Influences of Family Relational Factors and Immigration Generation Status on Mental Health Service Utilization Among Asian Americans

Abstract

Drawing on data from the National Latino and Asian American Study, this article examines the influence of family relational factors, independently and jointly with immigration generation status, on past-year mental health service utilization among Asian Americans (N = 1,599). Findings revealed the important role of family relation in influencing the likelihood and type of Asian Americans’ mental health service use. Lower level of family cohesion and higher level of family conflict were associated with increased likelihood of service use. Results from multiple logistic regressions further indicated that generation status interacts with family relation in affecting service use. Specifically, effect of family cohesion on general health service use was modified by generation status among third- or later-generation Asian Americans. Practice implications and future research directions are discussed to better understand and address the mental health needs of this population.

Keywords

Asian Americans family relation immigration mental health service use

Introduction

Asian Americans represent the fastest growing minority group in the United States. Between 2000 and 2015, this population grew 72%, reaching more than 20 million (Pew Research Center, 2017). As the Asian American population burgeons, so will their mental health needs. Nationally, Asian Americans have been consistently found to significantly underutilize mental health services as compared with the non-Hispanic White population (K. M. Harris et al., 2005) and the general population (Abe-Kim et al., 2007; Kung, 2003, 2004). According to the 2018 National Survey on Drug Use and Health, Asian Americans (6.3%) use mental health services approximately two thirds less than do Whites (18.6%). Their rates of mental health service use were lowest among all racial or ethnic groups examined (Substance Abuse and Mental Health Services Administration, 2018). In addition to low utilization rate, the problem of Asian Americans’ mental health service use is also exemplified by greater likelihood of using informal human or alternative services (e.g., religious adviser or self-help group) or medical services (e.g., medical doctors or nurses), rather than using specialty mental health services (Abe-Kim et al., 2007; Chu et al., 2011). If, when, and from whom Asian Americans seek help can have profound and significant impact on their access to and quality of services, and, consequently, their mental health outcomes (Hwang et al., 2008). Therefore, a refined understanding of the factors influencing Asian Americans’ unique mental health service utilization pattern is crucial to the development of tailored approaches that address the ever-increasing mental health needs of this fast-growing population.

Conceptual Framework

This study is guided by Andersen’s Behavioral Model of Health Services Utilization (Andersen, 1995). Andersen’s model has been frequently applied to studies determining factors of health service use among diverse racial and ethnic groups. Andersen’s model states that health service use is affected by three major types of factors, including (a) predisposing factors which refer to individuals’ demographic and background characteristics, such as age, gender, race/ethnicity, and education; (b) enabling or impeding factors which explain differences in the resources available to the individual in their use of health services, such as income, insurance coverage, family relation, social support, and acculturation; and (c) need factors which include the actual and perceived problems that are in need of health services, such as number of medical conditions and self-perceived health status (Andersen, 1995).

Previous studies have identified various enabling factors that may promote, or because of absence of such factors may impede, Asian Americans’ service use, such as insurance coverage, English proficiency, and experience of discrimination (Guo et al., 2019; Snowden & Yamada, 2005; Wong et al., 2006). Given the centrality of family in Asian cultures, family relation, which is hypothesized as an enabling or impeding factor according to Andersen’s model, requires a thorough examination on its role in affecting Asian Americans’ mental health service use.

Family Relation and Mental Health Service Use

In Asian’s collectivist cultures, family is the most important unit. Asian’s family-oriented cultures lay the foundation of understanding the impact of family relation on mental health and service use among Asian Americans. Previous studies have found that family relation had positive effects to mental health. Specifically, strong family cohesion is found to have potential buffering effects to psychosocial stressors and is linked to reduced likelihood of psychological distress, depression, and suicide ideation (T. L. Harris & Molock, 2000; Meyerson et al., 2002; Ta et al., 2010), whereas higher level of family conflict leads to a significantly greater risk of attempting suicide (Cheng et al., 2010). The importance of family relation is salient for many Asian Americans, whose lives are highly dependent on the dynamic and resources of their families due to a host of factors such as cultural norms/values, economic challenges, and language barriers (Guo et al., 2019; Treas, 2008).

More importantly, family relation plays a critical yet delicate role in influencing Asian Americans’ service use. Some studies suggested that positive family relation may give rise to the use of mental health services by providing emotional (e.g., encouraging service use) and financial support, as well as other concrete assistance, such as providing transportation and bridging language barriers (Carpentier & White, 2002; Guo et al., 2019). Nevertheless, a counterargument upheld that cohesive family relation may instead impede Asian Americans from seeking professional help from outside of the family. Such tendency was tied to the fact that taking care of ill family members was viewed as the families’ responsibility in Asian cultures. As such, seeking help outside of family may be viewed as the family being unable or irresponsible to take care of the ill members, and thus, may embarrass the entire family unit. In addition, given the stigmatized perception of mental illness and service use in Asian cultures, cohesive families may be more reluctant to reveal the mental health needs of and seek mental health services for their family members, in the hope of keeping the pride and honor of the family, or “saving face” of the family (Ta et al., 2010). On the contrary, some studies reported that more conflictual family relation led to an increased likelihood of services (Abe-Kim et al., 2002), whereas others suggested vice versa (Keeley & Wiens, 2008). Such discrepancy in understanding indicates a need to examine the influence of family relation on mental health service use among Asian Americans.

Moreover, the twofold impact of family on Asian Americans’ mental health service use may be modified by immigration generation status. Compared with Asian immigrants, later generations tend to have a broader range of support and resources, and becoming less dependent on their families (Wierzbicki, 2004). In addition, succeeding generations are likely to be more familiar with and acculturated to Western conceptualization of mental health and service use, in relation to the first generations. Consequently, they tend to be less constrained by the stigma and shame associated with seeking professional help beyond the family, and more encouraging in service use (Abe-Kim et al., 2007; Ta et al., 2010). However, scant literature has examined the compounding effect of immigration generation status and family relation on Asian Americans’ service use. Due to the facts that approximately 60% of the U.S. Asian population are immigrants, and that greater family conflict and greater family cohesion has been found among immigrants, it is important to investigate if and how generation status may interact with family relation and jointly influence Asian Americans’ mental health service use (Lopez et al., 2017; Walton & Takeuchi, 2010).

Furthermore, the scant studies that examined family relation and generation status have focused primarily on the use of specialty mental health services, or the overall use of any type of mental health–related services (Chang et al., 2013; Ta et al., 2010). Given the stigma and shame associated with seeking specialty mental health care, it is critical to understand the role of family relation and generation status on Asian Americans’ use of other treatment options, such as general health services and alternative services, rather than overgeneralizing by looking at overall usage or focusing on specialty service usage only. A clear understanding of how family relation and generation status may affect each type of mental health services is warranted as it will provide practical information that aids to the planning and delivery of services to best meet the needs of this population.

The Current Study

In light of the literature gaps, this study will enrich extant understanding on the influence of family cohesion and family conflict on Asian Americans’ mental health service utilization. This study also investigates the joint effect of immigration generation status together with family relational factors on the likelihood and pattern of mental health service utilization among Asian Americans.

Specifically, it is hypothesized that a higher level of family cohesion would be associated with less use of mental health services, whereas a higher level of family conflict would likely result in greater mental health service utilization. It is also hypothesized that immigration generation status would interact with family relation and jointly affect mental health service use among Asian Americans. However, given limited existing research, no hypotheses were formed regarding which specific types of mental health service use may be associated with family relation, or the joint effect of family relation and generation status.

Method

Data and Sample

The present study featured secondary data analysis using data derived from the National Latino and Asian American Study (NLAAS, 2002–2003; Alegría & Takeuchi). Up to 2019, NLAAS has been the most comprehensive study that provides national information on mental illness and service use of Latinos and Asian Americans (Alegría et al., 2004). The study design and sampling procedure of NLAAS have been previously documented in great detail. The NLAAS full sample consisted of a total of 4,649 respondents, including 2,554 Latino- and 2,095 Asian Americans (Alegría et al., 2004; Heeringa et al., 2004).

The analysis conducted for the present study was restricted to Asian Americans whose ages were 18 or older and were from three specific ethnic groups: Vietnamese, Filipino, and Chinese. Respondents identified as “Other Asians” were excluded in the present data analyses due to small sample size of each ethnic subgroup and heterogeneity among subgroups. In addition, 29 respondents were omitted from the analysis due to missing information in key variables. The final sample size of the present study was N = 1,599 (53.1% female; M_age = 42.11, SD = 14.94), consisting of 510 Vietnamese, 503 Filipino, and 586 Chinese, respectively. This secondary data analysis was performed in compliance with the university institutional review board.

Measures

Dependent variable

The dependent variables in the present study were past-year service provider use. Past-year service provider was assessed by asking respondents if they went to see [provider on list] for problems with their “emotions, nerves, or use of alcohol or drugs” from a list of service providers within the past 12 months. Three types of services were constructed in the study: (a) specialty mental health care provider, including psychiatrists, psychologists, or social workers or counselors seen in medical settings; (b) general medical care provider, such as medical doctors, non-MD health care practitioners, or nurses; and (c) human or alternative service providers, including social workers or counselors seen at nonmedical settings, religious or spiritual advisers, healers, self-help groups, and online support groups. Moreover, to obtain detailed information on family relational factors’ influence on the overall use of mental health services, this study also examined “any mental health–related service use,” which was defined as using any services that represented any of the aforementioned service providers within the past 12 months.

The final dependent variables were four binary variables, including specialty mental health service use, general medical service use, human or alternative service use, and any mental health–related service use. For each of the four binary variables, service use was coded 0 if respondent did not have any use of the corresponding type of service within the past 12 months, otherwise coded as 1 if the service was used at least once.

Family cohesion

Family cohesion was assessed using the 10-item Likert-type family cohesion scale (Olson, 1986). Examples of family cohesion included family members respect one another, share similar values and beliefs as a family, feel loyal to and proud of family, and like to spend time with each other. Responses ranged from 1 (strongly agree) to 4 (strongly disagree). Responses were reverse coded. Sum of scores in this scale ranged from 10 to 40, with higher sum indicating higher level of family cohesion. This measure has excellent reliability (α = .928).

Family conflict

Family conflict was assessed using a 5-item Likert-type family conflict scale (Alegría et al., 2004). Respondents were asked to use a 3-point scale to assess the frequency of family conflict that occurred. Examples of family conflict included having arguments with family members because of different customs, feeling lonely and isolated due to lack of family unity, and feeling being too close to family interferes own goals. Responses ranged from 1 (hardly ever) to 3 (often). Sum of scores in this scale ranged from 5 to 15, with higher scores indicative of greater frequency of family conflict (α = .766).

Immigration generation status

Immigration generation status was assessed by asking the nativity status of respondents. Responses were divided into three categories: first generation (i.e., respondents were born outside the United States), second generation (i.e., respondents were born in the United States and had at least one parent who was an immigrant), and third or later generation (i.e., respondents and both of his or her parents were all born in the United States).

Covariates

Covariates in this study included (a) any past-year psychiatric disorder diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994). Responses were coded as 0 (no) if respondents were not diagnosed with any DSM-IV disorders within the past 12 months. Otherwise, the response was coded as 1 (yes); and (b) self-reported mental health which was assessed with one question “How would you rate your overall mental health?” Responses were separated into five groups: excellent, very good, good, fair, and poor (Alegría et al., 2004). Demographic variables controlled in the present study included gender (female/male), age (18–34, 35–49, 50–64, and 65 years or above), work status (employed, unemployed, and not in labor force), marital status (married/cohabiting, previously married, and never married), education (less than 11, 12, 13–15, and 16 years or above), ethnicity (Vietnamese-, Filipino-, and Chinese-Americans), household income (less than US$15,000, US$15,000–US$34,999, US$35,000–US$74,999, and no less than US$75,000), and English proficiency (poor/fair, and good/excellent).

Procedures

Data analysis of the current study consisted of three steps. First, a descriptive analysis was run to provide the demographic characteristics of the three ethnic subgroups, and the total Asian American sample in the study. Chi-square or analysis of variance (ANOVA) tests were performed to examine differences across the three ethnic subgroups. Second, a set of bivariate analyses was conducted using SPSS to examine the association between past-year service provider use and each explanatory variable. Third, a series of multiple logistic regression analyses were performed to estimate the effects of family cohesion and family conflict, respectively, to each type of past-year service provider use, adjusting for covariates. In this step, if generation status was found significant in the first set of multivariate models, interactions between family cohesion/family conflict and generation status would be added into the second set of multivariate models.

Results

Descriptive Analysis

Table 1 presents descriptive statistics of the demographics of the three ethnic subgroups (Vietnamese-, Filipino-, and Chinese-Americans) and the total Asian American sample. In brief, for the total Asian American sample, most were female, less than 50 years old, employed, married or cohabiting, with good or excellent English proficiency, having at least high school diploma, and with household income no less than US$35,000. The mean score of family cohesion was 36.83 (SD = 4.66), indicating a relatively high level of family cohesion among the total Asian American sample. The mean of family conflict was 6.42 (SD = 1.82), suggesting a relatively low level of family conflict.

Table 1.

Sample Description of Three Ethnic Subgroups and the Total Asian American Sample (Weighted %, N = 1,599).

		Asian ethnic subgroups
Demographic variables	Total Asian (N = 1,599)	Vietnamese (n = 510)	Filipinos (n = 503)	Chinese (n = 586)	p
Demographic variables	%/M (SD)	%/M (SD)	%/M (SD)	%/M (SD)
Gender					.95
Male	46.9	47.1	46.3	47.3
Female	53.1	52.9	53.7	52.7
Age					.17
18–34	34.8	31.0	37.8	35.5
35–49	35.5	36.3	32.6	37.4
50–64	21.3	23.1	20.7	20.1
≥65	8.4	9.6	8.9	7.0
Work status					.07
Employed	66.5	63.1	67.6	68.4
Not employed	7.2	9.8	5.8	6.1
Not in labor force	26.3	27.1	26.6	25.4
Marital status					.22
Married/cohabiting	70.4	74.1	68.4	68.9
Previously married	8.9	7.1	9.5	9.9
Never married	20.7	18.8	22.1	21.2
English proficiency					<.001
Poor or fair	43.9	70.4	17.7	43.3
Good or excellent	56.1	29.6	82.3	56.7
Education (years)					<.001
0–11	17.4	28.8	10.1	13.7
12	18.8	22.2	19.1	15.5
13–15	25.6	25.1	33.2	19.6
≥16	38.2	23.9	37.6	51.2
Household income (US$)					<.001
<15,000	18.8	25.7	12.3	18.3
15,000–34,999	15.9	22.7	11.3	13.8
35,000–74,999	25.5	25.9	26.8	23.9
≥75,000	39.9	25.7	49.5	44.0
Generation status					<.001
First	88.6	98	81.7	86.3
Second	4.8	1.8	8.7	4.1
Third or later	6.6	0.2	9.5	9.6
Service use (yes)
Specialty	3.1	3.7	2.2	3.4	.33
General	2.8	3.1	2.8	2.4	.75
Human/Alternative	2.8	1.4	3.4	3.6	.06
Any related	6.8	6.7	6.8	7.0	.98
Family cohesion	36.83 (4.66)	37.93 (3.94)	36.95 (4.36)	35.76 (5.23)	<.001
Family conflict	6.42 (1.82)	6.14 (1.73)	6.60 (1.88)	6.51 (1.82)	<.001

Sociodemographic characteristics in the three ethnic subgroups were similar as those of the total Asian American sample in regard of gender, age group, work status, and marital status. Significant differences existed in English proficiency, education, household income, and generation status at p < .001 level among the three ethnic subgroups. Vietnamese reported the lowest English proficiency, whereas Filipinos rated their English proficiency best. In addition, the majority of Chinese respondents (51.2%) held at least college degree, whereas only 23.9% of Vietnamese respondents and 37.6% of Filipino respondents had same level of education attainment. Moreover, 49.5% of Filipinos and 44.0% of Chinese reported high yearly household income (no less than $75,000), whereas only 25.7% of Vietnamese made comparable income. With regard to generation status, Vietnamese reported higher percentage of first generation (98%), as compared with Filipinos (81.7%) and Chinese (86.3%). As for family relation, with significant group differences found in family cohesion (F(2, 1,596) = 30.71, p < .001), Vietnamese reported the highest score of family cohesion (M = 37.93, SD = 3.94), whereas Chinese reported the lowest (M = 35.76, SD = 5.23). Significant group differences were also observed in family conflict scores (F(2, 1,596) = 9.47, p < .001). Filipinos reported the highest level of family conflict (M = 6.60, SD = 1.88), whereas Vietnamese reported the lowest (M = 6.14, SD = 1.73).

Bivariate Analysis

Bivariate analyses were conducted for each type of mental health service provider use. Family cohesion was found to have significant negative association with past-year use of each and any type of mental health–related services. Specifically, each 1-point increase in family cohesion lowered respondents’ odds ratio (OR) of receiving specialty mental health services (OR = 0.93, p < .01), general health services (OR = 0.90, p < .001), human or alternative services (OR = 0.90, p < .001), and any type of mental health–related services (OR = 0.91, p < .001).

Family conflict was also found as a significant predictor of mental health–related service use. The ORs of the receipt of treatment with a 1-point increment of family conflict were OR = 1.24 (p < .01) for specialty mental health services, OR = 1.38 (p < .001) for general health services, OR = 1.36 (p < .001) for human or alternative services, and OR = 1.36 (p < .001) for the use of any type of mental health–related services, respectively. In other words, higher level of family conflict would increase the likelihood of mental health service use among Asian Americans.

Generation status also emerged as a significant predictor of mental health service use. As compared with their first-generation counterparts, third generation or later demonstrated higher odds of using each and all types of mental health services, whereas second-generation participants were more likely to use general health services and any type of mental health–related services only.

Multivariate Analysis

A set of multiple logistic regression analyses were conducted to test the effects of family cohesion and family conflict, respectively, to each type of past-year service provider use, adjusting for covariates. The second set of logistic regression further includes the interaction term between family cohesion/family conflict and generation status, if corresponding statistical significance is found in the first set of multivariate models.

Table 2 presents results from two multiple logistic regression models performed to estimate the effects of family cohesion and family conflict, respectively, to the use of specialty mental health services. Multiple logistic regression models revealed that neither family cohesion nor family conflict was significant in influencing Asian Americans’ specialty mental health service use, controlling for covariates. Given that generation status was also not found significant in the models, no interaction effect between generation status and family cohesion/family conflict was tested for past-year use of specialty mental health services.

Table 2.

Multiple Logistic Regression Results for Past-Year Use of Specialty Mental Health Services.

Variables	Model 1	Model 2
Variables	OR (95% CI)	OR (95% CI)
Gender (Female)
Male	1.04 (0.56, 1.93)	1.04 (0.56, 1.93)
Age group (18–34)
35–49	0.67 (0.28, 1.62)	0.71 (0.30, 1.68)
50–64	1.13 (0.44, 2.92)	1.15 (0.44, 2.97)
≥65	0.77 (0.21, 2.79)	0.78 (0.22, 2.82)
Work status (Employed)
Unemployed	0.52 (0.13, 2.03)	0.55 (0.15, 2.10)
Not in labor force	2.06 (1.01, 4.21)*	2.06 (1.01, 4.19)*
Marital status (Married/cohabiting)
Previously married	2.57 (1.05, 6.25)*	2.64 (1.09, 6.37)*
Never married	1.33 (0.57, 3.15)	1.39 (0.60, 3.26)
Education (0–11 years)
12 years	0.99 (0.36, 2.72)	0.97 (0.35, 2.68)
13–15 years	0.60 (0.20, 1.76)	0.60 (0.20, 1.76)
≥16 years	0.81 (0.28, 2.34)	0.82 (0.28, 2.35)
Household income (<15,000)
15,000–34,999	0.46 (0.16, 1.34)	0.46 (0.16, 1.33)
35,000–74,999	0.78 (0.33, 1.84)	0.75 (0.32, 1.77)
≥75,000	0.79 (0.33, 1.91)	0.76 (0.32, 1.84)
English proficiency (Good or excellent)
Poor or fair	0.64 (0.28, 1.46)	0.63 (0.28, 1.45)
Ethnicity (Chinese)
Vietnamese	1.86 (0.85, 4.03)	1.83 (0.85, 3.95)
Filipinos	0.58 (0.25, 1.30)	0.56 (0.25, 1.27)
Generation status (First generation)
Second	1.75 (0.53, 5.73)	1.80 (0.55, 5.93)
Third or later	2.53 (0.98, 6.53)	2.52 (0.97, 6.52)
DSM-IV disorder in past 12-month (No)
Yes	8.00 (4.17, 15.36)***	7.54 (3.86, 14.76)***
Family Cohesion	0.98 (0.93, 1.03)
Family Cohesion × Generation Status (First generation)
Second
Third or later
Family conflict		1.08 (0.95, 1.24)
Family Conflict × Generation Status (First generation)
Second
Third or later

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; OR = odds ratio; CI = confidence interval.

p < .05. **p < .01. ***p < .001.

With regard to general health services, Model 3a presented in Table 3 revealed that family cohesion was a significant predictor. With each 1-point increase in family cohesion, the odds of using general health services for mental health problems decreased (OR = 0.93, p < .01). Moreover, generation status was also found significant in the use of general health services. Respondents who were second (OR = 3.28, p < .05) and third- or later-generations were more likely (OR = 3.84, p < .05) to use services than first-generation participants. It is also noteworthy that Vietnamese respondents were found to have greater odds to use general health services for mental health concerns, as compared with Chinese respondents (OR = 2.48, p < .05). As shown in Model 3b, interaction effect between family cohesion and generation status was significant (p < .05) among third- or later-generation Asian Americans in relation to their first-generation counterparts, adjusting for covariates.

Table 3.

Multiple Logistic Regression Results for Past-Year Use of General Health Services.

Variables	Model 3a	Model 3b	Model 4a	Model 4b
Variables	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Gender (Female)
Male	0.65 (0.33, 1.29)	0.58 (0.29, 1.18)	0.65 (0.33, 1.30)	0.66 (0.33, 1.33)
Age group (18–34)
35–49	1.16 (0.47, 2.89)	1.28 (0.51, 3.21)	1.34 (0.55, 3.30)	1.39 (0.56, 3.43)
50–64	1.44 (0.48, 4.31)	1.29 (0.42, 3.96)	1.52 (0.51, 4.57)	1.53 (0.50, 4.64)
≥65	2.42 (0.68, 8.64)	2.15 (0.59, 7.86)	2.48 (0.69, 8.87)	2.48 (0.69, 8.98)
Work status (Employed)
Unemployed	0.75 (0.18, 3.17)	0.84 (0.19, 3.76)	0.84 (0.21, 3.45)	0.85 (0.20, 3.58)
Not in labor force	2.57 (1.17, 5.63)*	3.10 (1.39, 6.93)**	2.59 (1.19, 5.66)*	2.77 (1.26, 6.10)*
Marital status (Married/cohabiting)
Previously married	1.60 (0.60, 4.25)	1.61 (0.61, 4.29)	1.89 (0.72, 4.93)	1.78 (0.68, 4.67)
Never married	1.75 (0.69, 4.45)	1.54 (0.59, 4.02)	2.05 (0.82, 5.13)	1.71 (0.66, 4.41)
Education (0–11 years)
12 years	1.14 (0.37, 3.53)	1.20 (0.39, 3.71)	1.10 (0.36, 3.39)	1.18 (0.38, 3.68)
13–15 years	1.17 (0.38, 3.58)	1.13 (0.36, 3.50)	1.17 (0.38, 3.59)	1.16 (0.37, 3.60)
≥16 years	1.29 (0.41, 4.07)	1.04 (0.32, 3.39)	1.37 (0.44, 4.28)	1.28 (0.40, 4.05)
Household income (<15,000)
15,000–34,999	0.66 (0.21, 2.07)	0.58 (0.18, 1.87)	0.64 (0.20. 2.00)	0.63 (0.20, 1.99)
35,000–74,999	1.25 (0.47, 3.32)	1.27 (0.48, 3.41)	1.06 (0.39, 2.83)	1.03 (0.38, 2.75)
≥75,000	1.75 (0.66, 4.64)	1.76 (0.66, 4.67)	1.56 (0.60, 4.10)	1.44 (0.54, 3.81)
English proficiency (Good or excellent)
Poor or fair	1.98 (0.80, 4.89)	1.88 (0.76, 4.66)	1.85 (0.76, 4.50)	1.75 (0.72, 4.28)
Ethnicity (Chinese)
Vietnamese	2.48 (1.01, 6.06)*	2.72 (1.09, 6.79)*	2.35 (0.97, 5.70)	2.30 (0.94, 5.60)
Filipinos	1.61 (0.67, 3.85)	1.69 (0.70, 4.08)	1.39 (0.59, 3.26)	1.26 (0.54, 2.96)
Generation status (First generation)
Second	3.28 (1.02, 10.50)*	1.28 (0.01, 134.25)	3.74 (1.17, 11.98)*	34.08 (1.47, 788.86)*
Third or later	3.84 (1.34, 10.96)*	.00 (0.00, 1.52)	3.92 (1.36, 11.34)*	44.19 (1.64, 1,190.24)*
DSM-IV disorder in past 12 months (No)
Yes	10.60 (5.33, 21.09)***	10.26 (5.08, 20.72)***	9.19 (4.52, 18.68)***	9.34 (4.60, 18.96)***
Family cohesion	0.93 (0.89, .98)**	0.90 (0.85, .96)**
Family Cohesion × Generation Status (First generation)
Second		1.03 (0.89, 1.18)
Third or later		1.40 (1.04, 1.87)*
Family conflict			1.21 (1.05, 1.38)**	1.31 (1.12, 1.53)**
Family Conflict × Generation Status (First generation)
Second				0.75 (0.49, 1.13)
Third or later				0.72 (0.46, 1.12)

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; OR = odds ratio; CI = confidence interval.

p < .05. **p < .01. ***p < .001.

Significant association was observed between family conflict and general health service use (p < .01) in Model 4a. Respondents’ likelihood of using general health services increased (OR = 1.21) as family conflict heightened. Adding interaction between family conflict and generation status to Model 4a, Model 4b, however, found no significant differences exist in the use of general health services.

As shown in Table 4, significant differences existed in past-year use of human or alternative services among generation status. Third- or later-generation Asian Americans were more likely to use human or alternative services, as compared with their first-generation counterparts with comparable family cohesion or family conflict scores (p < .05). With regard to family relation, family cohesion was found to have no significant impact to the use of human or alternative services, whereas family conflict was found a significant predictor to the use of human or alternative services. Specifically, the OR of family conflict was 1.17 (p < .05), indicating that higher level of family conflict increased the likelihood of using human or alternative services. After examining the interaction effect, however, neither family conflict nor generation status remained significant in predicting the use of human or alternative services. The interaction term was not significant either.

Table 4.

Multiple Logistic Regression Results for Past-Year Use of Human or Alternative Services.

Variables	Model 5a	Model 5b	Model 6a	Model 6b
Variables	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Gender (Female)
Male	0.41 (0.20, .84)*	0.40 (0.20, .82)*	0.41 (0.20, .84)*	0.41 (0.20, .85)*
Age group (18–34)
35–49	1.09 (0.47, 2.53)	1.12 (0.48, 2.62)	1.15 (0.50, 2.65)	1.08 (0.46, 2.52)
50–64	0.30 (0.06, 1.52)	0.28 (0.05, 1.43)	0.30 (0.06, 1.53)	0.30 (0.06, 1.51)
≥65	1.10 (0.23, 5.15)	1.06 (0.22, 5.01)	1.10 (0.23, 5.14)	1.09 (0.23, 5.14)
Work status (Employed)
Unemployed	1.47 (0.47, 4.57)	1.62 (0.52, 5.06)	1.56 (0.51, 4.77)	1.51 (0.50, 4.63)
Not in labor force	1.68 (0.78, 3.61)	1.75 (0.81 3.77)	1.70 (0.79, 3.63)	1.62 (0.74, 3.54)
Marital status (Married/cohabiting)
Previously married	1.73 (0.55, 5.52)	1.82 (0.58, 5.72)	1.92 (0.61, 6.03)	2.14 (0.66, 6.93)
Never married	3.09 (1.31, 7.32)*	3.03 (1.27, 7.24)*	3.30 (1.40, 7.77)**	3.96 (1.63, 9.62)**
Education (0–11 years)
12 years	0.83 (0.21, 3.30)	0.83 (0.21, 3.29)	0.82 (0.21, 3.26)	0.70 (0.17, 2.89)
13–15 years	0.99 (0.27, 3.62)	0.97 (0.27, 3.56)	0.96 (0.26, 3.55)	1.00 (0.27, 3.68)
≥16 years	.93 (0.25, 3.50)	.88 (0.23, 3.32)	.94 (0.25, 3.51)	1.00 (0.27, 3.70)
Household income (<15,000)
15,000–34,999	1.19 (0.41, 3.50)	1.13 (0.39, 3.31)	1.14 (0.39, 3.33)	1.09 (0.37, 3.24)
35,000–74,999	0.82 (0.28, 2.40)	0.79 (0.27, 2.32)	0.72 (0.25, 2.12)	0.68 (0.22, 2.08)
≥75,000	1.82 (0.69, 4.77)	1.76 (0.68, 4.60)	1.68 (0.65, 4.38)	1.81 (0.69, 4.76)
English proficiency (Good or excellent)
Poor or fair	0.87 (0.34, 2.18)	0.84 (0.33, 2.12)	0.84 (0.33, 2.10)	0.93 (0.36, 2.37)
Ethnicity (Chinese)
Vietnamese	0.71 (0.27, 1.87)	0.71 (0.27, 1.88)	0.68 (0.26, 1.81)	0.72 (0.27, 1.91)
Filipinos	1.04 (0.49, 2.21)	1.05 (0.49, 2.23)	0.97 (0.46, 2.05)	1.00 (0.47, 2.16)
Generation status (First generation)
Second	0.67 (0.14, 3.11)	0.83 (0.00, 222.98)	0.75 (0.16, 3.48)	0.00 (0.00, 14.35)
Third or later	2.95 (1.21, 7.23)*	0.25 (0.00, 23.12)	3.26 (1.32, 8.03)*	1.17 (0.06, 22.40)
DSM-IV disorder in past 12 months (No)
Yes	6.92 (3.53, 13.59)***	6.69 (3.39, 13.21)***	5.82 (2.87, 11.79)***	5.80 (2.80, 12.00)***
Family cohesion	0.96 (0.92, 1.01)	0.95 (0.90. 1.00)
Family Cohesion × Generation Status (First generation)
Second		0.99 (0.84, 1.18)
Third or later		1.07 (0.95, 1.22)
Family conflict			1.17 (1.01, 1.34)*	1.08 (0.92, 1.28)
Family Conflict × Generation Status (First generation)
Second				2.38 (0.90, 6.29)
Third or later				1.16 (0.78, 1.72)

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; OR = odds ratio; CI = confidence interval.

p < .05. **p < .01. ***p < .001.

As for past-year use of any type of mental health–related services, family cohesion was found significant (OR = 0.95, p < .05), indicating higher level of family cohesion reduced Asian Americans’ likelihood of service use. Generation status also emerged as a predictor. Third- or later-generation Asian Americans were found to have higher odds of using any type of mental health–related services (OR = 3.10, p < .01), in relation to the first generations. With regard to family conflict, respondents’ likelihood of using any type of mental health services increased (OR = 1.21, p < .001) with each 1-point increment in family conflict. Being second generation (OR = 2.30, p < .05) and third- or later-generation (OR = 3.34, p < .01) also was associated with heightened odds of using any type of mental health services. When taking the compound effect of family relation and generation status into consideration, however, the interaction effects were found to be not significant (Table 5).

Table 5.

Multiple Logistic Regression Results for Past-Year Use of Any Mental Health–Related Services.

Variables	Model 7a	Model 7b	Model 8a	Model 8b
Variables	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Gender (Female)
Male	0.66 (0.42, 1.04)	0.65 (0.41, 1.03)	0.67 (0.42, 1.05)	0.67 (0.42, 1.06)
Age group (18–34)
35–49	0.93 (0.51, 1.68)	0.94 (0.52, 1.70)	1.00 (0.55, 1.81)	1.00 (0.55, 1.81)
50–64	0.71 (0.34, 1.50)	0.70 (0.33, 1.49)	0.73 (0.34, 1.54)	0.73 (0.34, 1.54)
≥65	0.98 (0.40, 2.41)	0.98 (0.39, 2.43)	1.02 (0.41, 2.53)	1.01 (0.41, 2.53)
Work status (Employed)
Unemployed	0.80 (0.32, 1.97)	0.84 (0.34, 2.07)	0.85 (0.35, 2.07)	0.85 (0.35, 2.06)
Not in labor force	2.26 (1.35, 3.78)**	2.29 (1.37, 3.83)**	2.26 (1.35, 3.79)**	2.26 (1.35, 3.78)**
Marital status (Married/cohabiting)
Previously married	2.59 (1.33, 5.03)**	2.56 (1.32, 4.98)**	2.79 (1.45, 5.39)**	2.81 (1.45, 5.45)**
Never married	1.75 (0.96, 3.19)	1.70 (0.93, 3.12)	1.89 (1.03, 3.44)*	1.91 (1.04, 3.51)*
Education (0–11 years)
12 years	0.74 (0.35, 1.58)	0.75 (0.35, 1.60)	0.71(0.33, 1.53)	0.71 (0.33, 1.53)
13–15 years	0.65 (0.31, 1.36)	0.64 (0.30, 1.36)	0.64 (0.30, 1.35)	0.64 (0.30, 1.35)
≥16 years	0.98 (0.46, 2.05)	0.95 (0.45, 2.01)	0.98 (0.46, 2.06)	0.98 (0.46, 2.07)
Household income (<15,000)
15,000–34,999	0.74 (0.36, 1.54)	0.72 (0.34, 1.49)	0.71 (0.34, 1.47)	0.70 (0.34, 1.47)
35,000–74,999	1.07 (0.56, 2.04)	1.06 (0.56, 2.02)	0.98 (0.51, 1.87)	0.98 (0.51, 1.88)
≥75,000	1.21 (0.63, 2.33)	1.20 (0.62, 2.31)	1.11 (0.58, 2.15)	1.12 (0.58, 2.16)
English proficiency (Good or excellent)
Poor or fair	0.99 (0.55, 1.79)	0.98 (0.55, 1.78)	0.97 (0.54, 1.75)	0.98 (0.54, 1.77)
Ethnicity (Chinese)
Vietnamese	1.78 (1.00, 3.18)	1.82 (1.02, 3.28)*	1.73 (0.97, 3.09)	1.74 (0.97, 3.09)
Filipinos	1.08 (0.63, 1.87)	1.10 (0.63, 1.90)	1.00 (0.58, 1.73)	1.01 (0.58, 1.74)
Generation status (First generation)
Second	2.07 (0.91, 4.69)	.73 (0.01, 40.47)	2.30 (1.01, 5.24)*	1.75 (0.16, 19.23)
Third or later	3.10 (1.55, 6.19)**	.32 (0.01, 13.90)	3.34 (1.66, 6.73)**	2.99 (0.30, 29.64)
DSM-IV disorder in past 12 months (No)
Yes	8.35 (5.21, 13.40)***	8.16 (5.08, 13.12)***	7.12 (4.38, 11.57)***	7.10 (4.36, 11.57)***
Family Cohesion	0.95 (0.92, 99)*	0.94 (0.90, .98)**
Family Cohesion × Generation Status (First generation)
Second		1.03 (0.92, 1.16)
Third or later		1.07 (0.96, 1.18)
Family conflict			1.21 (1.10, 1.33)***	1.20 (1.08, 1.34)**
Family Conflict × Generation Status (First generation)
Second				1.04 (0.76, 1.41)
Third or later				1.02 (0.75, 1.38)

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; OR = odds ratio; CI = confidence interval.

p < .05. **p < .01. ***p < .001.

Conclusion and Discussions

The current study investigated the impact of family cohesion and family conflict to past-year use of specialty mental health services, general health services, human or alternative services, and overall, any type of mental health–related services in nationally representative sample of Asian Americans. Results of bivariate analyses indicated that family cohesion and family conflict were both significant predictors to the use of mental health services. As expected, participants reporting higher level of family cohesion were less likely, whereas participants with higher level of family conflict were more likely, to receive each and any type of mental health–related services.

After controlling for covariates, the effects of family cohesion and family conflict varied across each type of services. Family cohesion remained a significant predictor to the receipt of general health services and the overall use of any type of mental health–related services. Higher level of family cohesion is associated with lower likelihood of using general health services and any type of mental health–related services among Asian Americans. Taking immigration into consideration, interaction effect between family cohesion and generation status was found significant only in the use of general health services among third- or later-generation Asian Americans. Effect of family cohesion was modified by immigration generation status in influencing the use of general health services. The interaction effect of family cohesion and generation status on the receipt of general health services is more salient among third- or later-generation Asian Americans.

Family conflict, on the contrary, was found to have significant association with the use of each and any type of mental health–related services, with the only exception of specialty mental health services, after adjusting for all other covariates. Interaction effect between family conflict and generation status was not found statistically significant across each and any types of mental health services examined.

To sum up, findings of the present study are in line with previous studies in understanding the effects of family cohesion (Ta et al., 2010) and family conflict (Abe-Kim et al., 2002; Chang et al., 2013) to the overall rate of mental health service use among Asian Americans. Generally speaking, more cohesive families are less likely to use mental health services. This is probably because people from cohesive families may have less mental health needs as strong family bonding buffers their psychosocial stressors (Meyerson et al., 2002), or may be able to have their mental health needs addressed within the family (Marin et al., 2006). Yet, another possible explanation is that people from more cohesive families may have stronger attempts to keep the honor and pride of their families. Therefore, they may choose to keep their problems within their families, instead of seeking help outside of their families, to not shame their families with stigmatized mental illness (Ta et al., 2010). On the contrary, more conflictual families are found to have higher odds to use mental health services, which is probably resulted by elevated mental health needs associated with tensioned family relations, or mental health needs that are unmet due to the absence of sufficient trust and support.

More importantly, this study advances extant knowledge in how family relation may influence Asian Americans’ decision of mental health service use, especially in the use of general health services and human or alternative services, which has seldom been explored before. The probe of using general, human, or alternative services to address mental health needs is of particular importance among Asian Americans. Due to culturally based stigma and shame associated with mental illness and help-seeking, Asian Americans have been consistently found to underuse professional services, especially specialty mental health services which are particularly stigmatized (Fung & Wong, 2007; Hwang et al., 2008). Thus, it is critical to understand the alternative approaches that Asian Americans may be prone to use, and in what ways family relation affects the likelihood of such use.

Furthermore, this study sheds light on the interaction effect between generation status and family relation to mental health service use. It is important to note that this study identifies the interaction effect between family cohesion and generation status in affecting the use of general health services. Specifically, family cohesion is found to have pronounced impact on third- or later-generation Asian Americans in their receipt of general health services for mental health problems, as compared with the first generation.

Limitations and Future Research

Findings of the present study should be seen in the context of several limitations. First, the study excludes the respondents who self-identified as “Other Asians,” due to the extremely small sample size in some service type categories. Given the known ethnic and cultural heterogeneity, the prevalence and patterns of mental health services use among other Asians are in need of further study. Second, this study is a secondary data analysis of the NLAAS study. The cross-sectional nature of the NLAAS refrains the current study from determining the longitudinal effects and establishing causality. Third, the present study examines past-year service use, which provides important information on Asian Americans’ current mental health service use. However, this measure may not always reflect the most accurate rate and pattern of service use, as many individuals tend to delay treatment for mental health problems (Wang et al., 2005). Future studies should consider assessing both current (i.e., past year) and lifetime mental health service use among Asian Americans.

Moreover, findings from the study lend great support to the hypothesis that Asian families that are more cohesive or less conflictual are less likely to use mental health services. Results also highlight the important yet rarely understood role of family relation in affecting Asian Americans’ use of general health services and human or alternative services. Yet, it remains unknown that whether such tendency should be attributed to the lack of mental health needs due to cohesive family relation, or the discouragement from the family in the attempt of “saving face” of the entire family. It is suggested that future studies should utilize qualitative research methods to obtain an in-depth understanding of the impact of family relation and establish reliable causality. It also points to the possibility that increased psychological distress or mental disorder symptoms may mediate the association between family relation and service use. Future studies should consider conducting mediation analyses to examine such potential underlying mechanism.

It should also be noted that this study only examined Asian Americans’ use of formal services in addressing mental health concerns, instead of informal help-seeking from spouse, family, or friends. Given that literature has shown Asian Americans prefer seeking help from informal sources over mental health professionals, findings from this study may not reflect the full picture of Asian Americans’ coping strategies in the face of mental health problems, and how their coping may be impacted by family relation and generation status (Sue et al., 2012; Turner et al., 2016). Future studies should examine the impact of family relation and generation status on both the informal and formal help-seeking behaviors used by Asian Americans to better understand and address their mental health needs.

Implications for Practice

Despite the caveats, the present study contributes to the extant literature by lending several important practice implications. First, results from the present study evidence the significant effect of family relation to mental health service use among Asian Americans. In collectivist Asian cultures, family relation plays a critical role in influencing whether Asian Americans reveal their mental health needs, whether they seek for help to address their mental health needs, and which types of treatment they use. Mental health professionals could benefit from this empirical study by integrating the findings of the study into program planning and implementation. To be specific, given the pivotal role of family, it is suggested that mental health professionals outreach to entire Asian family units instead of individual Asian Americans and engage the entire family units in the decision process (Gaw, n.d.).

In addition, this research is one of the few studies that investigates the impact of family relation and immigration generation status on the use of different types of mental health services in a nationally representative sample of Asian Americans. As noted earlier, mental illness and seeking mental health treatment are stigmatized in Asian cultures, which may result in families being reluctant to reveal mental health needs and seek professional help, particularly specialty mental health services. It is imperative for mental health professionals to become aware of the potential promoting or hindering effect of family relation and continuously screen for and outreach to people who may be in need of services. It is also critical for health and mental health professionals to strive to provide mental health services in a nonstigmatizing fashion, as an alternative or supplement to specialty mental health services. For instance, practitioners may consider integrating mental health care into physical check-ups or primary health care to reduce Asian Americans’ exposure to stigmatized events or shameful feelings. Meanwhile, helping professionals should develop and provide educational programs that address the stigma issues to increase Asian families’ awareness and acceptability of mental health services (Sentell et al., 2007). Moreover, results of the study suggest that Asian Americans of different immigration generations and with varied family relations may differ in their tendency of utilizing different types of mental health services. These findings provide important information that may assist health and mental health professionals in their planning and delivery of services when serving Asian Americans. Tailored policies and interventions targeting Asian families, accounting for immigration generation and family relation variations, are suggested and expected to better meet the mental health needs of this population.

Footnotes

Disposition editor: Sondra J. Fogel

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Xiaochuan Wang

References

Abe-Kim

Takeuchi

Hwang

W. C.

(2002). Predictors of help seeking for emotional distress among Chinese Americans: Family matters. Journal of Consulting and Clinical Psychology, 70, 1186–1190. https://doi.org/10.1037/0022-006X.70.5.1186

Abe-Kim

Takeuchi

D. T.

Hong

Zane

Sue

Spencer

M. S.

Alegría

(2007). Use of mental health-related services among immigrant and US-born Asian Americans: Results from the National Latino and Asian American Study. American Journal of Public Health, 97(1), 91–98. https://doi.org/10.2105/AJPH.2006.098541

Alegría

Takeuchi

Canino

Duan

Shrout

Meng

X.-L.

… Gong

(2004). Considering context, place and culture: The National Latino and Asian American Study. International Journal of Methods in Psychiatric Research, 13(4), 208–220. https://doi.org/10.1002/mpr.178

Alegría

Takeuchi

(2013, September 18) National Latino and Asian American Study (NLAAS), 2002-2003 [ICPSR 191]. Inter-university Consortium for Political and Social Research [distributor].

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).

Andersen

R. M.

(1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36, 1–10. https://doi.org/10.2307/2137284

Carpentier

White

(2002). Cohesion of the primary social network and sustained service use before the first psychiatric hospitalization. Journal of Behavioral Health Services and Research, 29(4), 404–418. https://doi.org/10.1007/bf02287347

Chang

Natsuaki

Chen

C.-N.

(2013). The importance of family factors and generation status: Mental health service use among Latino and Asian Americans. Cultural Diversity and Ethnic Minority Psychology, 19(3), 236–247. https://doi.org/10.1037/a0032901

Cheng

Francher

Ratanasen

Conner

Duberstein

Sue

Takeuchi

(2010). Lifetime suicidal ideation and suicide attempts in Asian Americans. Asian American Journal of Psychology, 1(1), 18–30. https://doi.org/10.1037/a0018799

10.

Chu

J. P.

Hsieh

Tokars

(2011). Help-seeking tendencies in Asian Americans with suicidal ideation and attempts. Asian American Journal of Psychology, 2, 25–38. https://doi.org/10.1037/a0023326

11.

Fung

Wong

Y. R.

(2007). Factors influencing attitudes towards seeking professional help among East and Southeast Asian immigrants and refugee women. International Journal of Social Psychiatry, 53, 216–231. https://doi.org/10.1177/0020764006074541

12.

Gaw

. (n.d). Working with Asian American patients. https://www.psychiatry.org/psychiatrists/cultural-competency/education/best-practice-highlights/working-with-asian-american-patients

13.

Guo

Steinberg

Dong

Tiwari

(2019). Is family relations related to health service utilisation among older immigrants: Evidence from Chinese elderly in the United States. Health and Social Care in the Community, 27(1), 215–225. https://doi.org/10.1111/hsc.12642

14.

Harris

K. M.

Edlund

M. J.

Larson

(2005). Racial and ethnic differences in the mental health problems and use of mental health care. Medical Care, 43(8), 775–784. https://doi.org/10.1097/01.mlr.0000170405.66264.23

15.

Harris

T. L.

Molock

S. D.

(2000). Cultural orientation, family cohesion, and family support in suicide ideation and depression among African American college students. Suicide and Life-Threatening Behavior, 30(4), 341–353. https://doi.org/10.1111/j.1943-278X.2000.tb01100.x

16.

Heeringa

S. G.

Wagner

Torres

Duan

Adams

Berglund

(2004). Sample designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies (CPES). International Journal of Methods in Psychiatric Research, 13, 221–240. https://doi.org/10.1002/mpr.179

17.

Hwang

Myers

Abe-Kim

Ting

(2008). A conceptual paradigm for understanding culture’s impact on mental health: The Cultural Influences on Mental Health (CIMH) model. Clinical Psychology Review, 28, 211–227. https://doi.org/10.1016/j.cpr.2007.05.001

18.

Keeley

M. L.

Wiens

B. A.

(2008). Family influences on treatment refusal in school-linked mental health. Journal of Child and Family Studies, 17, 109–126. https://doi.org/10.1007/s10826-007-9141-6

19.

Kung

W. W.

(2003). Chinese Americans’ help seeking for emotional distress. Social Service Review, 77, 110–134. https://doi.org/10.1086/345707

20.

Kung

W. W.

(2004). Cultural and practical barriers to seeking mental health treatment for Chinese Americans. Journal of Community Psychology, 32, 27–43. https://doi.org/10.1002/jcop.10077

21.

Lopez

Ruiz

Patten

(2017). Key facts about Asian Americans, a diverse and growing population. http://www.pewresearch.org/fact-tank/2017/09/08/key-facts-about-asian-americans/

22.

Marin

Escobar

J. I.

Vega

W. A.

(2006). Mental illness in Hispanics: A review of the literature. Focus, 4(1), 23–37. https://doi.org/10.1176/foc.4.1.23

23.

Meyerson

L. A.

Long

P. J.

Miranda

Jr. Marx

B. P.

(2002). The influence of childhood sexual abuse, physical abuse, family environment, and gender on the psychological adjustment of adolescents. Child Abuse & Neglect, 26(4), 387–405. https://doi.org/10.1016/s0145-2134(02)00315-0

24.

Olson

D. H.

(1986). Circumplex Model VII: Validation studies and FACES III. Family Process, 25, 337–351. https://doi.org/10.1111/j.1545-5300.1986.00337.x

25.

Pew Research Center. (2017). Key facts about Asian Americans, a diverse and growing population.https://www.pewresearch.org/fact-tank/2017/09/08/key-facts-about-asian-americans/

26.

Sentell

Shumway

Snowden

(2007). Access to mental health treatment by English language proficiency and race/ethnicity. Journal of General Internal Medicine, 22, 289–293. https://doi.org/10.1007/s11606-007-0345-7

27.

Snowden

L. R.

Yamada

A. M.

(2005). Cultural differences in access to care. Annual Review of Clinical Psychology, 1, 143–166. https://doi.org/10.1146/annurev.clinpsy.1.102803.143846

28.

Substance Abuse and Mental Health Services Administration. (2018). 2018 National Survey on Drug Use and Health Detailed tables. https://www.samhsa.gov/data/report/2018-nsduh-detailed-tables

29.

Sue

Cheng

J. K. Y.

Saad

C. S.

Chu

J. P.

(2012). Asian American mental health: A call to action. American Psychologist, 67(7), 532–544. https://doi.org/10.1037/a0028900

30.

V. M.

Holck

Gee

G. C.

(2010). Generational status and family cohesion effects on the receipt of mental health services among Asian Americans: Findings from the National Latino and Asian American Study. American Journal of Public Health, 100(1), 115–121. https://doi.org/10.2105/AJPH.2009.160762

31.

Treas

(2008). Transnational older adults and their families. Family Relations, 57(4), 468–478. https://doi.org/10.1111/j.1741-3729.2008.00515.x

32.

Turner

E. A.

Cheng

H. L.

Llamas

J. D.

Tran

A. G.

Hill

K. X.

Fretts

J. M.

Mercado

(2016). Factors impacting the current trends in the use of outpatient psychiatric treatment among diverse ethnic groups. Current Psychiatry Reviews, 12(2), 199–220. https://doi.org/10.2174/1573400512666160216234524

33.

Walton

Takeuchi

D. T.

(2010). Family structure, family processes, and well- being among Asian Americans: Considering gender and nativity. Journal of Family Issues, 31, 301–332. https://doi.org/10.1177/0192513X09350873

34.

Wang

P. S.

Lane

Olfson

Pincus

H. A.

Wells

K. B.

Kessler

R. C.

(2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 629–640. https://doi.org/10.1001/archpsyc.62.6.629

35.

Wierzbicki

(2004). Beyond the immigrant enclave: Network change and assimilation. LFB Scholarly Publishing LLC.

36.

Wong

E. C.

Marshall

G. N.

Schell

T. L.

Elliott

M. N.

Hambarsoomians

Chun

C.-A.

Berthold

S. M.

(2006). Barriers to mental health care utilization for U.S. Cambodian refugees. Journal of Consulting and Clinical Psychology, 74, 1116–1120. https://doi.org/10.1037/0022-006X.74.6.1116