USE THE CHAPTER 1 INTRODUCTION TEMPLATE. You will write your chapter 1/introduction which is 2-4 pages in length, and also include a title page, and a list of 10 reference articles.

CHAPTER 1. INTRODUCTION

Introduction to the Problem

Untreated mental health issues are a worldwide public health concern (Chelala, 2013,

June 14). Approximately 450 million individuals suffer from some type of mental condition,

placing it as one of the leading contributors to ill-health and disability globally (World Health

Organization [WHO], 2001, October 4). According to the WHO (2001, October 4), although

there are existing treatments available, about two-thirds of people with a mental disorder do not

seek assistance from traditional services due to barriers such as stigma, discrimination and

disregard for health, which may result from a lack of understanding of mental health.

Background of the Problem

Great concern is seen with the mental health of Asian communities among developed

countries of North America (American Psychological Association [APA], 2016; Farah, Khanlou,

& Tamim, 2014). They are known to represent a vast population that is continuing to increase,

hold a prevalence of mental health issues, and are notably recognized to underutilize mental

health services (Leong, 2011). For example, the United States, known as a melting pot of diverse

cultures, has an Asian represents the fastest-growing race group with an estimated amount of

17.3 million residents (Hoeffl, Rastogi, Kim, & Shahid, 2014). As a result, 13% of the Asian

American and Pacific Islanders (AAPIs) in the United States – totaling 2.2 million people – are

diagnosed with a mental illness in a given year (Mental Health America, 2016). In fact, one-third

of this population size utilizes mental health services (Abe-Kim et al., 2007). Research has

analyzed different Asian cultures and their subgroups, reporting that many that go undiagnosed

and untreated (Bauer, Chen, & Alegria, 2010; Derr, 2016).

Canada is another country experiencing a significant growth in their population of Asians

with a reported 4.5 million people (Asian Pacific Foundation of Canada, 2016). Studies reveal

that 1 in 5 Canadians will experience a mental illness at some point in their lifetime (Canadian

Mental Health Association, 2016). More concern is seen among South Asians, which represent

the largest visible minority group (1.26 million) in that country alone (Farah, Khanlou, &

Tamim, 2014). In Canada, the highest rate of South Asian people with unmet healthcare

treatment needs who have a major depression disorder was reported at 48%, with 33% indicating

that they had experienced barriers to accessing mental health services when compared to five

other ethnic groups, including Japanese, Chinese, Koreans, Aboriginals, and Whites (Gadalla,

2010).

Studies analyzing Asian subgroups in their foreign countries have recognized various

barriers affecting their ability to access treatment, such as shame and stigma culture (David,

2010), lack of mental health literacy (Nguyen & Bornheimer, 2014), lack of health insurance

(Lee & Matejekowski, 2012), and immigrant status (Kim & Keefe, 2010). Identifying and

understanding these and other perceived barriers to mental health issues among the Asian

population is imperative in order produce better tailored interventions which, in turn, will allow

them to receive the most appropriate assistance (National Alliance of Mental Illness, 2011).

In order to facilitate solution efforts made by public health professionals and policy

makers, research should continue to address all factors impacting their access to mental health

services (Snowden & Yamada, 2005). Much of recent published research has studied barriers

either as a single factor (e.g., language proficiency, stigma, acculturation difficulties) affecting

one specific Asian group (e.g., Asian refugees, Asian elderly immigrants, Asian American

college students) (Lai & Surood, 2013; Leong, 2011; Shannon, Vinson, Cook, & Lennon, 2016)

or collectively with other ethnic minority groups (Abe-Kim et al., 2007). There have been few

reports which have offered summarized data on barriers to health care treatment (Kim & Keefe,

2010), but no comprehensive review of the issue. Recent relevant systematic reviews are specific

to access to treatment (Greenwood, Habibi, Smith, & Manthrope, 2015), language barriers

(Ohtani, Suzuki, Takeuchi, & Uchida, 2015) and the impact of mental health-related stigma

(Akutsu & Chu, 2006).

Statement of the Problem

Asian populations in developed countries of North America experience barriers to mental

health services. Research aiming to learn more about each of the individual Asian sub groups

will offer critical details to assist with development of personalized mental health interventions,

thereby providing each one with the essential support that result in decreasing the prevalence and

incidence of mental health issues (Leong & Kalibatseva, 2011). In fact, the “one size fits all”

method has been shown to have limited effectiveness over time (Betancourt, Green, Carrillo, &

Park, 2005, para. 18). Research has also identified how tailored approaches to health care, such

as cultural competency are found to improve health outcomes as well as the quality of care

(Health Policy Institute, 2004).

Purpose of the Study

Taking various forms, and experienced at different levels of intensity, mental illness is a

common health issue affecting many individuals not only in North America, but worldwide.

Several studies have examined barriers to mental health services among Asian subgroups

collectively, but there is very little research separating the separating them to gather their

similarities and differences in mental illness among them (Leong & Kalibatseva, 2011).

Therefore, the aim and scope of this systematic literature review is to provide a comprehensive

synthesis of barriers to mental health services found among Asian groups living in North

America. Furthermore, reveal which factors giving the most hindrance among Asian populations,

and identify barrier trends among the Asian subgroups.

Research Question

This project aims to answer the following research question: What are the major barriers

preventing Asian populations from seeking mental health services?

Significance of the Study

According to data and findings collected from the Substance Abuse and Mental Health

Services Administration (SAMHSA), the Social Security Administration, and the National

Comorbidity Survey – Replication (NCS-R), the National Institute of Mental Health (NIMH)

estimates an excess of $300 billion of total annual expenses are related to serious mental illness

which affects about 6% of the adult population. Furthermore, the approximate total amount spent

on all items associated with mental illness is rooted from the direct expenditures (e.g., treatment,

mental health services), as well as indirect expenditures consisting of losses resulting from

disability related to the mental condition (e.g., lost earnings, disability support) (NIMH, 2016a).

Lost earnings alone for serious mental illness costs the U.S. about $193.2 billion per year (Insel,

2008). The objectives of this systematic literature review are to analyze a collection of numerous

studies published in the past 11 years, identifying barriers hindering Asian populations in the

U.S. and Canada from receiving mental health care services and to highlight the trending barriers

found among individual Asian subgroups.

Assumptions

The systematic literature review was conducted by a single author; therefore, the

assumption is that the validity of the results may be affected as there is a risk of bias during the

assessment of studies. It is further assumed that production of generalize results can be found as

majority of the research studies involved quantitative methodology involving large populations.

Lastly, the review can be replicated as it follows a step-by-step systematic process of collecting,

examining, and synthesizing data from research studies.

Limitations

The review consisted exclusively of peer-reviewed articles published within an 11-year

timeframe. Credible online resources and books were not included as they posed potential

complications with coding and issues with data analysis. Due to these limitations, the review

may have not examined all pertinent articles. Although, there is certainty that the results may not

have differed significantly if there were more articles included. The majority of the studies were

conducted in the U.S. and a few from Canada. The review itself uncovered commonalities in

barriers to mental health services (e.g., stigma, strong cultural adherence among older

immigrants) between both Asian Americans and Asian Canadians which contributed more

knowledge of the Asian subgroups found in developed countries. Unfortunately, it does not

reflect all barriers found in populations located in other developed nations within North America.

In addition, bias may have occurred during the article selection process (e.g., setting of inclusion

and exclusion criteria) and the reviewing stages (e.g., coding) due to the examination being

conducted by one author.

Summary

There is scarce research examining the unique barriers to mental health services among

the individual Asian subgroups. It creates a challenge for public health professionals to develop

effective interventions for these people who have been identified as one of the populations

experiencing a high incidence of mental health issues in North America. The intention of the

systematic literature review is to provide a comprehensive synthesis of distinct barriers found in

each Asian subgroup and identify influences contributing the greatest challenge to seeking help

for their mental illnesses.

Chapter 2 consists of a literature review of past research providing its history and current

state, which will provide support to the given public health issue. Chapter 3 includes the

methodology of the systematic literature review consisting of the description of the participants,

as well as the inclusion and exclusion of studies selected. Chapter 4 discusses the data collection

procedures, analysis, and results. Lastly, the project closes with Chapter 5, which provides

further discussion, conclusions, as well as recommendations for future studies.

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Bauer, A. M., Chen, C. N., & Alegria, M. (2010). English language proficiency and mental

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Betancourt, J. R., Green, A., Carrillo, E., & Park, E. R. (2005) Cultural competence and health

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Chelala, D. (2013, June 14). Untreated mental health issues: A global reality. Movement for

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Farah, I., Khanlou, N., & Tamim, H. (2014). South Asian population in Canada: Migration and

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Gadalla, T. (2010). Ethnicity and seeking treatment for depression: A Canadian society. Journal

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Health Policy Institute. (2004). Cultural competence in health care: is it important for people

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Kim, W., & Keefe, R. (2010). Barriers to healthcare among Asian Americans. Social Work in

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Lai, D.W., & Surood, S. (2013). Effect of service barriers on health status of aging South Asian

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Lee, S., & Matejkowski, J. (2012). Mental health services utilization among non-citizens in the

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Foundation. Retrieved from http://www.dana.org/Cerebrum/Default.aspx?id=39458

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services in the United States. The Dana Foundation. Retrieved from

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Mental Health America. (2016). Asian American/Pacific Islander communities and mental

health. Retrieved from http://www.mentalhealthamerica.net/issues/asian-americanpacific-

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depression. NAMI Releases Report. Retrieved from http://www.nami.org/Press-

Media/Press-Releases/2011/Asian-American-Teenage-Girls-Have-Highest-Rates-of

Nguyen, D., & Bornheimer, L. (2014). Mental health service use types among Asian Americans

with a psychiatric disorder: Consideration of culture and need. Journal of Behavioral

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Shannon, P., Vinson, G.A., Cook, T. L., & Lennon, E. (2015). Characteristics of successful and

unsuccessful mental health referrals of refugees. Administration and Policy in Mental

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Snowden, L., & Yamada, A. (2005). Cultural differences in access to care. Annual Review of

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World Health Organization. (2001, October 4) Mental disorders affect one in four people.

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The Capstone Project

Signature Page

Abstract

Table of Contents

Introduction

Literature Review

Methods

Results

Discussion

References