners tend to maintain a distance of about three feet, or an arm's length, in conversations [33]. In a public setting, where both parties are engaged in a neutral, nonpersonal topic, Westerners will feel encroached upon and uncomfortable if an individual maintains a closer conversational distance. However, in other cultures, such as Latino and Middle Eastern, a closer distance would be the norm [33]. Asians tend to prefer more space between the two conversational parties until they have developed a relationship. Chung recommends that in a clinical setting the practitioner allow Asian clients/patients to set the tone and social distance [36]. The practitioner can sit first and permit the client/patient to select where he/she wants to sit.

Gestures and touch are often used to reinforce or supplement communication. Interestingly, although different cultures may recognize gestures, how the gesture is interpreted will vary. For example, studies have shown that different cultural groups maintain they recognize 70% to 100% of gestures from other groups, but their accuracy rate in terms of interpretation was as low as 30% [33]. White Americans, for example, may touch a child's head to connote affection. However, in Thailand, this is interpreted as an insult [103]. Nodding one's head typically signals understanding and agreement in the United States [33]. However, in Asian culture, it is only an indication that one hears the speaker [33]. Therefore, it does not connote agreement, but to disagree is impolite and considered rude, and therefore, they will nod their head. Consequently, practitioners cannot assume that an Asian client/patient agrees to something by a nod of the head.

It is important to take into account the role of deference and hierarchy of the parties involved. For example, even the use of "yes" is embedded in a cultural context. Because respect and deference are highly valued cultural norms in Asian culture, Asian immigrant clients may say "yes" to a practitioner despite the fact that they may not agree with or even understand the practitioner. The "yes" statement may be an acknowledgement rather than a statement of agreement [238]. Some nonverbal communications, such as smiling, bowing, and silence, may be interpreted as acquiescence when in fact they are conveyances of respect and saving face [119]. Taking into account other individual(s) in the room or in the clinical encounter is also necessary. In Asian cultures, there is a distinct adherence to the hierarchical structure. If a practitioner poses a question to an individual who is subordinate (in power, age, etc.) to the other individual in the room, the person in the lower position may feel uncomfortable answering the question [249].

Cross-cultural communication is by no means simple, and there is no set of rules to merely abide by. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [132].

Practitioners may be categorized as either disease-centric or client/patient-centric [31]. Disease-centered practitioners are concerned with sign/symptom observation and, ultimately, diagnosis. On the other hand, client/patient-centered practitioners focus more on the client's/patient's experience of the illness, subjective descriptions, and personal beliefs [31]. Client/patient-centered practice involves culturally sensitive assessment. It allows practitioners to move assessment and practice away from a pathology-oriented model and instead acknowledge the complex transactions of the individual's movement within, among, and between various systems [25].

Practitioners who engage in culturally sensitive assessment nonjudgementally obtain information related to the client's/patient's cultural beliefs, overall perspective, and specific health beliefs [138]. They also allow the client to control the timing [137].

The goal is to avoid the tendency to misinterpret health concerns of ethnic minority patients. Panos and Panos have developed a qualitative culturally sensitive assessment process that focuses on several domains (Table 1) [138]. Each domain includes several questions a practitioner may address in order to ensure that he or she is providing culturally responsive care.

Alternatively, Kleinman suggests that the practitioner ask the client/patient what he or she thinks is the nature of the problem [96]. He highlights the following types of questions that may be posed to the client/patient [96]:

Similar to Kleinman's culturally sensitive assessment questions, Galanti has proposed the 4 Cs of Culture [356]:

Pachter proposed a dynamic model that involves several tiers and transactions, similar to Panos and Panos' model [135]. The first component of Pachter's model calls for the practitioner to take responsibility for cultural awareness and knowledge. The professional must be willing to acknowledge that he/she does not possess enough or adequate knowledge in health beliefs and practices among the different ethnic and cultural groups he/she comes in contact with. Reading and becoming familiar with medical anthropology is a good first step, and in the final section of this course, some useful resources will be provided.

The second component emphasizes the need for specifically tailored assessment [135]. Pachter advocates the notion that there is tremendous diversity within groups. For example, one cannot automatically assume that an Asian immigrant adheres to traditional beliefs. Often, there are many variables, such as level of acculturation, age at immigration, educational level, and socioeconomic status, that influence health ideologies. Finally, the third component involves a negotiation process between the client/patient and the professional [135]. The negotiation consists of a dialogue that involves a genuine respect of beliefs. The professional might recommend a combination of alternative and Western treatments.

Beckerman and Corbett further recommend that recently immigrated families be assessed for [208]:

Practitioners should seek to understand the sociopolitical context of the origin country [422]. A migration narrative is also recommended, whereby an individual provides a story of his or her migration history. Asking about how long the family has been in the United States, who immigrated first, who was left behind, and what support networks are lacking gives the practitioner an overview of the individual's present situation [239]. The theme of loss is very important to explore. Types of losses may include family and friends left behind, social status, social identity, financial resources, and familiarity [239]. For refugees and newly immigrated individuals and families, assessment of basic needs (e.g., food, housing, transportation) is necessary [422].

Culturally sensitive assessment involves a dynamic framework whereby the practitioner engages in a continual process of questioning. Similarly, culturally sensitive assessment entails recognizing that there are a host of factors that contribute to patients'/clients' multiple identities (e.g., race, gender, socioeconomic status, religion) [226]. The domains and related assessment questions are meant to provide an introduction to help practitioners recognize the range of dimensions, including physical, biological, social, and cultural factors, that affect Asian immigrants and their families.

Informed consent is now the backbone of Western bioethics; however, it was not an ethical mandate until 1957, when it was explicitly formalized in the Code of Ethics of the American Medical Association [120]. The Code of Ethics requires physicians and any helping professionals to communicate diagnoses, prognoses, courses of treatment or intervention, and alternative options in such a manner that is understood, so an informed decision regarding treatment can be made by the client/patient [120]. An individual's ability and prerogative to make one's own decision about treatment is now seen as a vital expression of autonomy and is a prerequisite to participation in treatment or interventions.

Autonomy, individualism, and self-determination are values that are highly important in Western societies, especially in the United States. Autonomy may be organized into two categories: first-order autonomy and second-order autonomy [69]. First-order autonomy is what is espoused and valued in Western cultures: self-determination and autonomy in decision-making. Second-order autonomy, however, is prevalent in collectivistic societies where decision-making is group-oriented and takes into account another decision-maker who is accorded authority and respect [69]. In many Asian cultures, particularly if the family system is based on a patriarchal authority system, a male elder or male family head who is regarded as the primary decision-maker is key in this process of informed consent [423]. Therefore, the Western ideal of autonomy will have different connotations in cultures in which paternalism is valued [240].

As described, the process of informed consent entails the explicit communication of information in order for the individual to make a decision. Again, Western cultures value explicit information, which is centered on American consumerism; believing in having choices and being able to exercise choices in purchases extends to health care. Western values also support the idea that the more information given is better. Therefore, there are underlying dominant norms about the amount and content of information as well as how it is conveyed [241,242]. Some cultures, for example, believe that language and information also shape reality [30]. In other words, explicit information, particularly if it is bad information, will affect the course of reality. The Japanese, for example, believe that it is important not to discuss terminal illnesses and death and dying. The Chinese believe that discussing illnesses will bring about bad fortune and bad luck, and such discussions ensure that illness will inevitably occur [120,185]. For some Asian patients, a direct statement conveying bad news (e.g., a very poor prognosis) may be construed as rude. Instead, a more indirect way using euphemisms is preferred. Yet, for many Americans, this would not be acceptable [241,242].

A signature is required on most Western informed consent forms to represent understanding and agreement on the part of the individual involved. This might be viewed as violation in social etiquette in some cultures. In some cultures (for example, Egypt), signatures are usually associated with major life events and legal matters. Therefore, requiring a signature outside these circumstances would imply a lack of trust, particularly when verbal consent has been given [146]. The traditional written consent forms may be replaced by oral consent, video or audio recordings, or even pictorial images [423]. Thumbprints may also be permissible in lieu of signatures. In a study of Muslim women, the researchers recorded the women's verbal consent and literate family members reviewed the consent form [357].

Some studies have explored the appropriateness of audio consent, particularly when institutional review boards require some form of consent. In India, audiovisual consent forms are now mandatory [358]. In one study, potential participants were given audio and written information about the study to review, and then they were invited to attend a meeting where the informed consent process was reviewed [140]. In an HIV prevention clinical trial in Tanzania, pictorial flipcharts were employed after having been developed in conjunction with community leaders and experts. The researchers recorded audio to provide information about the study and then invited participants to ask questions [143]. In a study of various delivery methods for obtaining informed consent, a slideshow with voiceover was the most effective in communicating the basic essence of the consent forms [359].

Consent forms often contain technical and legal jargon that may be overwhelming to the native English speaking individual, but can be much more daunting for immigrants who may not be English proficient or familiar with various legal concepts. It is important for professionals to recognize that some Asian immigrants may be reasonably fluent in English for day-to-day activities, but when they have to communicate about healthcare issues, they may not be able to communicate as comfortably in this arena [240]. It is incumbent upon the healthcare professional to determine if the client/patient has full understanding of presented options. For some Asian immigrants who have experienced political persecution in their homelands, asking for a signature on a consent form that contains foreign legal and technical terms can potentially place them at risk for secondary traumatization, as some were persecuted, tortured, and forced to sign documents in their homelands [184]. Undocumented immigrants may be fearful that if they do not consent to participate in a study they risk being deported. In this way, they can be viewed as a vulnerable population similar to incarcerated individuals [360].

This cultural dissonance can be a challenge to many general healthcare and mental health practitioners. Cultural experts are highly recommended for consultations to assist in the interpretation and navigation of the complex web of cultural interactions. Healthcare professionals must remember that the professional communication they are used to stems from a "medico-legal risk management" perspective, which is very foreign to those not from the dominant Western culture [241].

The Institute for Clinical Systems Improvement recommends that clinicians should follow the established best practices of utilizing professional medical interpreters when English is not a patient's first language or when there are gaps in understanding English.

(https://www.icsi.org/wp-content/uploads/2020/01/PalliativeCare_6th-Ed_2020_v2.pdf Last Accessed: November 8, 2021)

Strength of Recommendation/Level of Evidence: Low-Quality Evidence, Strong Recommendation

When there is an obvious disconnect in the communication process between the practitioner and client/patient due to the client's/patient's lack of proficiency in the English language, an interpreter is required. (In many cases, the terms "interpreting" and "translating" are used interchangeably, but interpreting is specifically associated with oral communication while translating refers to written text.) Frequently, this may be easier said than done, as there may be institutional or client/patient barriers. Depending upon the client's/patient's language, an interpreter may be difficult to locate. Or, an organization may not have the funds to bring in an interpreter. Also, bringing in an interpreter creates a triangular relationship with a host of communication dynamics that must be negotiated [17]. Many view interpreters merely as neutral individuals who communicate information back and forth. The most common belief about the role of the interpreter in healthcare settings is the "interpreter as a conduit" model, which views interpreters as machines or robots that remain in the background and merely relay information back and forth [243,247,424]. Many interpreters indicate that they are treated as voices representing both the professional and the patient [244]. They are often required to interpret without omission, revision, or addition [424]. Some interpreters feel they have to be invisible so that they reinforce the privacy of the provider-client/patient relationship [244].

Another perspective is that the interpreter is an active agent or co-diagnostician, negotiating between two cultures and assisting in promoting culturally competent communication and practice [81,244]. In a study with 27 healthcare interpreters, the participants summarized their work as "a complex mental and social activity that went beyond linguistic transformation and included deciphering body language, establishing trust with multiple stakeholders, and brokering cultural concepts and frameworks" [203]. As co-diagnosticians, interpreters determine what medical information is valuable, seek illness-related information outside of the providers questioning, and participate in the diagnostic process by identifying symptoms the provider may not have directly asked the client/patient about [244]. In this more active role, the interpreter's behavior is also influenced by a host of cultural variables such as gender, class, religion, educational differences, and power/authority perceptions of the client/patient [81]. In one study, some interpreters reported feeling that speaking out was part of their professional obligation to act as a cultural broker for the client [150]. The downside is that interpreters may overstep their roles [161]. Consequently, an intricate, triangular relationship develops between all three parties. Another factor affecting the communication process is the fact that many interpreters are not adequately trained in the art of interpretation in mental health and general health settings, as there are many technical and unfamiliar terms. An ideal interpreter goes beyond being merely proficient in the needed language/dialect [33]. Interpreters who are professionally trained have covered aspects of ethics, impartiality, accuracy, and completeness [70]. They are also well-versed in interpreting both the overt and latent content of information without changing any meanings and without interjecting their own biases and opinions [70]. Furthermore, knowledge about cross-cultural communication and all the subtle nuances of the dynamics of communicating in a mental health or general health setting is vital [33].

On the clients'/patients' side, they may be wary about utilizing interpreters for a host of reasons. They may find it difficult to express themselves through an interpreter [104]. If an interpreter is from the same community as the client/patient, the client/patient may have concerns about sharing private information with an individual who is known in the community and the extent to which the information disclosed would remain confidential. In some cases, raising the issue of obtaining an interpreter causes the client/patient to feel insulted that their language proficiency has been questioned. Finally, if an interpreter is from a conflicting ethnic group, the client/patient may refuse having interpreter services [17].

The ideal situation is to have a well-trained interpreter who is familiar with health and mental health concepts. However, this may not be realistic, as health and mental health settings are often underfunded. Consequently, different models of accessing interpreters have been utilized [104].