Ethnic status and engagement with health services: Attitudes toward help-seeking and intercultural willingness to interact among South East Asian students in Australia

Abstract

Previous research has demonstrated the importance of intercultural willingness to interact; however, these investigations have yet to be applied to a health context or to compare an ethnic minority with a majority sample. Consequently, the current study sought to better understand engagement with health services by investigating both attitudes towards seeking psychological help and intercultural willingness to interact within an ethnic minority South East Asian population, relative to an Anglo Australian sample. As predicted, negative attitudes towards seeking psychological help were higher in the South East Asian sample, with this relationship persisting across generations, despite significant differences in acculturation. In contrast, intercultural willingness to interact was not associated with ethnicity status but was associated with higher anxiety, uncertainty, ethnocentrism and help-seeking, consistent with current empirical and theoretical literature. The current study also sought to examine factors associated with help-seeking attitudes and found that ethnocentrism was a significant predictor, when accounting for previous health experience.

Keywords

Australia ethnic minority help-seeking intercultural communication mental health service/care South East Asian postsecondary students

Almost one quarter of Australia’s population are migrants, with the greatest proportion of new and non-English speaking migrants coming from countries in Asia (Australian Bureau of Statistics, 2016). Collectively, migrants from India, China, the Philippines, Vietnam, and Malaysia made up 6.3% of the Australian population, or 1.4 million people, with all migrant groups increasing over the last decade (Australian Bureau of Statistics, 2016). Literature in Australia reports that migrants of an Indochinese background report more barriers to help-seeking regarding mental health services compared to Anglo Australians (Ho, Hunt, & Li, 2008; Lam & Kavanagh, 1996) and lower rates of service utilisation (Blignault, Ponzio, Rong, & Eisenbruch, 2008; Jirojwong & Manderson, 2001). This is important, considering that underutilisation of health services is associated with an increased risk for the development of a mental disorder (Australian Bureau of Statistics, 2007). Given the increasing cultural mosaic of Australia, and many other countries worldwide, it is paramount that cultural differences in help-seeking and communicating with health services are better understood.

Migrants of South East (SE) Asian background report consistent underutilisation of health services within Australia (Anikeeva et al., 2010; Hart, 2002). A review of migrants’ health service utilisation within Australia (Anikeeva et al., 2010) has highlighted that those of SE Asian background underutilise health services across all health conditions. Regarding mental health specifically, lower mental health service use led to a high degree of family burden and involuntary hospital admissions due to acute mental illness in this group, relative to the Australian-born population. These low levels of health service engagement by SE Asian migrants may be partly explained by sociocultural difficulties, such as social isolation, language barriers, lack of knowledge regarding available or appropriate services, and the mental health stigma that is present within Asian communities in Australia (Anikeeva et al., 2010).

Despite a need for mental health services (Hart, 2002), this pattern of lower levels of engagement for SE Asian immigrants is mirrored in many Western English-speaking health settings (Hsu, Davies, & Hansen, 2004). Within the United States for example, migrants of SE Asian heritage are also less likely to present for treatment of mental health problems (Lu & Hsu, 2008). This finding may be further complicated by the notion that those of Asian ethnicity may experience and embody mental distress in a different way than do those from Western cultural backgrounds (Beiser, 2003). A better understanding of factors that impact on willingness to engage in intercultural health settings, or communicate with health professionals may therefore assist in bettering the service use outcomes for SE Asian migrants living within Australia.

Research into the factors that promote or interfere with intercultural communication in a general setting has identified a consistent association between heightened anxiety and uncertainty, and the likelihood of engaging in intercultural communication (Duronto, Nishida, & Nakayama, 2005; Logan, Steel, & Hunt, 2014a; Rohmann, Florack, Samochowiec, & Simonett, 2014; Samochowiec & Florack, 2010). These findings support the theoretical work of Gudykunst and colleagues: anxiety and uncertainty reduce willingness to engage in intercultural communication and the perceived effectiveness of communication when it does occur (Gudykunst, 2005; Gudykunst & Nishida, 2001). Our research extended this by demonstrating that reduced likelihood of engaging in intercultural communication was not only associated with trait anxiety but reduced in settings associated with increased state anxiety, underscoring the importance of the context in promoting intercultural communication (Logan et al., 2014a).

Research has also highlighted the importance of understanding individual traits or cultural values, alongside anxiety and uncertainty, in order to better understand barriers to intercultural interactions. Intercultural traits, such as adaptability and openness, impact on negative affect experienced during intercultural interactions (van der Zee, van Oudenhoven, & de Grijs, 2004), whilst ethnocentrism, or the preference for one’s own cultural values over another’s, is related to lower levels of willingness to interact interculturally (Lin, Rancer, & Lim, 2003; Lin, Rancer, & Trimbitas, 2005). Research by the current authors with an Australian university student sample of mixed ethnicity has indicated that ethnocentrism may be a stronger predictor of willingness to interact interculturally, when considered in conjunction with trait measures of anxiety and uncertainty (Logan et al., 2014a). However, to date these relationships have not been explored in an ethnic minority sample.

Whilst this previous research has been integral in advancing the understanding of intercultural communication generally, research has yet to assess whether these relationships are pertinent to health care engagement and communication. When considering engagement within a health setting, attitudes towards seeking psychological help may also be predictive of willingness to interact. Stigma surrounding mental illness may reduce willingness of patients to disclose health information over these other communication barriers, especially when the communication is intercultural (Hwang, Myers, Abe-Kim, & Ting, 2008; Logan & Hunt, 2014; Wagner & Joukhador, 2001). It might also be argued that in ethnic minority populations who experience a high degree of stigma surrounding mental health, such as those of SE Asian background (Ng, 1997), ethnocentrism may impact heavily on negative attitudes towards seeking health treatment. For example, culturally determined causal beliefs and explanations for mental distress are associated with patterns of help-seeking behaviour among Asian migrants within the United Kingdom (Sheik & Furnham, 2000). It is therefore important to understand how cultural values and individual dispositions may individually impact on, or are related to, attitudes towards help-seeking and intercultural willingness to interact.

In considering the impact of culture on engagement with health services it is important to assess the impact of acculturation and previous experience with health services. Acculturation, the process by which an individual either acquires or retains certain values of one culture when moving to another culture (Andersen et al., 1993), has been found to be related to more positive attitudes towards seeking professional psychological help within an ethnic minority Asian university student sample within Australia (Hamid, Simmonds, & Bowles, 2009). Previous experience of health services may also be pertinent to attitudes towards seeking help and intercultural willingness to interact in a health setting. In the context of the present study, it was predicted that previous intercultural health service encounters that are higher in anxiety or where the perceived predictability (as a measure of uncertainty) of a health professional was lower will be associated with more negative current attitudes towards seeking professional psychological help and lower willingness to interact.

As attitudes towards help-seeking (Hwang et al., 2008; Mojaverian, Hashimoto, & Kim, 2013) and intercultural willingness to communicate (Barraclough, Christophel, & McCroskey, 1988; Lu & Hsu, 2008) differ across cultural groups, it is important to evaluate individual ethnic groups, so that these differences may be adequately captured (Dogra, Singh, Svirydzenka, & Vostanis, 2012). Given that SE Asian migrants form one of the largest foreign-born groups residing within Australia (Anikeeva et al., 2010), accounting for approximately 3% of the Australian population (Australian Bureau of Statistics, 2016), it is crucial that this specific ethnic group be better able to access and utilise health care services.

Moreover, as young people experience higher rates of mental disorder within Australia (Australian Bureau of Statistics, 2007), it is worthwhile investigating factors that may inhibit or promote intercultural communication in health settings in a young adult SE Asian sample. Previous research investigating these processes has used samples of university students with the hope of making inferences about the wider community. This research has included studies of intercultural willingness to interact (Logan et al., 2014a; Samochowiec & Florack, 2010), ethnocentrism (Goldstein & Kim, 2006; Lin et al., 2003; Lin et al., 2005), acculturation and help-seeking behaviour (Hamid et al., 2009). By testing a university sample in the current research, we are able to determine how the current results may be compared to previous research conducted in this field. Additionally, given the high rate of Asian migrant and international tertiary students (“Student Numbers at Australian Universities,” 2015), studies of university students are relevant to a large cohort currently residing within Australia.

Therefore, the aim of the current study was to investigate both attitudes towards seeking psychological help and intercultural willingness to interact in a SE Asian university student sample relative to an Anglo Australian sample. SE Asian heritage or ethnicity was defined by the Australian Standard Classification of Cultural and Ethnic Groups and included all SE Asian subethnic groups where applicable (e.g., Hmong, Vietnamese, etc.; Australian Bureau of Statistics, 2011b). Acculturation was taken into account by assessing group differences between first- and second-generation persons of SE Asian heritage or ethnicity. Secondly, the study sought to explore whether factors previously shown to influence intercultural willingness to communicate, such as anxiety, uncertainty, ethnocentrism, and attitudes towards help-seeking, show similar relationships in an ethnic minority sample’s experience of engagement with health services. Thirdly, the current study aimed to determine which factors uniquely contribute towards these domains: previous health experience or cultural values, and cultural values alongside trait-based dispositions, respectively. We hypothesised that:

H1: Negative attitudes toward help-seeking will be higher in a SE Asian sample overall relative to an Anglo Australian sample, with differences also seen between SE Asian generations, with first-generation individuals reporting greater negative attitudes than second-generation individuals.

H2: Intercultural willingness to communicate will be lower in a SE Asian sample relative to an Anglo Australian sample, with differences also seen between SE Asian generations, with first-generation individuals reporting lower intercultural willingness to communicate relative to second-generation individuals.

H3: Within a SE Asian sample, intercultural willingness to communicate will be negatively associated with negative attitudes towards help-seeking, ethnocentrism, trait anxiety, the anxiety experienced during a previous intercultural interaction with a health professional, and intolerance to uncertainty. Intercultural willingness to communicate will be positively associated with the perceived predictability of a health professional of a different cultural background and acculturation.

The study also provided the opportunity to explore the contribution of previous health interactions (anxiety experienced during a previous intercultural health interaction, perceived predictability of a health professional of a different cultural background, and degree of contact with a general practitioner within Australia) alongside ethnocentrism to attitudes towards help-seeking within a SE Asian sample. Lastly, the contribution of ethnocentrism, acculturation, help-seeking behaviour, anxiety, intolerance of uncertainty, and willingness to communicate generally to intercultural willingness to communicate in a SE Asian sample was explored.

Method

Participants

Participants were first-year undergraduate psychology students at the University of Sydney, recruited through an advertisement on an online student recruitment website. A total of 94 participants completed the study and received course credit for their participation. Inclusion criteria for SE Asian participants included having a family history of SE Asian heritage or identifying as SE Asian ethnicity. Participants were provided with a list of ethnic identities residing in South East Asia (Australian Bureau of Statistics, 2011b). Eight participants were later excluded as they did not report SE Asian heritage or ethnicity despite being assigned to a SE Asian cohort group, leaving a total sample of 86 for further analysis, which was predominantly female (79% female; M_age = 19.40 SD = 1.86). Participants were divided into first generation (those who had been born overseas; n = 27) or second generation (those whose parents had been born overseas; n = 38). All first-generation participants identified with a SE Asian ethnicity. Countries of birth for first-generation participants included Singapore (n = 9), Philippines (n = 5), Indonesia (n = 4), Vietnam (n = 4), Burma (n = 2), and Malaysia (n = 1). Two participants were born outside of South East Asia (New Zealand and the United States of America); however, both had two generations of SE Asian heritage from Malaysia and Singapore respectively. Of the second-generation participants, 28 identified with a SE Asian ethnicity, six with North East (NE) Asian ethnicity and a SE Asian heritage, and four with an Australian ethnicity and SE Asian heritage. A cohort of Anglo Australian participants formed a control comparison group who were third-generation Australian-born or greater (whose parents were born in Australia; n = 21). The Human Research Ethics Committee at the University of Sydney granted ethics approval for the study. Data was collected by the primary author from January through August 2014. Participants completed all measures in their own time on a computer in online survey format.

Measures

Attitudes towards help-seeking

The revised Attitudes Towards Seeking Professional Psychological Help Scale-Short Form (ATSPPH-SF; Ang, Lau, Tan, & Lim, 2007) assesses attitudes towards seeking psychological help, measured on a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree), with higher scores indicating greater reluctance. This scale has been adapted and used to assess an Asian Australian university student sample (n = 112, 60% female, M_age = 21 years, ethnicities = Chinese, Indian, Sri Lankan, Vietnamese, Indonesian, Korean, and Japanese) with high internal consistency reported (Cronbach’s α = .83; Hamid et al., 2009). Within the current sample of SE Asian participants internal consistency was also high (Cronbach’s α = .82).

Intercultural willingness to communicate

The Intercultural Willingness to Communicate Scale (IWTC; Kassing, 1997) is a 12-item self-report questionnaire used to assess willingness to engage with someone from a different cultural background. The scale consists of two subscales which measure intercultural willingness (six items) and general willingness to communicate (six items) on an 11-point Likert scale (0 = no chance, 10 = every chance you get). This scale has reported high internal consistency in university student samples in the United States (n = 339, 55% female, M_age 22.40 years, Cronbach’s α = .91; Lin & Rancer, 2003), Korea (n = 297, 57% female, M_age 22.76 years, Cronbach’s α = .83; Lin et al., 2003) and Romania (n = 110, 59% female, M_age 22.13 years, Cronbach’s α = .82; Lin et al., 2005). Within the current sample of SE Asian participants excellent internal consistency was found for intercultural willingness to communicate (Cronbach’s α = .92) and good internal consistency for willingness to communicate generally (Cronbach’s α = .72).

Ethnocentrism

The revised Generalized Ethnocentrism Scale (GENE; Neuliep & McCroskey, 1997) is a self-report questionnaire rated on a 5-point Likert scale (1 = disagree, 5 = strongly agree), that assesses the degree to which participants judge another culture solely on the values and standards of their own culture, with higher scores indicating greater ethnocentrism. Psychometric analyses for this scale report high reliability across previous samples (Cronbach’s α = .84–.94; Neuliep, 2002). This scale has been utilised within university student samples of mixed ethnicity in both the United States (n = 282, Cronbach’s α = .87; Goldstein & Kim, 2006) and Australia (n = 143, 64% female, M_age 20 years, Cronbach’s α = .82; Logan et al., 2014a). Within the current sample of SE Asian participants internal consistency was also high (Cronbach’s α = .85).

Acculturation

The Suinn-Lew Asian Self-Identity Scale (SL-ASIA; Suinn, Ahuna, & Khoo, 1992) is a 21-item multiple-choice self-report measure which assesses acculturation over four criteria: language familiarity, usage and preference; ethnic identity; cultural behaviours; and ethnic interactions. An acculturation score is obtained by averaging the total score with scores close to 1 indicating Asian-identified, close to 3 indicating bicultural, and close to 5 indicating Western-identified or high levels of acculturation. Previous research utilising an Asian Australian university student sample (n = 112, 60% female, M_age = 21 years, ethnicities = Chinese, Indian, Sri Lankan, Vietnamese, Indonesian, Korean, and Japanese) reported high internal consistency (Cronbach’s α = .88; Hamid et al., 2009). Internal consistency was excellent for the current sample of SE Asian participants (Cronbach’s α = .90).

Trait anxiety

The State Trait Anxiety Inventory trait measure (STAI; Spielberger, 1983) assesses trait levels of anxiety rated on a 4-point Likert scale (1 = not at all, 4 = very much so), with higher scores indicating greater levels of anxiety. An assessment of psychometric properties for the STAI reported good test–retest reliability (average r = .88; Gros, Antony, Simms, & McCabe, 2007). In a native Malaysian university student sample (n = 253, 57% female, age range = 18–26) reliability and construct validity for the STAI trait were also high (r = .85, Cronbach’s α = .78; Vitasari, Wahab, Herawan, Othman, & Sinnadurai, 2011). Internal consistency was excellent for the current sample of SE Asian participants (Cronbach’s α = .90).

Intolerance of uncertainty

The Intolerance of Uncertainty Scale (IUS; Freeston, Rhéaume, Letarte, Dugas, & Ladouceur, 1994) assesses the degree to which one experiences uncertainty as intolerable, rated on a 5-point Likert scale (1 = not at all true, 5 = extremely true). This measure demonstrates excellent internal consistency (Cronbach’s α = .94) and good test–retest reliability (r = .74; Buhr & Dugas, 2006). The psychometric properties of the IUS have been assessed in a SE Asian university student sample living within the United States (n = 94), alongside African American, Hispanic, and Caucasian students (total sample n = 540, 69% female, M_age = 21.6 years), with results indicating excellent internal consistency (Cronbach’s α = .95; Norton, 2005). Excellent internal consistency was also demonstrated for the current sample of SE Asian participants (Cronbach’s α = .96).

State anxiety

A modified version of the Intergroup Anxiety Scale (Stephan et al., 2002) was used to assess emotional responses experienced when interacting with a health professional from another cultural group, rated on a 10-point Likert scale (0 = not at all, 10 = extremely). Higher scores indicate greater levels of anxiety. An extended version of this measure showed high internal consistency in an African American and Caucasian American university student sample (total sample n = 911, 70% female, M_age = 18 years, Cronbach’s α = .83–.92; Stephan et al., 2002), and excellent internal consistency in Asian American (n = 133, ethnicities = Japanese, Chinese, and Filipino), Hispanic (n = 123), and Caucasian American (n = 171) university student samples (Cronbach’s α = .97; Stephan & Stephan, 1989). Within the current sample of SE Asian participants internal consistency was also high (Cronbach’s α = .84).

Perceived predictability

The perceived predictability of a health professional of a different cultural background was assessed by two questions (“How well can you predict their behaviour in different situations?” and “How well can you predict their reactions to your own behaviour?”), rated on an 11-point Likert scale (0 = not at all, 10 = very much). These two scores were averaged to create a single score for perceived predictability, with high values indicating that the health professional of a different cultural background was perceived as predictable. A similar scale has been used in an Australian university student sample of mixed ethnicity (n = 143, 64% female, M_age = 20, ethnicities = Oceanic, NE Asian, SE Asian, Southern and Central Asian, North African and Middle Eastern, European, Sub-Saharan African, and American) with high internal consistency (Cronbach’s α = .91; Logan et al., 2014a). Within the current sample of SE Asian participants internal consistency was also high (Cronbach’s α = .87).

Previous contact with health services

Number of previous encounters with different types of health services (general practitioner, mental health, community health, inpatient hospital, emergency department, or other) in both Australia and overseas was recorded.

Statistical analyses

Hypotheses 1 and 2 were tested with ANOVA with planned contrasts and correlational analyses were used to test Hypothesis 3. Additional exploratory analyses used multiple regression and hierarchical multiple regression, with all measures converted to standardised z scores. Analysis of the results was conducted using SPSS Version 21, with the significance level of all tests set at p < .05. Initial data analysis undertaken indicated that no extreme univariate or multivariate outliers were present and no corrections for skewness or kurtosis were necessary.

Results

Means and standard deviations for baseline measures across participant groups are displayed in Table 1. The three groups were of a similar age, F(2, 83) = 1.60, p = .208, and sex ratio, χ ² (2) = 1.32, p = .571. The t-test analyses indicated a significant difference between first- and second-generation SE Asian participants on acculturation, t(61) = −6.30, p < .001, supporting the use of generation as a proxy measure of acculturation. Table 2 displays frequency and percentile information for those who reported having any previous contact with health services within Australia and overseas by group.

Table 1.

Means and standard deviations of measures by participant groups (n = 86)

	First-generation SE Asian (n = 27)		Second-generation SE Asian (n = 38)		Third-generation Australian (n = 21)
	n	%	n	%	n	%
Sex (female)	22	81.5	28	73.7	18	85.7
	M	SD	M	SD	M	SD
Age	19.78	1.97	19.00	1.87	19.63	1.63
Attitudes towards help-seeking	14.63	5.89	12.53	5.15	10.05	4.74
Intercultural willingness to interact	36.07	10.84	34.11	11.92	35.90	12.23
Willingness to interact generally	38.78	7.83	39.45	7.92	42.76	7.68
Ethnocentrism	33.44	6.25	32.11	7.12	37.14	2.65
Acculturation	2.72	0.42	3.33	0.35
Trait anxiety	44.56	9.12	47.05	9.56	39.38	9.57
Intolerance of uncertainty	64.63	20.04	59.10	18.74	53.10	15.68
State anxiety	29.07	9.96	24.79	9.58	24.14	9.26
Perceived predictability	5.12	1.92	5.57	1.61	4.86	2.10

M: Mean; SD: standard deviation

Table 2.

Frequency and percentile of reported previous contact with health services within Australia and overseas by participant groups (n = 86)

	First- generation SE Asian (n = 27)		Second-generation SE Asian (n = 38)		Third-generation Anglo Australian (n = 21)
	n	%	n	%	n	%
Within Australia
General Practitioner (GP)	14	51.9	37	97.3	21	100.0
Mental health	5	18.5	10	26.3	7	33.3
Emergency department	8	29.6	19	50.0	15	71.4
Inpatient hospital	2	7.4	15	39.5	10	47.6
Community health	8	29.6	9	23.7	3	14.3
Other	4	14.8	6	15.8	4	19.0
Overseas
General Practitioner (GP)	21	77.8	12	31.6	8	38.1
Mental health	6	22.2	0	0	0	0
Emergency department	9	33.3	2	5.3	0	0
Inpatient hospital	6	22.2	1	2.6	0	0
Community health	2	7.4	1	2.6	1	4.8
Other	3	11.1	1	2.6	1	4.8

There was a significant difference between groups on negative attitudes towards help-seeking, F(2, 83) = 4.42, p = .015. A significant difference was found between the Australian cohort and all SE Asians, t(83) = −2.64, p = .010, in the predicted direction. However, the difference between SE Asian cohorts was not significant, t(83) = 1.58, p = .119, providing only partial support for Hypothesis 1.

No significant difference between groups on intercultural willingness to interact was shown, F(2, 83) = 0.281, p = .756, indicating Hypothesis 2 was not supported.

In support of Hypothesis 3, intercultural willingness to interact was significantly associated with ethnocentrism, negative attitudes towards help-seeking, trait anxiety, intolerance of uncertainty, state anxiety, and perceived predictability, in the expected directions (see Table 3). However, no significant association was found with acculturation.

Table 3.

Bivariate correlations between intercultural willingness to interact and other measures in a South East Asian sample (n = 65)

	r	p
Ethnocentrism	−.41	.001
Acculturation	−.09	.467
Negative attitudes towards help-seeking	−.37	.002
Trait anxiety	−.43	<.001
Intolerance of uncertainty	−.37	.002
State anxiety	−.29	.018
Perceived predictability	.34	.006

Multiple regression models assessed the contribution of previous health interactions (anxiety experienced, perceived predictability, and contact with general practitioners in Australia) and ethnocentrism on negative attitudes towards seeking psychological help (see Table 4). Overall the model was significant, R²= .24, F(4, 57) = 4.48, p = .003; however, only ethnocentrism made a significant contribution.

Table 4.

Determinants of negative attitudes toward help-seeking and intercultural willingness to interact in a South East Asian sample (n = 65)

	β	t	p	β	t	p
Negative attitudes towards help-seeking
State anxiety	.112	0.86	.394
Perceived predictability	.190	1.46	.149
Previous contact with a GP in Australia	−.155	−1.27	.211
Ethnocentrism	.391	3.16	.003
Intercultural willingness to interact	Step 1			Step 2
Willing to interact	.740	8.59	<.001	.599	6.35	<.001
Ethnocentrism				−.169	−1.83	.072
Acculturation				−.141	−1.72	.091
Negative attitudes towards help-seeking				−.030	−.31	.758
Trait anxiety				−.160	−1.45	.153
Intolerance of uncertainty				−.074	−0.68	.502

Hierarchical multiple regression was used to assess the contribution of ethnocentrism, acculturation, attitudes towards seeking help, trait anxiety, and intolerance of uncertainty on intercultural willingness to interact, after controlling for the willingness to interact generally within the SE Asian sample. Willingness to interact generally was entered at Step 1, making a significant contribution to intercultural willingness to interact, R²= .55, F(1, 61) = 73.85 p < .001. After entering ethnocentrism, acculturation, attitudes towards seeking help, trait anxiety, and intolerance of uncertainty at Step 2 the model remained significant, R²= .63, F(6, 56) = 16.18, p < .001; however, only willingness to interact generally contributed significantly towards the final model (see Table 4).

Discussion

The current study sought to understand how ethnicity impacts on attitudes towards help-seeking and willingness to interact interculturally amongst SE Asian university students living in Sydney, Australia. We hypothesised that SE Asian students would report higher negative attitudes towards seeking psychological help, and lower intercultural willingness to communicate, relative to Anglo Australian participants. Additionally, we predicted that differences would be seen between first- and second-generation migrants on these measures, due to the effects of acculturation.

Participants with SE Asian ethnicity were significantly more likely than Anglo Australians to report negative attitudes towards seeking professional psychological help. This finding is consistent with previous research, indicating that cultural differences between ethnic groups will impact on the stigma associated with mental illness (Wagner & Joukhador, 2001) and help-seeking behaviour (Hwang et al., 2008; Mojaverian et al., 2013). Interestingly, despite significant differences in acculturation between first- and second-generation SE Asian participants, these negative attitudes appeared to persist generationally, with no differences found between first- and second-generation SE Asian participants on attitudes towards help-seeking. Thus, despite some level of acculturation, cultural views on health and help-seeking specifically may persist over time. This may help to explain the consistent finding that SE Asians underutilise mental health services in Western settings.

Contrary to expectations, there was no significant difference between groups in intercultural willingness to interact. This contrasts with previous studies using the same measure, which report significant cultural differences in intercultural willingness to interact between Eastern and Western cultural groups (Lu & Hsu, 2008) and between different Western cultural groups (Barraclough et al., 1988). Although this information was not gathered, it is likely that many of the first-generation SE Asian students in our study were current international or exchange students. One in five tertiary students in Australia are international students, and the majority of these students have an Asian background (Australian Bureau of Statistics, 2011a). Recent data suggest that approximately 20% of students at the University of Sydney, where the current study was conducted, are international students (“Student Numbers at Australian Universities,” 2015). One might therefore expect that the level of intercultural willingness to interact would be elevated in this sample, compared to a native population, as these participants chose to study in a cross-cultural environment. Previous research has indicated that ethnic minorities in university samples may be more willing to interact, relative to persons of the same ethnicity in their native homeland (Lu & Hsu, 2008). Moreover, as all participants volunteered to take part in a study on intercultural communication, it is likely that they had a heightened willingness to interact, relative to the general Australian community. The finding of no clear differences between the groups therefore needs to be interpreted with caution and further research is needed to examine these variables in the general population.

Given current theoretical models, it was also hypothesised that within the SE Asian sample intercultural willingness to interact would be significantly associated with trait dispositions and cultural values or attitudes, as well as state anxiety and perceived predictability. This hypothesis was supported, with willingness to interact significantly associated with higher trait anxiety and intolerance of uncertainty. This finding is consistent with previous studies suggesting that both anxiety and uncertainty lead to reluctance to engage in intercultural communication (Gudykunst, 2005; Logan et al., 2014a; Samochowiec & Florack, 2010). This theory is also applicable to an ethnic minority sample in which intercultural willingness to interact might be expected to be higher than in community samples.

Of particular importance to the current topic, this relationship was also present when considering a health situation, with heightened state anxiety and lower perceived predictability experienced during previous health interactions significantly related to intercultural willingness to interact. Although acculturation was not associated, both negative attitudes towards help-seeking within a mental health context and ethnocentrism were related to willingness to interact. This finding suggests that previous experience, along with individual values regarding mental health or culture, influence willingness to engage in intercultural interaction.

The study also examined the contribution of previous intercultural health service experience and cultural values on attitudes toward help-seeking. Findings suggest that previous anxiety and perceptions of predictability stemming from prior health care interactions were not influential in predicting negative attitudes towards seeking psychological help. In contrast, degree of ethnocentrism was associated with negative attitudes towards seeking help. This may be due to the notion within SE Asian communities that there is a stigma attached to ill mental health (Ng, 1997), with those who are also holding on strongly to their own cultural values less likely to engage with mental health services. This relationship has also been found in Australian-born Chinese and Chinese immigrants of Taiwanese background, where those who adhered strongly to Chinese cultural practices and had a lower adoption of Australian (mainstream) cultural practices were more likely to report stigmatising attitudes towards ill mental health (Mellor, Carne, Chen, McCabe, & Wang, 2012).

The results also indicate that adherence to or preference for SE Asian cultural values (as measured through ethnocentrism and acculturation), help-seeking attitudes, and personality dispositions (such as trait anxiety or intolerance of uncertainty) collectively contribute to intercultural willingness to communicate. However, only willingness to communicate was found to uniquely contribute to the final model. This finding indicates that although cultural values and trait measures are all important, and related to willingness to interact interculturally, one’s general willingness to interact may be a better predictor of whether engagement will occur.

Despite these significant relationships, caution must be taken in translating these findings to the general community. As discussed, it is probable that the use of a sample of university students influenced the degree of intercultural willingness to interact reported across the entire cohort. The study is limited in that it has not accounted for individual factors, such as length of time within Australia or immigration experience or status; for example, we did not consider whether participants were on exchange or living more permanently within Sydney, Australia. Given that acculturation significantly impacts on help-seeking behaviour (Hamid et al., 2009), these factors warrant further examination. Future investigations of domains such as immigration experience within an ethnic minority community sample are necessary if the results are to be used to inform strategies that may impact help-seeking and engagement with health services in the community.

The measure of acculturation used in the present study was chosen because it had been previously translated for use with an Asian Australian university sample (Hamid et al., 2009) and provided a quick screening tool to confirm significant acculturation differences across generations of the SE Asian cohort. However, more recent research has advocated a multidimensional approach to the measurement of acculturation in health settings (Wallace, Pomery, Latimer, Martinez, & Peter, 2010) that accounts for a greater sociocultural context of the migration experience (Allen et al., 2014). Future research could better account for cultural differences within migrant groups through a more thorough assessment of acculturation, along with health attributions or health behaviours (Fox, Malcarne, Roesch, & Sadler, 2014) in order to more comprehensively measure the impact of culture on health engagement. Moreover, given that important cultural differences may exist between subethnic groups within a SE Asian sample, further ethnicity information could be obtained. These investigations could be undertaken with either community members who are yet to engage with health services, or with ethnic minority patients who have already engaged, in order to better understand how low willingness to communicate and negative attitudes towards help-seeking act as barriers to engagement with health services.

Conclusion and future directions

The present study found that negative attitudes towards seeking psychological help were higher among a SE Asian ethnic minority sample residing in Australia, compared to an Anglo Australian sample. Despite evidence of acculturation across the different generational cohorts, these attitudes were present in first- and second-generation SE Asian participants. The persistence of such negative attitudes among SE Asian respondents may help account for the low rates of mental health service utilisation of this group and their reported difficulties with engagement of health services. We also found that intercultural willingness to interact in a health setting was lower among those with heightened anxiety and uncertainty or who had a history of previous negative intercultural health interactions, a finding that is in accord with non-health-related theoretical and empirical literature.

The current study also demonstrated that ethnocentrism is important in predicting both negative attitudes toward help-seeking and willingness to interact across cultures. Both trait and state levels of anxiety and uncertainty/predictability were also related to willingness to interact interculturally. This finding highlights the potential value of community intervention or education programs to address barriers to mental health care and appropriate help for ethic minority groups (Jirojwong & Manderson, 2001; Lam & Kavanagh, 1996). A growing body of research suggests that culturally competent care and the provision of culturally appropriate mental health information can aid intercultural communication in health settings (Logan, Steel, & Hunt, 2014b; Teal & Street, 2009). Given that many first health encounters by ethnic minority patients for the treatment of psychiatric distress are with a general practitioner (Steel et al., 2006) it may be worthwhile to assess the type and quantity of information regarding mental health that practitioners currently provide. Interventions could then be targeted at improving mental health awareness where needed.

Footnotes

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.

Shanna Logan, DClinPsych, PhD, completed a PhD in Mental Health Service Utilisation and Engagement of Ethnic Minority Populations at the School of Psychology, University of Sydney, Australia. Her published works focus on cross-cultural communication in a mental health setting.

Zachary Steel, PhD, MClinPsych, holds the St John of God Professorial Chair of Trauma and Mental Health, a partnership between St John of God Health Care, Richmond Hospital; the School of Psychiatry, University of New South Wales; and the Black Dog Institute. Prof. Steel’s program of research has examined the prevalence, social determinants, and intervention models for mental health problems across diverse communities and settings with a particular focus on traumatic stress, forced displacement, conflict, and culturally specific symptoms of mental disorder and distress.

Caroline Hunt, PhD, is Associate Head (Clinical) and Associate Professor in the School of Psychology at the University of Sydney. Dr. Hunt researches mental health services for anxiety disorders in a range of ethnic populations. Her published works focus on mental health services research, the prevention of anxiety and depression, and bullying in schools.

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