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1 Social Work in Public Health ISSN: (Print) X (Online) Journal homepage: The Effects of Discrimination and Acculturation to Service Seeking Satisfaction for Latina and Asian American Women: Implications for Mental Health Professions Bu Huang PhD and MS, Hoa Appel & Amy L. Ai To cite this article: Bu Huang PhD and MS, Hoa Appel & Amy L. Ai (2011) The Effects of Discrimination and Acculturation to Service Seeking Satisfaction for Latina and Asian American Women: Implications for Mental Health Professions, Social Work in Public Health, 26:1, 46-59, DOI: / To link to this article: Published online: 04 Jan Submit your article to this journal Article views: 815 View related articles Citing articles: 10 View citing articles Full Terms & Conditions of access and use can be found at

2 Social Work in Public Health, 26:46 59, 2011 Copyright Taylor & Francis Group, LLC ISSN: print/ x online DOI: / The Effects of Discrimination and Acculturation to Service Seeking Satisfaction for Latina and Asian American Women: Implications for Mental Health Professions BU HUANG Research Institute, Bastyr University, Kenmore, Washington, USA HOA APPEL Independent Researcher, Everett, Washington, USA AMY L. AI School of Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania, USA There is ample research showing that there are health disparities for minorities with respect to seeking mental health services in the United States. Although there are general barriers for minorities in seeking service health, minority women are more vulnerable due to their negative experiences and lower satisfaction in receiving health care, compared to men. This study utilized the National Latino and Asian American Study (NLAAS) data set, which is the first population-based mental health study on Latino and Asian Americans, to give a full description of Latina and Asian American women s experience in mental health service seeking and identifies the opportunities in increasing their satisfaction levels. The results showed that perceived discrimination attributed to gender or race/ethnicity is negatively predicting levels of satisfaction of mental health service seeking. Older age, higher education levels, longer duration in the United States, and better mental health, are positively related to satisfaction levels for Latina and Asian American women. KEYWORDS Race and gender-related discrimination, mental health service seeking, patient satisfaction, immigration, acculturation, education, Asian American woman, Latina women Address correspondence to Bu Huang, PhD, MS, Research Institute, Bastyr University, Juanita Dr. NE, Kenmore, WA buhuang@gmail.com 46

3 Effects of Discrimination and Acculturation 47 INTRODUCTION As a profession, social work represents a major part of health and mental health practice in the United States. Compared with psychiatry and clinical psychology, the profession has long taken the lead in issues related to race, ethnicity, and gender-related disparity (National Association of Social Workers [NASW], 2007). However, there is a need for more evidence-based research on this topic to keep up with the profession s practice-based leadership role on the national stage. The Latino and Asian American populations have been rapidly increasing in the United States (Passel & Cohn, 2008; U.S. Census Bureau, 2002). Nevertheless, there is scant research to present information about mental health service in these two subgroups. Minorities frequently receive health care that is inadequate with respect to quantity and quality (Briggance & Burke, 2002; Jones, Cason, & Bond, 2002). One of the most significant factors contributing to ethnic disparities in health care is social and economic inequality (Nazroo, 2003; Seguin, Potvin, St-Denis, & Loiselle, 1999; Snowden, 2003). Another contributing factor is the inability of providers to recognize the cultural barriers faced by their minority patients (Ivey & Faust, 2001; Sherer, 2003; Snowden, 2003). Still others have to do with a culturally based stigma connected to mental illness. Snowden (2003) theorized that health care disparities among minorities occur due to the clinicians and mental health administrators making unwarranted judgments about people on the basis of race or ethnicity. It is imperative that providers respect their ethnic minority patients and patients cultural beliefs and health practices. Ngo-Metzger, Legedza, and Phillips (2004) recommended that providers must try to understand and incorporate cultural understanding into their health care practice. These problems were exacerbated in a managed care setting employing gatekeepers in which ethnic minorities were less likely than White patients to receive appropriate care (Cooper et al., 2003; Hargraves, Cunningham, & Hughes, 2001; Shi, Forrest, von Schrader, & Ng, 2003; Van Ryn & Fu, 2003). Culture-related identity and family structure in minority groups may vary and may significantly affect their service needs and help-seeking behaviors involved. For example, in Hispanic families, identity is often derived from being a member of a group, rather than being an individual (Ivey & Faust, 2001). Hispanic males and elders advise family members regarding decisions and become privy to a great deal of information; therefore, it may be unacceptable in that culture for a youngster to accompany his mother to serve as a translator (Haffner, 1992; Sherer, 2003). Ivey and Faust (2001) noted that having family members as translators may cause potential stress and also introduce bias, causing errors in the translation of symptoms and medical history. Hispanics feel compelled to appear agreeable to their physicians out of respect and courtesy, and as a result, these patients fail to question their physicians without understanding them (Haffner, 1992). More important,

4 48 B. Huang et al. ethnic minority patients would like providers to respect their culturally based health beliefs and practices, and providers must recognize and understand the cultural differences (Ngo-Metzger et al., 2004). It has been suggested to learn the cultural differences among ethnic groups and also address cultural differences before psychotherapy begins (LaRoche & Maxie, 2003). Further, mental health providers from a mainstream background may lack of knowledge about culture-related mental health manifestations. In Asian American cultures, for example, somatic symptoms and nonverbal expressions are more culturally accepted and less stigmatized (Herrick & Brown, 1998). The lack of culturally appropriate services contributes to the low levels of mental health usage for Asian Americans (Okazaki, 2000; Takeuchi & Kramer, 1995; Takeuchi, Sue, & Yeh, 1995). Takeuchi et al. (1998) found that Chinese immigrants and native-born Chinese living in Los Angeles County were better served with ethnically matched health services. Asian Americans are usually hesitant to seek services for their emotional needs (Cheung & Snowden, 1990; Ying & Hu, 1994). This may be due in part to health beliefs, centered in oriental medicine, taking a holistic view of physical health and mental health rather than separating them (Ai, in press). Emotional problems are closely associated with organ-based health, though these organ functions are systematic as functionally described rather than anatomically described (Ai, in press). Perhaps for the same reason, research has found that Latinos living in the United States have underused mental health services, and this is troubling from the standpoint of research and in clinical practice (Vega & Lopez, 2001; Wang et al., 2005). Women of color may face double barriers. Hispanic women make up a disproportionate number of insured patients (Jones et al., 2002). They faced barriers such as lack of education, low income, and single status that prevent them from making their postpartum check-up visits (Jones et al., 2002; Miranda et al., 2003). Minority women with low socioeconomic status (SES) and inadequate social support networks have an increased risk of depression (Cunningham & Zayas, 2002). On the other hand, minority women do have a heightened need for appropriate mental health care (Diala et al., 2001). Noh and Kasper (2003), for example, showed a significant association between perceived discrimination against Korean immigrants and depressive symptoms. Mental health issues may manifest themselves as gastrointestinal symptoms or chest pains in Hispanics, or complaints of dizziness in Asians (McCarthy, 2001). The manifestation of distress, negative emotion, and depression among Hispanics and Asians are more somatic than emotional (Takeuchi, Chun, Gong, & Shen, 2002). As shown in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV), the cultural variations of certain mental health issues, such as hwa-byung in Korean housewives, blacking out in Caribbean women, koro in Malaysians, locura in Latino and Latina, and qi-gong psychotic reaction in Chinese (pp ; also see Ai, in press), may not be fully understandable by

5 Effects of Discrimination and Acculturation 49 mental health professionals from the mainstream backgrounds in the United States. The key to improving the utilization of mental health service for Latina and Asian American women therefore lies in the improvement of provider patient relationship. As a start, social workers and major mental health providers should know better whether the existing service is meeting women s basic needs. A study by Ayanian et al. (2005) identified that Hispanics reported more problems with coordination of health care, and non- English-speaking Hispanic patients reported more problems with their health care providers. Similarly, Asian Americans patients rated their health care experience poorly compared to Whites (Haviland, Morales, Reise, & Hays, 2003). Taira et al. (1997) reported that Asian Americans rated their overall satisfaction with their primary care physician lower than that of Whites in their cross-sectional study of 502 patients. Likewise, Hunt, Gaba, and Lavizzo- Mourey s (2005) study showed that ethnic minorities were more likely than Whites to have lower levels of trust and satisfaction with their physicians. Moreover, Ngo-Metzger et al. s (2004) study revealed that Asian Americans were less likely to report positive interactions with their physicians than were White patients. Additionally, results from the Consumer Assessment of Health Plans Study of 47,300 Medicaid enrollees showed that racial/ethnic and linguistic minorities reported worse care than did Whites (Weech- Maldonado, Morales, Elliott, Spritzer, Marshall, & Hays, 2003). Taken together, it is likely that discrimination and acculturation-related issues may contribute to the lack of service seeking and satisfaction among Latina and Asian American women. To test this hypothesis, we analyzed the data from the national study on Latina and Asian American population, conducted as part of the Collaborative Psychiatric Epidemiology Studies (CPES) (Heeringa et al., 2004; Kessler et al., 2004; Pennell et al., 2004). The main purpose of the CPES was to collect data on the prevalence and patterns of mental disorders and their treatment patterns in U.S. adults (Heeringa et al., 2004). The National Latino Asian American Study (NLAAS) adapted its research design (e.g., procedure, main questionnaire about sociodemographics and mental health issues) from the National Comorbidity Survey (NCS), in which the sample sizes were relatively small for ethnic minorities, specifically for Asians (Kessler et al., 1994; Wang et al., 2005). The NLAAS is specifically designed to integrate the psychiatric epidemiologic data and psychiatric disorders of Latinos and Asian Americans (Alegria et al., 2004). To date, new and limited publications on the NLAAS data noted that Asian women born outside the United States were less likely than U.S.-born women to experience a mental disorder during their lifetime (Abe-Kim et al., 2006). For the purpose of the current study, we selected only Latina and Asian American women who had sought mental health service within the past 12 months. Based on the literature, we hypothesize that discrimination attributed to race and/or gender issues would negatively affect satisfaction

6 50 B. Huang et al. with service provided. However, we also expect other influences from acculturation may be related to better outcomes. Finally, mental health status and certain demographics were selected as controls. Participants and Sample Design METHOD Based on the model of the National Comorbidity Study Replication (NCS-R) and the National Survey of American Life (Alegria et al., 2004), the NLAAS became the first population-based national survey for Latino and Asian American. The NLAAS questionnaire was available in six languages: English, Spanish, Mandarin, Cantonese, Tagalog, and Vietnamese. Instruments include social demographic variables, mental health screening and diagnosis variables, service usage and evaluations, and acculturation and immigration items, among others. The sampling procedure for the NLAAS was previously documented, and weights were developed to correct for sampling bias (Alegria et al., 2004; Heeringa et al., 2004). The total sample size of the NLAAS is 4,649, including 2,554 Latinos, and 2,095 Asian Americans, among them, 1,427 Latina and 1,097 Asian American women. However, it is worth noting that, among Asian descendents, this national study mainly targeted the three diverse major subgroups with respect to SES, namely those with Chinese, Filipino, and Vietnamese heritage. However, the survey did not target those in other major Asian American subgroups with above-average SES, such as Eastern Indian, Japanese, and Korean descendents (U.S. Census Bureau, 2002). In the current study, we used 268 Latina and Asian American women who had been seeking mental health service in the past 12 months (n D 188 for Latina, and n D 80 for Asian American women). Measures The dependent variable in this study is satisfaction of service use. The variable used to select the sample was service usage. Respondents in the NLAAS survey were asked the types of mental health services they used with these questions: How many visits did you make to a (provider list) in the past 12 months? These providers include psychiatrist, psychologist, other mental health professional, general practitioner, nurse, occupational therapist or other health professional, social worker, counselor and religious or spiritual advisors, and any other healers). This variable was dichotomously coded (0 D none, 1 D at least once). For every kind of providers the women went to see in the last 12 years, they were asked about their satisfaction with care received with the question In general, how satisfied are you with

7 Effects of Discrimination and Acculturation 51 the treatments and services you received from [service provider] in the past 12 months very satisfied, satisfied, neither satisfied or dissatisfied, or very dissatisfied? In the current study, we average the satisfaction scores, if the women had gone to different kind of service providers, and use the mean as the general satisfaction for mental service. Based on literature review, we have included the major independent variables as following: acculturation, discrimination, and reason for discrimination. Acculturation is measured by English-language proficiency, using an average of three items, self reported, on how well they speak, read, and write English (Cronbach s alpha is 0.98); Discrimination was assessed using the nine-question asking in the day-to-day life how often these things happen to you, for example, you were treated with less courtesy than other people. The internal consistency for this nine-item scale in this sample was We used the mean of the nine items, and the mean is around 2. With 1 means never and 6 means almost every day, the overall mean in this sample is around less than once a year. However, only about one fourth of the women never had any discrimination toward her. Reason for discrimination was measured by the answer to the questions: what do you think was the main reason for these experiences, we grouped the answers your ancestry or national origin or ethnicity gender or sex, and your race together versus other reasons such as your age your sexual orientation, and your weight, because we feel that the first three options are discrimination, that is, speak to the fact that we were focusing on discrimination that is specific to Latina and Asian American women. The resulting dichotomous variables showed that among the 268 women, 35.1% feel that the discrimination she experienced is the result of her being a Latina or Asian woman. The women who had never had any discrimination experiences are coded 0 for this item. For controls, we used age, education, and income, race/ethnicity (Latina or Asian in our sample), U.S. born, and years in the United States, and mental health self-rating. Income is measured using an index as the ratio to poverty threshold. Years in the United States is categorized as 0 to 5, 6 to 10, 11 to 20, and 21 years and beyond). The mental health self-rating was assessed with one question: How would you rate your overall mental health Excellent, very good, good, fair or poor? Descriptive Analysis ANALYSIS AND RESULTS Table 1 shows characteristics of women respondents on whom they seek for health care and the number of visits in the past 12 months. For service utilization, 607 of the female respondents in NLAAS (24%) have seen at least one of the nine kinds of professional for mental health issues in their lifetime.

8 52 B. Huang et al. TABLE 1 Types of Professionals Visited in the Last 12 Months and the Numbers of Visit (N D 268) Providers % Visited last year # of Times past 12 months if visited Psychiatrist General practitioner or family doctor Psychologist Social worker Counselor Other mental health professional Nurse/occupational therapy/other health professional Religious or spiritual advisor Other healer And, 268 of the women (10.6%) have gone to see at least one those professionals in the past 12 months. In our sample of 268, if a woman went to seek help, most likely, she went to general practitioner for help (47%), followed by psychiatrist (one of three). Only 12% used a social worker for help. The statistics of the dependent and predictor variables used in the analysis are presented in Table 2. In the current analysis, satisfaction is the outcome, dependent variable of the proposed regression analysis, with higher score meaning higher levels of satisfaction. As shown in Table 2, among the 268 women we are studying, the average score of satisfaction ranges from 1 to 5, with 1 indicating very dissatisfied and 5 indicating very satisfied, and mean of 4 indicating satisfied. Among the 268 women in our analysis, age ranges from 18 to 88, with a median at 41; education level ranges from fourth grade or less to 17 years or more, with a median of 12th grade; income is measured using the 2001 Census household income-to-needs ratio; there are 40.3% of the sample who are born in United States, and for the years in United States, the U.S.-born TABLE 2 Means, Standard Deviations and Ranges of the Variables in the Analyses (N D 268) Outcome/dependent variable Mean/or % SD Minimum Maximum Satisfaction Age Asian 29.9% Education level Poverty index United States born 40.3% Years in United States (Categorical) English proficiency Discrimination experience Discrimination reason (gender/ethnicity) 35.1% Mental health self-rating

9 Effects of Discrimination and Acculturation 53 were assigned the highest categories. In the current study sample, the mental health self-rated has a mean of good, and few people choose the extreme values. MULTIVARIATE REGRESSION The analysis plan is to run multiple regressions to test which variables are significant after controlling of other potential predictors. Weights are used in all regression attempts to account for sampling bias. There seems to be no difference between Asian and Latina in terms of service seeking satisfaction. The final regression results (N D 268) are presented in Table 3. With df D 10, and F D 4.283, the R 2 (.143) indicated that the multiple regression model explained 14.3% of the variance in Latina and Asian women s mental health seeking satisfaction. As expected, mental health self-rating is closely related to satisfaction, with higher level of mental health rating indicating higher satisfaction. For our main hypothesis, the results showed that levels of discrimination are not predicting levels of satisfaction; however, if the reason of discriminating is perceived to be because of race/ethnicity or gender, it leads to a lower level of satisfaction. For our secondary hypothesis, higher level of English proficiency does not predicts higher level of satisfaction; Being U.S. born alone does not predict satisfaction; however, longer years of being in the United States is associated with higher levels of satisfaction. Furthermore, education is also significantly predicting satisfaction level, with higher level of education predicts higher level of satisfaction. Age has a positive relationship with satisfaction level. When other variables are controlled for, poverty level or income does not predict satisfaction. TABLE 3 Ordinary Least Square Regressions Predicting Mental Health Service Satisfaction Among Latina and Asian American Women Predictors Beta Age.275*** Asian.014 Education level.209* Poverty index.009 United States born.134 Years in United States (Categorical).232* English proficiency.153 Discrimination experience.035 Discrimination reason (gender/ethnicity).132* Mental health self-rating.168** F statistics df 10 R Note. *p < 0.05, **p < 0.01, ***p <

10 54 B. Huang et al. DISCUSSION The current study may be the first to demonstrate the satisfaction pattern among Latina and Asian American women who sought mental health service over the past 12 months when the NLAAS was conducted. Not surprisingly, the rate of service seeking is low, consistent with the general report from this database (Alegria et al., 2007). Interestingly, some significant predictors for satisfaction for service in the NLAAS are consistent with the finding for other minority groups with respect to age and education (Jackson, Chamerlin, & Kroenke, 2001; Sitzia & Wood, 1997). Similar to Abe-Kim et al. s (2006) study, for Latino and Asian Americans, the immigration factor in terms of years in the United States is very important to mental health service seeking and evaluations. This indicates that this acculturation related variable is a key to accept the U.S. type of mental health services. Most of service seekers were born outside of United States. Nonetheless, though the years in the United States predict satisfaction levels significantly, being born in the United States alone does not predict satisfaction level. It is also interesting to see that income level is not a significant predictor in the current study. The most novel finding in this analysis was that multivariate analysis singled out that race and gender-based discrimination, rather than simple frequency of discrimination experience, has the direct and independent effect on service satisfaction. This finding not only lends strong support for our primary hypothesis, but also highlights the fact of the quality of discrimination perceived by Latina and Asian American women overweighs its quantity in the count for service-seeking satisfaction. Discrimination perceived by minorities may impose negative impacts in general; however, for women of color, if the discrimination is perceived to be because of being a woman or because of being of color, the satisfaction of service seeking is especially lower. Clearly, this finding will warrant the greater future research attention among social workers and social scientists in the mental health professions. The perceived reason for discrimination experience is especially noted that we need not only study discrimination but also investigate the perceived reason at a deep level with a more culture oriented perspective as well. Another noteworthy factor lies in education, also standing out as predicting satisfaction level, contrasting with English proficiency that is not predictive. Indeed, education, as a factor of individuals early-life SES, may be considered as one important faction of acculturation. This is because in general race issues tend to interplay with social class problems in the United States and in other countries where immigrants might be born. Certain groups, due to better SES in their origins, might have already expose to the U.S. or Western culture even before they came to the United States. In contrast, those who were born in the minority and low SES communities within the poor living environment (e.g., poor areas where Mexican American farmers reside or Chinese Americans with low education in the inner-city

11 Effects of Discrimination and Acculturation 55 Chinatowns) may have a slow process to adapt to the mainstream culture characteristics even after immigrating for generations. These findings thus bear some theoretical and clinical significance in that they provide insights to what is actually at stake English proficiency is important in women s life, however, getting a higher level of education may be more beneficial to move up alongside social ladders. Unlike age or years in the United States, education and perceived reason for discrimination can be modified, if professional effort can be made to prevent or intervene in a culturally sensitive manner. In other words, the two significant variables are individual or group characters that could be changed through some effort by mental health professions and beyond. The current study has important implications for the research, education, and practice of mental health professions in general and social work in particular with respect to their roles in the U.S. public health. According to a national study of licensed social workers from the Center for Workforce Studies by Whitaker, Weismiller, and Clark (2006), the top two practice areas for licensed social workers are the areas of mental health (39%) and health (13%), with 56% of health care social workers practicing within hospital settings. Approximately 5 of 10 jobs in social work were in health care and social assistance settings, and 41% of social workers in 2006 were employed in medical and mental health settings (Bureau of Labor Statistics, 2008). According to the Social Work Imperatives adopted at the National Association of Social Work Congress on March 2005, one key imperative was that social workers as a profession must elevate the public s awareness of the efficacy and cost-effectiveness of social work practice in health care. Along with the diversification and aging trends of the U.S. population, social workers will play an increasingly critical role in health and mental health care. To echo the profession s call, social work must demonstrate its professional service satisfaction with the disadvantaged populations such as Latinos and Asian Americans. As rapidly growing subgroups, the current study clearly indicates their service challenges to social worker providers, as well as other professions in mental and physical health. In addition to the need for more research, educational formats and content must be modified at all levels in schools of social work to expand the skills of social workers. However, first of all, social work professors need to integrate the knowledge about health beliefs and seeking behaviors in these hard-working but care-wise disparity subgroups. Furthermore, to deal more effectively with their unmet mental health needs, social issues in relation to their race, ethnicity, and gender must be addressed in curricular development. Culture-based stigmas and name-calling myths, such as immigrants who steal Americans jobs typically tied to Latino Americans, and the so-called model immigrants typically attached to Asian Americans, should be clarified first among professionals and educators.

12 56 B. Huang et al. Finally, and more important, the current and new generations of social workers need more in-school and postgraduate refreshment education on the diversity-based population change and the rising recognition of the behavioral impact on public health. It can be envisaged that there will be a rise in need for the permanent role of social work in public health and primary care to reduce race, ethnicity, and gender-based disparities while saving costs for hiring more costly nurses, clinical psychologists, and psychiatrists in these areas. As such, we must endorse the integration of health and mental health components in curricular development rather than continuing the conventional overspecialized social work education. However, most important, our professionals need to enhance their capacities in assessment and treatment of these mental health disorders on the basis of the culturally sensitive practice. Certain limitations inherent in the current study should be noted. The current study is based on a cross sectional sample and is not an intervention study. Findings here thus do not inform causality. Limited by sample size, we do not present exact satisfaction rates for social work services. Furthermore, as noted above, the three Asian American populations in the NLAAS mostly excluded some major subgroups with the on-average better-off SES, which may have certain impacts on the understanding of the interplay between acculturation and SES in Latino and Asian Americans as two with more new immigrants. There is the likelihood that with higher education these undetected subgroups may share more similarity with mainstream Americans in terms of mental health service seeking. Perhaps in part due to this exclusion, the effect size in this analysis is modest. However, these assumptions must be tested when the national survey includes these major subgroups who number in the millions (U.S. Census Bureau, 2002). Although this new design may not be attainable in a short term, more in-depth studies, including qualitative ones, can be done to explore the undetected predictors and to cover and represent wide range of ethnic groups. Another limitation of the current study is the survey questionnaire does not include items on the characteristics of the providers. Race, gender, and age discordances are factors in patientprovider satisfaction research, which have special cultural meanings for Asian and Latina women who seek mental health care. In summary, the current study demonstrates that race and gender-based discrimination, as well as several acculturation-related variables (e.g., years in the United States and education) are significant predictors for satisfaction of service seeking among women of Hispanic and Asian origin. It provides us with opportunity in future prevention programs. The current study opens a door for further exploring the effects of discrimination based on gender and ethnicity. Mechanisms underlying the predictions of these factors for the satisfaction with mental health service-seeking behaviors should also be explored in the future for improvement for Latina and Asian American women, two rapidly growing U.S. subpopulations.

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