Demographic, Contextual, and Cultural Barriers to Mental Healthcare Seeking Behavior in the United States Among Southeast Asian Women Refugees: A Systematic Review Open Access

DiVitale, Sandra (Summer 2020)

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Little is known about Southeast Asian refugees’ American mental healthcare seeking behavior. Previous research has indicated that Southeast Asian refugees underutilize American mental healthcare services. However, the reasons for this underutilization are not fully understood. This systematic review examines the relationship between contextual, cultural, and demo graphic factors and their influence as barriers to accessing these services among Southeast Asian American refugees, especially women. An index search was conducted for peer-reviewed journals published from 1975 to 2019 using PubMed, EMBRACE, Web of Science, PsychInfo, and Anthropology Plus databases. This search was followed by manual handsearching and snowballing techniques to identify gray literature. Sixteen publications in total were included in the final analysis. 

Results from the review suggest that Southeast Asian women refugees have more positive attitudes toward and willingness to use American mental healthcare than men. Women refugees’ experiences of greater pre-migration and resettlement psychological distress are accredited for their motivation in having a more favorable view of American mental healthcare services. Review studies challenge previous research findings that Southeast Asian refugee underutilize these services. Findings suggest instead that American standards for minimally adequate mental healthcare do not meet the needs of Southeast Asian refugees when they do present for care.  Southeast Asian women refugees who experienced domestic violence indicated a preference for community, peer-based support groups that provide instrumental learning and psychoeducation instead of seeking outside mental healthcare. Cultural barriers are found to be less influential through time than structural/contextual barriers such as continued extreme poverty with limited access to transportation and health insurance. Recommendations include multi-level interven-tions that address decreasing barriers to accessing American mental healthcare at the individual/ family, community, and societal levels.


Table of Contents

List of Tables x                                                                                                                                                                                                                                                                     

List of Figures x

Select of Abbreviations x

Chapter One: Introduction

Background 1

Problem Statement 2

Purpose Statement 2

Research Objectives 2

An Overview: Southeast Asian (SEA) Refugee Countries of Origin 3

SEA History of Migration to the U.S. 5

Overview 5

Vietnamese Refugees 5

Cambodian Refugees 6

Laotian Refugees 7                                                                                                                                             

Current Migration Patterns within the U.S. 8

Understanding Migrant Status in Relation to Potential Mental Health Outcome 9

Overview 9                                                                                                                                             

Refugee Status 9

Immigrant Status 10

Contribution to Different Mental Health Outcomes 10

Theoretical Framework: Social Identity Theory in Relation to Southeast Asian American Refugee (SEAA) Mental Healthcare Utilization 12

Significance Statement 14                                                                                                                                             

Chapter Two: Review of the Literature

Definitions of Select Terms and Constructs 16                                                                                                                                             

Prevalence and Social Determinants of SEAA Refugee Unaddressed Mental Health Issues 20             

Overview 20

Gender Differences 22        

Intergenerational Transmission of Unresolved 25

Conclusion 27

Current SEAA Refugee U.S. Mental Healthcare Usage Patterns 27

Overview 27

SEAA Mental Healthcare Utilization 29

Gender Differences 30

Minimally Adequate Care 31

Conclusion 34

Current Research on Overall Barriers to SEAA Mental Healthcare Seeking Behaviors 35

Overview 35

Barriers for Asian Americans (AAs) 36

2.1 Contextual Barriers 37

2.2 Cultural Barriers 39         

2.3 Demographic Barriers 46

Summary Remarks on Barriers to Mental Healthcare Access for SEAA Refugees 49           

Chapter Three: Methodology—Data Collection and Analysis

Overview 51  

Literature Search Methodology 51

Data Extraction 57

Analysis Plan 58

Quantitative and Mixed-Methods Study Analysis 58

Qualitative Study Analysis 59

Chapter Four: Results

Overview: Study Selection 61

Systematic Review Study Characteristics 61

Analysis of Major Themes and Findings 64

Overview 64

4.1 Levels of Psychological Distress 65

4.2 Gender-Based Violence: Domestic Violence 68

4.3 American Mental Healthcare Seeking Behavior 70

4.4 Barriers to Accessing American Mental Healthcare Utilization 75

Summary Comments 83

Chapter Five: Discussion

Overview 86

Discussion of Review Studies’ Key Findings 86

5.1 Objective One: Gender, Ethnicity, and Cultural Influences on Help-Seeking 86

Summary Comments on Research Objective One 92

5.2 Objective Two: Barriers to SEAA Refugee Women Mental Health Help-Seeking 94                     

Summary Comments on Research Objective Two 96

5.3 Objective Three: Barrier Predictor Variables across SEAA Ethnic Groups 98

Summary Comments for Research Objective Three 100

5.4  Objective Four: Rethinking Acculturation as a Cultural Barrier 101

Summary Comments for Research Objective Four 103

Strengths and Limitations of Review Studies 105

Strengths 105 

Limitations 105

5.5 Objective Five: Current Interventions Intended to Increase Engagement in

Mental Healthcare Services 108

5.6 Objective Six: Recommendations for Intervention Approaches 110

Implications for U.S. Public Health 113

Suggested Future Research 115

Conclusions 118

References 121

Appendices 141

Appendix A: National Demographics: SEAA by County (2010) 142

Appendix B: General Characteristics of Systematic Review Selected Studies 143

Appendix C: Methodological Characteristics of Systematic Review 149


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