The effective analysis on the barriers for the Chinese Immigrants for care seeking of mental health 8

Abstract

According to the World Mental Health Survey carried out in [2001] and [2002] by the World Health Organization (WHO), the projected incidence of mental illnesses in Beijing was 9.1% and in Shanghai 4.3% (WHO World Mental Health Survey Consortium, 2004). In 2004, Phillips et al. (2009 discovered that the adjusted one-month incidence of any mental disorder was 17.5 percent, that of mood disorders was 6.1 percent, and that of anxiety disorders was 5.6 percent. More lately, statistics published in 2009 by the National Mental Health Center of China show that more than 100 million Chinese (i.e. one in 13) suffer from mental illness (Yu). What are the barriers that prevent Chinese people from accessing professional services who have emotional or mental problems? Hunt, & Li, 2008; Kung, 2004; Mo & Mak, 2009; Spencer & Chen, 2004; Spencer, Chen, Gee, Fabian & Takeuchi, 2010 received significant government attention (AB-KIME et al., 2007; KEN, KAZANGIAN, & Wong, 2009). Some studies also examined the impact of culture on the conduct of individuals seeking help in mainland China. 

This study examined perceived obstacles to mental health therapy based on a sample of 1747 from the Chinese American Psychiatric Epidemiological Study. Two variables arose, namely practical obstacles that included therapy costs, time, access and language expertise, and cultural obstacles that consisted of therapy credibility, recognition of need, and fear of face loss. Average scores of all practical barrier items were greater than cultural barrier items, showing the significance for this population of pragmatic factors. This research examined the empirical connection between these perceived obstacles and the real use of mental health services in a novel effort. The practical barrier factor showed importance for both the entire sample and a subsample of people with at least one lifetime mental disorder in anticipating service use. However, cultural obstacles did not acquire meaning. Implications of the results are discussed in practice and research. © 2004 Wiley Newspaper, Inc. Psychol 32 J Comm: 27–43, 2004.

Introduction/Background

As in many other nations, the population of China in the Netherlands has grown significantly over the last decade. Today, the population is around 100,000 [1,2] and is the fourth biggest and one of the longest established ethnic minorities in the nation. This article covers not just Chinese-speaking people (mainland China, Hong Kong, Macao, and Taiwan) with dominant Chinese culture, but those from foreign Chinese groups, such as Indonesia and Suriname. This article includes the Chinese category. Including kids of migrants born in the Netherlands, the second generation. Whilst efficient treatments, including medication and psychotherapy, are available (Mitchell, 1997), the overwhelming majority of individuals suffering from anxiety are not properly looked after (Kohn et al., 2004). In Canada, 63.1% of significant depressive patients seek therapy for 12 months and 33.1% in 2012 (Patten et al., 2015). In China, 91.7% of mood disorder patients were not conscious of the need to seek therapy (Phillips et al. 2009) and over one year of therapy only 22.7% of those who had significant depression (Lee etc al. 2009). This low level of therapy was likely owing to several variables, including stigmatization of mental illness, absence of knowledge of the need for care, misunderstanding of therapy, inaccessibility of facilities due to price or distance, incorrect dosage of medicines by primary care physicians, or other variables [3].

2.1 Needs and Utilization of Health Care

According to Emerging Dimensions of Business Ethics in China article it states, “With China's emergence as an important business destination, an understanding of the ethical viewpoints is relevant. Much is to be desired in understanding the country's ethical landscape. Ethical behavior study in China is a challenging research arena with several underlying issues (Habib & Zurawicki, 2001). It is important to understand the country's cultural background and how it can potentially shape ethical conduct. The Chinese tend to work alongside a distinct set of values and ideas (Ferrell, Fraedrich., & Ferrell, 2000). Many business practices in the country have been built upon its long history and remain anchored on its culture (Su & Littlefield, 2001). Aside from culture in general, religion and other belief systems specifically can shape business ethics” (Sardy, M., Munoz, J. M., Sun, J. J., & Alon, I., 2008) [4,5]. The absence of understanding in health and technological literacy between populations expected to assist with applications is another weakness in the current literature. The techniques for enhancing health education are not well established among the Chinese immigrant group [1,3]. While ethnic minorities parents have shown a strong interest in using smartphones for their children (St George et al. 2016), some study indicates that parents in the societies of South Asia and China tend to receive passively health information primarily via planned main and social networks (Kowal et al., 2).

This research is a pilot to assess the feasibility of a custom smart phone implementation that can efficiently provide Chinese immigrant parents with child mental health resources. First of all, the incidence of the use of smartphones and smartphones by Chinese parents with young kids in Greater Boston was evaluated. We have also assessed their use of health-themed apps, the amount of concern they show in smartphone applications for studying the subject-matters of child mental health, the resources presently being used for gaining data on children's mental health and the obstacles they face in accessing health-related data via a mobile app. Secondly, we found that the parent interest in using mental health-related smartphone applications relate to demographics, including revenue, education levels and years residing in the United States.

2.2 The impact on immigrant groups of mental illness

In China, the environments for the provision of depression care offer potential benefits for main care clinics. Firstly, patients need assistance because in most urban regions a main clinic can be found within a half a kilometer from their homes. Secondly, health insurance sponsored by the Government includes a higher percentage of main healthcare (90–100%) than hospitals (70%–100%) provided in main care. Third, Chinese people are known to be more susceptible to somatic anxiety (Kleinman, 2004, Parker et al., 2001), so that people may be less probable in primary care than in mental health hospitals to seek therapy for mental health issues (Roeloffs et al. 2003). This paper aims to explore how corporate social responsibility has given way to economic growth in China since the start of economic transition and its cultural and historical background, and how this has affected or been affected by the economic performance of firms [6].

Literature Review

While epidemiological surveys have identified a general pattern of reduced danger of mental health illnesses among first-generation (foreign-born) immigrants in the U.S., latest studies show how this pattern differs significantly by the junction of race, ethnicity, domestic origin, sexuality, and socio-economic status. Contextual variables, including the context of family and neighborhood; the social position of an immigrant; experiences of social support and social exclusion; language skills and capacity; and exposure to discrimination and accultural stress further affect the connection between immigration and mental health. Research on immigrant groups ' health and mental health has shown that first-generation immigrants (those born in one nation, the “home” country, who migrated to the U.S., here called the “host” country) are healthier in terms of the majority of physical and mental health results than their U.S. born counterparts [7].

Fig.1: Mental health illness statistics

Research undertaken over the previous century aimed to unpack these results by investigating the epidemiology of mental health results among particular subgroups of immigrants (e.g., those identified by race / ethnicity, ethnicity, immigration age) and exploring processes assumed to account for group differences. First, we present an overview of latest main results in immigrant mental health epidemiology in particular and then discuss results of concern for particular mental health illnesses. We present then a conceptual framework which integrates these results into understanding the danger and resilience of immigrants in terms of mental health and closely discusses the brief and long term study objectives in the sector [8].

There are two objectives to this research. The first aim is to conduct a more detailed examination in five different races of ethnic origin-European, African, Afro-Caribbean, Asian and Pacific Islanders, Histian and Puerto Rican-of the nativity-based disparities in the utilization of mental health care than was previously investigated. The review also separates immigrants of the first and second generation from immigrants and natives of the third or second generation. The second objective is to evaluate the connection among the first and second generation of immigrants between the distinct aspects of acculturation and use of mental health services. This research uses the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) to tackle these objectives [9,11]. In support of the first objective, the NESARC contains a much broader nationally representative sample of mentally ill people (approximately 8,000) than in the previous studies (approximately 200 to 1,500). In comparison with previous studies, the larger number of people with mental disorder in NESARC is the result of the largest source of psychiatric data for US adults [9] (Grant and Dawson 2006). NESARC is the largest and most current sample (N=43,093). In support of the second objective, NESARC involves a wider amount of interventions that encompass distinct dimensions of acculturation compared to previous research.

Research Methodology:

Data from this study are taken from the Undocumented Student Equity Project (USEP), specifically interviews with 30 learners of undocumented UC about their use of mental health and mental health services. The UC needs medical insurance from all registered learners and provides access to a student health insurance program that provides extensive advantages in terms of medicine, pharmacy, dentistry, vision, mental health and substance use disorder [10]. As a consequence, there was extensive health insurance and access to mental health services for all respondents, including short-term mental health services on campus. We first set up a community advisory committee to reach out to these proponents, which included representatives from healthcare organization in Latinx and Asian American immigrant populations. A preview of the training was presented to the advisory board so that each partner could see what the MHFA training entails and decide who should be trained as “first assistants” from their respective agencies. We established partnerships with the Refugee Resettlement Agency, the Latino Coalition and the Asian American Chamber of Commerce in collaboration with local medical centers [9,10]. We also reached out to important informants in faith-based communities as well as small business owners; both of these organizations are significant stakeholders in immigrant societies in Latinx and Asian American [11].

Fig.2: Community Partners and relationship

From 2011 to 2016, as part of the Oakland Elev8 initiative, the UCSF Department of Family Health Care Nursing was financed by Atlantic Philanthropies to promote the sustainability of new Oakland SBHCs through nursing practice, concentrated student service-learning initiatives and technical aid to SBHC suppliers and employees (Schapiro, Rose, & Franck, 2014). SBHC faculty and suppliers have created population-level screening processes in schools, bringing in additional employees and student health science volunteers to boost ability (Schapiro, Green, Keeton, & Gutierrez, 2016). SBHC employees adjusted this model for use in screenings for newcomers (Gutierrez, Schapiro, & Blackshaw, 2015) [12]. To raise awareness of clinical facilities (Saurman, 2016), a number of outreach strategies have been created by SBHC A and its parent FQHC to take learners to the hospital for original screening and clinical orientation (Schapiro et al., 2016), including targeted screening for newcomers. The outreach plan promotes future access by streamlining the enrollment process in relation to finding and serving young people in need of health care. More importantly, the clinic is provided on campus with multi-lingual employees and various facilities as a youth-friendly, newcomer-friendly setting. Participants were eligible if they identified themselves as Chinese and had at least one kid between 3 and 10 years of age. At a public Chinese community case in Quincy, Massachusetts (Greater Boston Area) in October 2016, the participants were hired in individual. A total of 100 Chinese immigrant parents were hired for this project (n= 100; 79% female; 35.8 ± 6.8 years old). They were provided a option in either English or Chinese to complete a paper-and-pencil study [13].

Table 1

Mental Health Care Utilization by Nativity Status.

First Generation

Second Generation

Non-immigrant

Mood disorder sample (N = 3,230)

 Proportion utilizing mental health care

.28

.37

.37

Anxiety disorder sample (N = 4,239)

 Proportion utilizing mental health care

.16

.26

.23

The sample included patients from Hangzhou City, China, main care hospitals. Depression incidence among main care patients was 15–20 percent, according to prior research (Gili et al., 2013, Yeung et al., 2002) [14]. The sample size should be 2266, calculated on the basis of the Cross sectional study simplification formula. We attempted to invite 3000 patients in account of the response rate. A technique of two-stage sampling has been used. First, from each of the 5 districts in Hangzhou City, twenty primary care hospitals were randomly chosen. A total of 100 hospitals have been chosen as the locations of the research. Secondly, 30 successive patients were hired from each clinic who met the following requirements: (1) age at 18 years of age; (2) residence in the neighborhood served by the primary care clinic (and therefore enrolled as a hospital patient); (3) ability to interact orally; and (4) ability to provide informed consent. Patients recorded in their medical records with cognitive impairment were excluded. The research was endorsed by the Zhejiang University Human Study Committee [14,15].

Table 2

Joint Distribution of Nativity Status and Racial-Ethnic Origins.

First Generation

Second Generation

Non-immigrant

Mood disorder sample (N = 3,230)

 African

31

62

553

 Asian/Pacific Islander

47

22

17

 European

82

236

1,599

 Hispanic

225

122

129

 Puerto Rican

57

43

5

Anxiety disorder sample (N = 4,239)

 African

31

74

795

 Asian/Pacific Islander

47

20

23

 European

111

293

2,152

 Hispanic

274

131

154

 Puerto Rican

66

52

16

4.1 Barriers for the Chinese Immigrants to seek Mental Health

Stigma:

Stigma is such a big issue that research is challenged by the very subject itself. Researchers have to contend with the reluctance of people to reveal attitudes that are often considered socially unacceptable. From two views, how stigma varies by culture can be explored. One view is that of stigma objectives, i.e. individuals with symptoms: are they more probable to experience stigma if they are members of a racial or ethnic minority than whites? The other view is that of the public in their attitudes towards mentally ill individuals: are members of every racial or ethnic minority group more probable to have stigmatizing attitudes towards mental illness than whites? There are far from definitive responses to these cross-cultural issues, but there are some interesting clues from studies. First of all, one of the few cross-cultural studies challenged Asian Americans residing in Los Angeles who experienced symptoms. The results were eye-opening: only 12 percent of Asians would tell a friend or relative about their mental health issues (compared to 25 percent of whites) [22,30]. A meager 4% of Asians would seek assistance from a psychiatrist or specialist (compared to 26% of whites). And only 3% of Asians would seek assistance from a doctor (compared to 13% of whites) [29].

In several surveys, while reporting service usage levels, scientists did not disaggregate immigrant and non-immigrant respondents, although they measured immigration variables in their sample [16,17]. Compared to domestic averages, these aggregated surveys showed very small service prices [4]. Only 4 percent of Asian participants had sought mental health services in the previous year [14]; 3 % of a Vietnamese sample had a mental health professional in the last three years [21]; only 3 percent of Filipino participants had sought official mental health care [20]; and 10 percent of African or Latino females had sought mental health care, although 45 % had sought mental health care [39]. Reporting service utilization rates without account of immigration status can offer a general feeling of service utilization rates among underrepresented racial and ethnic groups, but it can also obscure distinctions and make it hard to comprehend the distinctive mental health experience of immigrants. In the United States, health and mental health care are integrated in Western science and medicine, emphasizing scientific investigation and objective proof. Modern science's self-correcting characteristics–fresh techniques, peer review, and openness to scrutiny through publishing in professional publications –guarantee that it builds on, refines, and often replaces older theories and findings as knowledge is created. Western medicine's accomplishments have become the cornerstone of health care throughout the world. 

Other big, nationally representative research, on the other hand, discovered a distinct connection between race, gender and attitudes towards mental illness patients. They were seen by Asian and Hispanic Americans as more hazardous than whites. Although contact with mentally ill people helped to decrease white stigma, it did not help African Americans. On the other side, American Indians kept comparable attitudes to whites [25]. Taken together, these findings indicate that minorities have comparable, and sometimes stronger, stigmatizing mental illness attitudes than do whites. Societal stigma prevents minorities from seeking the mental health care they need, just as it does for whites. Stigma is so powerful that it impacts not only the self-esteem of mentally ill individuals, but also that of members of the family. The bottom line is that stigma discourages large sections of the population from seeking assistance, both majority and minority. It bears repeating that there is no therapy for most individuals with diagnosable mental illnesses (DHHS, 1999) [23,33].

Refusal of professional service:

Many kinds of professionals offer mental health services in a wide range of environments, differently known as environments and fields. Environmental conditions vary from home or community to organizations, and industries include main government or private care and special care. This chapter offers a comprehensive summary of mental health services, usage patterns and financial trends [51,34]. The SGR, which addresses these issues in higher detail, is referred to by interested readers. The emerging kinds of communal facilities currently available contrast sharply with the institutional orientation of the past. Motivated by reform movements, support and the emergence of management services, today's best mental health services cover prevention and satisfying more general requirements, including housing and jobs. They go beyond diagnosis and therapy. Professional or informal services (supplied by lay volunteers). Services are both formal and informal. The key change has been from organization to society in the context of service delivery [55,42].

There are four main areas in which mental health care is provided:

The specialist field of mental health is exclusively aimed at providing mental health services. It concerns mental hospitals, home therapy facilities and general hospital psychiatric units. The report also relates to specific community organizations and programs such as community centers for mental health, day therapy and recovery. Specialized mental-health professionals such as psychologists, psychiatric nurses, psychiatrists and social workers are providing services in this environment;

A broad array of health services including but not restricted to mental health services are offered in the overall medical and basic services industry. Primary care practitioners, nurses, internists and doctors are the general kinds of professionals who practice in a variety of environments, including clinics, offices, health centers and hospitals;

Social welfare (housing, transportation and jobs), criminal justice, academic, religious and charitable facilities are included in the human services industry. These services are provided in a wide variety of environments-at home, community and organizations;

The network of voluntary aid relates to self-help groups and organizations that are dedicated to schooling, communication and support. Voluntary support network services are mainly available in the community. Typically casual, patients and families often assist to improve understanding, decrease isolation emotions, receive references for formal therapy and deal with mental health issues and diseases.

The kinds of therapy they actually use can not necessarily be inferred from the consumer's preferences because expenses, reimbursements and accessibility of services can lead to their use rather than preferences [49,48]. For instance, it is often hard or impossible for minority patients who would like to see professionals of mental health from comparable racial or ethnic backgrounds since most practitioners are white. Because of the only number of Americans and Alaska psychiatrists in the nation, there will only be 1,5 Native Americans per 100,000 [49,12] American Indian people/alaska natives and only 2,0 Spanish psychiatrists per 100,000 Hispanic patients. Consumers can choose medicines mainly on the grounds of the range of efficient mental illness therapy and the wide variety of environments and areas of therapy [29,59]. Consumers can also opt for different therapy methods such as psychotherapy, counseling, drug therapy or rehabilitation. However, all kinds of serious mental diseases, as distribution mechanisms for their services, are generally vital (DHHS, 1999) [46].

Financing and management of Mental Health Services

Mental health services are funded from many government and private sector financing streams. In 1996, government payers, including Medicaid and Medicare, accounted for just over half of the $69 billion in mental health expenditure. The rest came mostly from patients and their families ' personal insurance (27 percent) or out – of-pocket payments (17 percent) [52]. In terms of quality of care, the SGR observed continuing attempts to establish quality reporting schemes within behavioral health care. It also noted that current incentives within and outside managed care do not foster emphasis on quality of care. While the SGR concluded that there is little direct proof of quality issues in well-developed managed care programs, it warned that “the threat of more disabled populations and kids remains a severe problem.”[47,9]. Finally, the managed care sector has been linked to legislative initiatives to ensure that mental health services are financed equally. In order to overcome decades of inequality, parity aims to cover mental health facilities equal to somatic (physical) disease. Managed cost management potentials are made more economically viable by multiple leadership approaches, which avoid overuse of facilities. Studies outlined in SGR discovered that the current parity programs in several states have made negligible rises in costs [45].

The striking change to managed care has been one of the most important modifications influencing both public and private facilities. Relatively rare two decades ago now, managed care now includes the majority of Americans in some way, whether government or private (Levit & Lundy, 1998), irrespective of whether they pay for it [28,3]. Technically, the word “managed care” relates to a multitude of organizational, delivery and payment arrangements for healthcare providers. It is appealing to buyers as it is promised to contain expenses, enhance access to care, better coordination of care, promote quality care based on evidence and emphasize avoidance. Research is hard to confirm these objectives for all ethnic and racial groups as changes take place at a fascinating rate in the healthcare market [9,32]. Studies in this region are also a challenge, as claim data are kept close to private businesses and are therefore frequently not available to scientists and because Insurers and suppliers often do not collect ethnic or racial information [19,37]. The management of health care, which is particularly critical for racial and ethnic minorities, should be increased at reduced cost. However, preliminary proof exists that some racial and ethnic minorities consider managed care to be more obstacles to therapy than Scholle & Kelleher fee-for-service care, 1997; Provan & Carle, 2000. However, enhanced access alone will not remove differences. Another key factor is to decrease the use of facilities by ethnic and racial minorities and to decrease the gap between minorities and whites [41].

 Cultural Barriers:

Cultural expertise emphasizes recognition of the cultures of nurses and develops abilities, understanding, and efficient treatment policies (Sue & Sue, 1999). The belief that cultural services would be more inviting, promote treatment of minorities and increase their outcomes once they have been treated is a key factor of cultural expertise. Cultural competence is a basic change in relations between ethnic groups and the race (Sue et al., 1998). The word competence places the obligation on organisations and professionals in the field of mentality-the most of them whites (Peterson et al., 1996) [40,41,42]. To be accurate, culture is one of the factors that affect business ethics. In the United States market the standard business ethics can cause ethical conflict when the United States build relationship with the market giant, China. When a small business enter China to develop a business relationship, the greater potential for ethical conflict increases. In order to reduce that potential conflict requires the knowledge of the nature and history of the China culture to gain a understanding of China ethical system. It is important to understand the expectations of China and understand the cultural ethical behavior in China to succeed in cross-cultural business.  Ethics and the expectations within cultures affect all business transactions [50,56]. In China in the next ten to twenty years it going to be one of the biggest players on the international stage. In this era where it will be numerous of foreign competition in the United States. The United States have a big influence on China culture until China is will to accept certain aspects about the United States culture and it helps China to business with the United States [47]. In China it’s a difference among the social classes, such as upper class a very small portion about six present and the lower class was the majority. The China culture consist of communication, religion, transparency, value and attitude, gender roles and social structure.

In the last four decades, the provision of mental health services has changed enormously. Become more aware of mental health system inadequacies when addressing the requirements of the ethnic and minority groups Rogler, & Co., 1987; Takeuchi & Uehara, 1996, as part of the civil rights movement, the extension of mental health care facilities into the society and demographic transitions towards higher diversity in the workforce [40,41]. Research has recorded enormous changes in usage between minorities and whites, and the impact of culture on mental health and mental disease has been discovered. Some manifestations of mental disorders, idioms for communication of distress and patterns of aid-seeking have shown significant distinctions. Mental health self-examination and the emergence of consumer and family support are the obvious outcomes of studies and government consciousness. As mentioned in above, the importance of culture in the evaluation of mental illness was recognized by the publication of the “Culture Formulation Outline” in DSM-IV [30]. 

The mental health treatment environment was also an innovation. This is probably a distinctive environment because patients and suppliers are strongly dependent on language, communication and trust. Knowledge of the cultural identity of patients, the social support, self-esteem, reticence about the therapeutic process owing to social stigma are essential components for therapeutic achievements [43]. Advocates, professionals and policy makers have begun calling for fresh approaches to therapy, drived by extensive knowledge of minority deficiencies, including their languages, histories, traditions, beliefs, and values: the provision of facilities to meet the cultural needs of race and ethnic minority groups. This approach to service provision has been supported mainly on the grounds of humanistic values and intuitive sensitivity instead of empirical evidence and is often called cultural competence [51,16]. Nevertheless, the results of research on substantive information from consumer and family self-reports, racial matching, and ethnic-specific facilities indicate that tailoring services to these groups ' particular requirements will enhance usage and results.

Language Barriers:

They also differ in how the mainstream Western health system seeks therapy. Biswas et al. [15] claim that mainstream health care providers in India tended to experience somatic symptoms more often, while those in America tended to show more cognitive signs. In addition, study conducted in high income countries (HICs) like Australia, Canada and the United States stresses the fact that varied cultures tend to seek assistance far more later than most people and many tend to present themselves in severe phases of mental distress in these nations [12, 17]. The nature of the disgrace mentioned in certain studies involving migrants and refugees in HICs as well as the general population in low-and middle-income countries (LMICs) in Asia and South-East Asia can be one of the factors. Hampton and Strong [24] have been very comprehensive with the character of disgrace by means of an inner and reflective structure, arguing that mental health systems, practitioners and scientists have an obligation, in order to ensure efficient management of mental health problems, to identify and mediate the consequences of disgrace on people from a wide range of cultures.

Hechanova and Waedle [14] suggested that a few reasons may be due to disgraceful reasons for lack of access to mental health services. The first option is to safeguard the reputation of the family and its own dignity. Secondly, the mental health professionals could consider them ' craze,' comparable to internal disgrace, and lastly, because of a number of variables, such as fearing' facial loss,' lack of confidence and a fear of revisiting painful occurrences, they might be unwilling to open up to strangers [17, 25, 26]. Research shows that speech therapies may not be the most helpful way for cultural organizations to intervene. The United States ' National Child Traumatic Stress Network argued that “refugees from communities in which psychological modeling is not Hegemonic cannot experience speaking about traumatic occurrences as precious or therapeutic” [27]. Such perceptions of speech-based therapies in turn open up the possibility that movement, expressive therapies and online therapy can be used more effectively [28]. According to Communicating disagreements among Malaysians: verbal or non-verbal? It states, “Communication can be both verbal and non-verbal. Verbal communication involves the use of spoken words while non-verbal communication encompasses body movements and facial expressions including silence. The concept of silence is addressed in both the collectivist and individualist cultures. The Japanese regard silence as a token of respect, agreement and harmony and in contrast, North Americans and the British may find silence awkward” (David, M. K., Hei, K. C., & Ling, W. N., 2011) [56].

Non-verbal communication in the Chinese culture includes tone of voice, facial expressions, gestures, and eye contact. Although non-verbal communication is an important role in many on our daily life it can powerful than the verbal communication. Non-verbal communication can consist of objects, touching, time, and body language [61,60]. In the Chinese culture, Men should wear dark color suits white shirt, women should wear subdued colors. Avoid wearing jewelry except watch and wedding ring. Meeting are required and should be made 3 to 4 weeks in advance. Meeting should not be scheduled during mid-July and mid-August or early October this is when China on vacation [42]. The China culture do not entertain during business discussion. China do not use movement when speaking. For example, speaking with their hands. 

According to Stella Xu, a professor of international management at Kennesaw State University in Georgia, consults with American companies doing business in China and vice versa. She points out to Americans that receiving a business card with both hands is a sign of respect and, more important, warns them not to expect that an agreement has the force of a contract when, to the Chinese, “personal relations are more important than honoring contracts,” she says. She warns Chinese that they can't just show up without an appointment, and that a business lunch is about business first” (Sandberg, 2008) [57].

Design Model

The full list of topics that have appeared in the exchanges in this area is provided in Table 2. The loss of land and housing problems in northern Tohuku stayed important. Cities like Otsuchi have been almost totally demolished with a reconstruction officer who notices 2000 of the 15,000 people who have been murdered or are lacking in temporary accommodation for most of the remaining population [71,39]]. The scope of the destruction in Otsuchi is shown in Fig. 2, Fig. 3. Jobs in significant sectors such as forestry, agriculture and fishing became scarce and the urban railway operated irregularly, restricting the movement of workers outside the region. The significance of the community in continuing recovery has often been mentioned by residents and health care providers. The town was relocated to prevent future catastrophes by a city welfare officer's guide and he remarked that this became problem because “the people are stuck on the ground, they don't want to give up and want to remain.” The reconstruction office of Otsuchi displays a model of the town before its destruction. Citizens can position their names on a town-scale model of their homes [21,20,11].

This diagram is one that I've done before, but the logic relationship in the middle isn't set, the question of increasing or decreasing direction isn't done. Because I want to do it before a point, discussing education intervention to eliminate the effect of stigma. And part of it was just looking at some of the projects mentioned in the article but I didn't understand how to do it.  Several traditional practical training sessions and survey information to demonstrate the efficacy of this stigma education. In my previous section, I wrote that interventions to young people are the best way to intervene. I wrote in my earlier chapter that youth intervention is the best way to intervene. It's better to follow these directions, but it doesn't matter if there are interventions to be made [32,33].

The group workshops were intended to last two hours and each participant got a tiny money refund for his time with a rest period halfway through the day. The focus group sessions were audiotaped and translated, if required, into English by the leaders of the focus group. The resulting transcript was introduced into The Ethnograph (Qualis Research Associates, 1998-1999) [50,23], a software package with instruments for quality information management and evaluation for sorting, editing and searching. The information were coded and analysed by means of a technique for content assessment, which drew inferences from the text by considering the most important ideas (Rosenthal & Rosnow 1991) [26,12,13]. These findings are structured into wide classifications, with examples given in each category, which are marked as “Info sources,” “Prevention Causes,” “Symptoms,” “Diagnosis and treating” and “Barriers to Care.”

Fig.4: Design Model

Comparison of Chinese immigrants in different countries

While immigration can cause strain and psychological distress afterwards, study findings do not show that immigration in itself leads to greater levels of mental disorder (e.g. Vega et al., 1998). However, the traumas encountered by adolescents and kids from war-torn nations both before and following immigrants to the U.S. seem to lead to elevated levels of post-traumatic stress disorder (PTSD) among these communities, as explained under the Asian Americans and Latinos chapters. Poverty influences ethnic and racial minorities disproportionately. There is a huge variation in the general US poverty rate (12% in 1999) [17,11]. While 8% of the white people are poorer, the levels of racial and ethnic minorities are much greater: 11% of Americans and Pacific Islands, 23% of Hispanic Americans, 26% of Americans and Alaskans (U. S. Census Bureau, 1999). In other words, racial and ethnic minority organizations have much lower per capita revenue than white people. Whoever perpetrates violence impacts the life of ethnic and racial minorities disproportionately. For African Americans, the level of victimization for violence offenses is greater than for any other race or ethnic group (Maguire and Pastore, 1999) [20,17]. Over 40% of urban youth saw individuals fired or stabbed (Schwab-Stone et al., 1995) [31,30,13]. As a victim of or as a witness to group abuse, the impact on mental health is immediate and sometimes protracted and, in particular, for youth Bell and Jenkins, 1993; Gorman-Smith & Tolan, 1998; Miller et al., 1999 [22,25].

Fig. 3: Immigrants statistics all over world

The U.S. immigration laws alternated in the last century closed and allowed various foreign communities to enter the immigration gates. The Immigration Act of 1924, for example, laid down in the 1890 census, the system of national origin, restricting annual immigration from any country to 2% of the United States population [30]. The 1937 Immigration Act strengthened patterns of white immigration and stopped immigration from other fields, including Asia, Latin America and Africa, because the majority of foreign born babies were from Northern and Western Europe during 1890 censuses. Around 2/3 of all legal immigrants from Europe and Canada came from the U.S. until the 1960s. The Immigration Act of 1965 substituted the national system of origin and permitted 20,000 persons in every nation in the Eastern Hemisphere to enter an annual migration quota [63,29]. The Act has also given preference to people in certain professions. The impact has been remarkable: in the 1950s, immigration from Asia skyrocketed by 6% to 37% by the 1980s [50]. Again, the act endorsed reunification of families and greeted individuals with families in the US, one factor behind the expansion in Mexico's immigration. 

In the last 20 years, immigration has resulted to a change of racial and ethnic structure in the United States since black slaves were included in the South (Muller, 1993) late 17th century [17,12]. While that wave of immigration is comparable to the increase in immigration at the beginning of this decade, the nations of origin have a major distinction. The immigrants came mainly from Europe and Canada in the early 1900s, whereas new immigrants arrived mainly from Asian and Latin American nations. More than anything in history, the racial and ethnic makeup of the USA has changed more quickly since 1965 [53]. The immigration policy reforms of 1965, the rise in ethnic minority self-identification and a reduction in the country's birth rates, particularly among non-Hispanic white Americans, all resulted to a growing and progressively varied population of the racial and ethnic minorities in the USA.

Data Collection

The information was obtained from a 5-year research of mixed methods at the Chinese Sexual Health Initiative (CSSHIP) Boston University [34]. The blended techniques included information from the study and semi-structured in-depth interviews. The information from the study were gathered between January 2010 and March 2011. In order to qualify for CSSHIP, females must be (a) single, (b) between the ages of 18 and 35, (c) self-identified as Chinese, Vietnamese, Korean, or a mixture of these ethnic groups, (4) generation 1.5 immigrants (women born in a foreign country and raised in the U.S.) or second generation immigrants (females who were kids of immigrants), and (5) situated in the higher Boston. Outreach workers sought to maintain ethnic diversity in the selected women's sample and a balance between women of the 1.5 generation and women of the second generation. As the CSSHIP project was concerned in the impacts of acculturation on health risk behaviors, international students or females whose relatives did not reside in the U.S. were excluded [44,15]. 

CSSHIP reached eight universities and twenty community organization including multiple libraries, health, legal and art organization and a radio station. These organization helped hire respondents and some of these universities and organization offered private rooms for interviews that enabled a computer-assisted survey interview (CASI). Of the 804 females screened during the 2010-2011 information collection period, about 2% (n= 17) were ineligible and 10% (n= 83) did not participate in the research. The initial sample consisted of 701 respondents; the biggest ethnic group was Chinese (51.5%, n= 361), followed by Korean (21.7%, n= 153), Vietnamese (19.5%, n= 137), and mixed ethnicity (7.2%, n= 50). The quantitative sample's mean age was 22.5 years. A CASI was finished by those who met the eligibility requirements. CASIs were provided in five distinct languages to accommodate a prospective linguistic barrier with English: English, Traditional Chinese, Simplified Chinese, Korean, and Vietnamese. The multilingual edition of CASI was the result of a total of 12 translators' and back translators ' work (two Chinese, Korean, and Vietnamese translators and two back translators each) [33].

Thirty-eight respondents agreed and interviewed about the history of their family's immigration, the effect on their families of American culture, intimate relations, sexual behaviour, the status of mental health and the use of mental health. Three Asian-American females, with skills in mental health, performed qualitative interviews: the lead investigator (PI), who is a Korean American doctoral scientist and clinician in social work, a Korean American sociologist, and an intern in chinese American Master of Social Work. The audio was registered and written verbatim on all interviews. Because the interview issues were delicate, the interview guidelines were semi- structured. The interview manual provided the interviewee with flexibility to examine particular subjects more closely and/or concentrate more specifically on certain elements of the interviewee's reaction. The interviewer asked, for instance, when debating depression: “Did you ever feel really at ease for over two weeks in your life?” [39]. The interviewer should ask questions concerning the phase of life, how long the low mood lasting, if mental medical services were used, according to the interviewee's answer” 

The first qualitative assessment demonstrated that numerous types of adversity have been encountered by many females, including suicide, substance use, and/or sexual abuse. We followed suggested guidelines [26,28] and over-sampled females who had a history of adversity to ensure the interviews were made up of a adequate amount of females who were able to define the effect of acculturation and depression. A subset of 17 respondents were chosen for the qualitative analysis for this research from 38 females who participated in qualitative interviews. Chinese (47%, n= 8), followed by Koreans (24%, n= 4), mixing (17%, n= 3) and Vietnamese (12%, n= 2).) were the biggest ethnically ethnical community. The quality sample was averaged 22.0 years. In order to report the present symptoms of moderate to serious anxiety in the CASI, participants were chosen with some reporting a lifetime history of suicidal ideation and/or suicide attempt. According to study information, participants were either midrisk (Group 2) or high-risk (Group 3). Pseudonyms 1–17 for confidentiality reasons were provided to interview respondents.

7.1 Data Analysis:

The Center on Depression Studies (CESD), which has been validated for high depression and sensitivity among Asian adolescents in Asia [29,30] as well as Asian women in the United States [31], defined moderate-to-severe depression ratings. The CESD is based on an independent test which measures the symptoms for the last 2 weeks of a serious depressive episode. The results ranged from 0 to 46, with no or minimal (0 to 15) or moderate / seven symptoms of depression (16 to 46), were examined in 20 surveys [32,33], and dichotomized as no or minimum symptoms of depression. This dichotomization is very consistent internally (the alpha of Cronbach=0,90). The history of suicide ideation and the attempt to commit suicide over the last 12 months was evaluated by asking respondents whether they regarded suicide seriously and whether they tried suicide. For both variables, respondents have been registered as “yes” or “no” [35]. Based on the present status of depression among respondents and the history of their behavior, mental health risk groups were established: 1) the mental risk group were found to be the participants with present modest to serious depression symptoms and with no lifetime history of suicidal ideation or attempted suicide (Group 1) ; 2) the mental health risk group was identified. Mental health utilization was indicated by: 1) Any mental health care, 2) minimally adequate mental health care, and 3) intensive mental health care.

Results

Quantitative Results

Table 3 demonstrates the usage patterns for the four groups: complete sample (n = 701), low-risk group (n = 401 females with no present moderate to serious depression symptoms and no lifetime suicidal ideation / attempt) ; medium-risk group (n = 226 females with either present moderate to serious depression symptoms or lifetime suicidal ideation / attempt) ; and high-risk group (n = 73 females).

Table 3

Prevalence of use patterns of mental health among low-risk females (Group 1), medium-risk women (Group 2), high-risk females (Group 3)

12.3% of the females reported using any mental health care in the previous 12 months among the total samples. As expected, women in the high risk group (Group 3) were more likely statistically than those who were in the medium risk group (group 2,) and the low-risk group (group 1) to receive minimal sufficient mental health care (4 times and 8 times), and intensive mental health care [53]. However, although the number of mental health services offered by females in Group 3 is considerably higher than in Groups 2 and 1. Overall mental health use for females in Group 3 remained small. For example, in the last 12 months, over 60 percent of females in Group 3 with present moderate to serious symptoms of anxiety and a lifetime record of suicidal thought had received no mental health care. More than 80% of females in Group 3 did not receive sufficient therapy to attend at least four or eight visits to their mental health. In addition, over 80 percent of females in group three received no extensive, hospital or partial hospitalization therapy in the form of extensive mental health care. This low pattern of mental health use was also prevalent in Group 2 females.

Qualitative Results

In comparison to participants ' severe mental health issues, the small rates of use of mental health were shown in the quantitative analysis and prompted the writers to examine the study question: What are the perceived obstacles that respondents have to use the mental health system? Either medium-risk Group 2 or the high risk Group 3 belonged to all 17 respondents. Group 2 consisted of nine females and Group 3 consisted of eight females. Fig.4 demonstrates the factors affecting our participants ' under-use of mental health services: the contribution of families and communities to the stigma of mental health, and the incompatibility of the U.S. mental health services with Asian American women's cultural requirements. 47 percent (n= 8) of interview participants reported contributions from their family to the stigma of mental health, 30 percent (n= 5) reported contributions by their community to the stigma of mental health, and 82 percent (n+ 14) discussed a cultural disorder between U.S. mental health services and the perceived needs of women from Asia [65].

Fig.4: Factors that influence Asian-American women's underuse of mental health services (complete sample n = 17)

Use of System Dynamics Models to simulate the mental care seeking

Causation and Prevalence:

In the cause of depression, the cultural and social context weighs more strongly. The incidence levels for major depression ranged from 2 to 19 percent across nations in the same international studies quoted above (Weissman et al., 1996) [27,8]. Studies of family and molecular biology also show less heritage for major depression than for bipolar disorder and schizophrenia (NIMH, 1998) [56]. Taken together, the proof points to social and cultural variables that play a higher part in the onset of major depression, including exposure to poverty and violence. In this sense the need to note is not unique to any portion of the world and the symptoms and manifestations that they generate: poverty, violence and other stress-induced social environments. However, the probability of exposure to such stressors can rise, often related to race or ethnicity such as socio-economic status or nation of origin. In the cause of post-traumatic stress disorder (PTSD) cultural and social variables have a most immediate function. PTSS is an exposure to serious trauma, such as genocide, warfare, torture or extreme threats of death or serious harm (APA, 1994). PTSD is a disease of mind. The subsequent growth of a protracted symptom pattern followed by biological modifications (Yehouda, 2000) [43,53] is connected with these traumatic experiences.

Family Factors:

There are differences among ethnic groups between family danger and mental health protective factors. However, study has yet to identify whether the difference between ethnic groups stems from the culture of this group, social classes and relationships with a wider community, or from the character of individual families. One of the most advanced areas of studies in family and mental health addresses recurrence in schizophrenia [58,59]. In the first study in Britain, schizophrenia individuals who came back from the hospital to live with family members who expressed critique, hostility or emotional participation discovered.

Coping Styles:

Culture is about how individuals face daily issues and more severe adversities. For instance, certain Asian American organizations tend not to dwell on annoying ideas, thinking reticence or avoidance is better than external speech [64]. The research shows that better knowledge of racial and ethnic minority coping styles has consequences for the promotion of psychiatric health, the prevention of mental illness and the nature and severity of mental health challenges.

Primary Care:

Primary care for ethnic and racial minorities is a critical portal for mental health therapy. In contrast to specialized care, minorities are more likely to seek assistance in main care and intercultural issues may arise in both settings (Cooper-Patrick et al. 1999) [37,2]. Primary care providers may not have the time, or the ability, to identify or treat mental illnesses properly, especially in cases of co-existing physical disorders, in particular under the constraints of managed care (Rost et al., 2000) [55,66]. Some calculations indicate that some 1/3 to half of the mental illnesses in primary care Higgins, 1994; Williams et al., 1999 are not diagnosed. Minority patients are one of the most vulnerable to non-detection of main care mental illnesses (Borowsky et al., 2000) [69]. Missing or inaccurate diagnostics have serious implications if patients are treated inadequately or potentially harmfully, while their underlying mental disease remains untreated.

Clinician Bias and Stereotyping

The clinical biosphere and the stereotyping of ethnic and racial minorities may also be misdiagnosed. Hospitallers often represent their society's attitudes and discriminatory methods (Whaley, 1998). The establishment of a distinct, totally separated mental hospital in Virginia for African American patients showed such institutional racism over one century ago (Prudhomme & Musto, 1973) [62]. Whilst there are traces of racism and discrimination that have definitely declined over the course of time, in less obvious medical practice today Giles and others, 1995; Shiefer, Escarce & Schulman, 2000 are notable for diagnosis, therapy, prescription and referrals. One research from the field of mental health shows that African American young people were four times less likely than whites to be restrained by acting in similar aggressive ways, indicating the professional decision to restrain blacks ' racial stereotypes as violent (Bond et al., 1988). In a second research, white therapists rated an African American customer with anxiety more negatively than a white patient with the same symptoms (Jenkins-Hall & Sacco, 1991) [67,13].

Service Settings and Sectors:

Numerous professionals in various environments, called settings and industries provide mental health services. Environmental conditions vary from home and community to organizations, and industries cover main and special care, both public and private. This chapter gives an extensive summary of mental health services, usage patterns and funding trends. The SGR, which includes these subjects more fully, is referred to by interested readers [23,60]. The burgeoning types of community services available today stand in sharp contrast to the institutional orientation of the past. Propelled by reform movements, advocacy, and the advent of managed care, today's best mental health services extend beyond diagnosis and treatment to cover prevention and the fulfillment of broader needs, including housing and employment. Services are formal (provided by professionals) or informal (provided by lay volunteers) [70]. The most fundamental shift has been in the setting for service delivery, from the institution to the community.

Evidence Based treatment and Minorities:

A full range of efficient therapies for numerous mental disorders was reported in the SGR (DHHS 1999) [26, 5]. These treatments on an evidence base depend, on controlled clinical trials, on coherent scientific evidence that they enhance the results of patients considerably (Drake et al., 2001). Although the effectiveness of medicines is powerful and consistent, SGR pointed out that evidence-based treatments are not translated into community environments and are not delivered to all caregivers. For racial and ethnic minorities, the gap between studies and practice is even worse. Problems cover both the settings of studies and practice. Specific assessment conducted for this Supplement shows that no unique tests for any group of minorities were carried out by controlled clinical trials for professional treatment guidelines [68]. The greatest scientific rigor to determine the operation of the therapy can be achieved by controlled clinical trials.

Potential Solutions

Mainstream mental health systems are increasingly acknowledging the intersection of cultural diversity. As an example, the provision of the cultural formulation interview in the DSM-5 is a positive step especially as it seeks to explore cultural identity, conceptualization of illness, psychosocial stressors, vulnerability, and resilience as well as the cultural features of the relationship between the clinician and the patient [51,71]. However, this is just one tool in the larger picture and cannot mean anything without more radical changes in systems and practices. Much of the literature in the field points to the need for holistic health services that incorporate the total context in which health and illness are experienced [29, 55, 62]. Some suggestions involve the integration of mental health services with primary health care as a way of getting past some of the stigma and discrimination issues [8, 66]. As Ng et al. [69] posit in the context of Low and Medium Income Countries “integrating mental health services into primary health care is a highly practical and viable way of closing the mental health treatment gap in settings where there are resource constraints.” Which is not to say that the same does not apply to the High-Income Countries like Australia where effective mental health responses in many Indigenous communities continue to be an unmet goal [71,72]. More recent approaches such as the biopsychosocial and the recovery approaches in mental health or renewed calls for medical pluralism also offer new opportunities to work with people in a more holistic way [73,75].

Fernando [11] suggests that “[m]ental health development, like development in any other field, must start by tapping into what people in any location currently want and value.” One of the ways that needs to exploration more systematically is the possibility of integrating positive resources in the community into the provision of mental health services. Marsella (45) argues that community-based ethno-cultural services are a positive resource in the community that can provide an essential function in working with mental health issues in diverse cultural groups. Further, he argues that the development of a strong social support and community-based network must be intrinsic to the process. In the context of working with refugees in the UK, Tribe [(1), p. 11] also endorses this view, suggesting that community-based mental health services “may prove more accessible, acceptable and relevant services which are more in line with other types of community care.” Besides these forms of services, there is also significant evidence to show that many people within culturally diverse communities are likely to utilize avenues other than professional therapists for dealing with mental distress, such elders in the community, religious leaders, priests, and traditional healers [19]. These positive resources, including especially traditional healing practices and systems can be involved in the provision of mental health services through collaborations, partnerships, and community-based health systems. An example here is the Muthuswamy healing temple in India where research conducted by the National Institute of Mental Health and Neurological Sciences (NIMHANS), India concluded that people with mental health issues staying at the temple showed significant reduction in psychiatric rating scale scores. The researchers suggested that “[h]ealing temples may constitute a community resource for mentally ill people in cultures where they are recognized and valued… [and the] potential for effective alliances involving indigenous local resources needs to be considered” [40]. Similarly, Gone [71,44] points to the widespread use of talking circles, pipe ceremonies, sweat lodges and other culturally specific practices in the federal Indian Health Service in the United States to argue for a renewed focus on participation in traditional cultural practices, and attendant possibilities of spiritual transformations, shifts in collective identity and meaning making. Boksa et al. [37] also reiterate the centrality of local Indigenous knowledge as a guide to the development of relevant mental health systems. Mahony and Donnelly [38] also point out that spiritual and traditional healing practices can prove very useful in terms of promoting immigrant women's mental health.

Another way forward is to go beyond cultural competence frameworks and practice toward developing cultural partnerships. Cultural competence “refers to the awareness, knowledge, and skills and the processes needed by individuals, profession, organizations and systems to function effectively and appropriately in culturally diverse situations in general and in particular encounters from different cultures” [23]. Quite a few authors point to cultural competence as the most commonly used framework of practice in working with issues of mental health in culturally diverse settings [58–60]. While the cultural competence framework has proved useful in terms of working across cultures, it suffers from a few significant flaws. Firstly, cultural competence frameworks approach culture from a purportedly value-neutral position, thereby ignoring the differences in power and the nature of historical and present-day oppression experienced by cultural groups [61]. Secondly the “competence” approach focuses on the providers and their institutions and their capabilities to provide culturally appropriate services and disregards the participation of the clients and their communities [21, 71]. In circumstances where some cultural groups can be marginalized, as in the context of the issues of historical dispossession, racism, stereotyping, stigmatization, and power differentials, it becomes extremely important to work toward more equitable ways of engaging with communities [51-55] And finally, cultural competence draws on static notions of cultures that are not based on the reality of the constantly changing and transforming nature of cultures [71].

These issues point toward the need for developing partnerships that are more equitable and that realign power relationships between service providers and individuals. The focus must be to move from traditional relationships built in power relationships to more interdependent and synergistic relationships [64]. A range of partnerships could be useful toward developing more effective mental health systems. They could include cultural partnerships between mental health providers and diverse cultural communities. It would certainly add to the nature of these partnerships if the providers also followed a deliberate policy of hiring workers of diverse backgrounds, and especially those from the communities that the service users come from. Murray and Skull [76] suggest that these forms of partnerships between refugee groups and health service providers have been shown to be more effective in terms of responding to health and other needs of the refugees than traditional top-down approaches. Partnerships could also be developed between mental health providers and traditional healers and/or community elders where synergies could be built on [74]. Finally, the relationship between the therapist and the client could be viewed as a cultural partnership, very much in line with the recovery approach, where the client would be an active participant in the process [72,74].

Discussion 

Main findings:

Sixty-two articles were reviewed for their findings on mental health service use among immigrants to the United States. A consistent finding was that immigrants access mental health services at lower rates than nonimmigrants. With some exceptions, rates of use were especially low for undocumented immigrants, men, younger individuals, and those without insurance. Service use among immigrants with a psychiatric diagnosis ranged from 5% to 40%. In studies that did not consider diagnostic criteria, the rates ranged from 3% to 6%. These levels are well below those for U.S.-born counterparts in the same samples and below the national average for mental health service use of 13% for the general public, 59% among adults with serious mental illness, and 71% among adults with depression [71,73]. For immigrants who did use services, informal channels such as family, friends, and religious communities played an important role in problem recognition and treatment initiation. Findings regarding provider preference were mixed. Some studies reported that participants preferred accessing mental health care through general medical providers, and others indicate that religious leaders were more accessible and trusted confidants [74,75]. Structural issues, such as lack of insurance, high cost and inaccessibility of services, and language barriers, were important deterrents to service use. Cultural issues, such as stigma and norms in regard to mental health, were also reported as barriers. Important demographic factors related to service use included gender, age, education level, and employment, marital, and insurance status. Perceived need and social support were found to be strong correlates of service use [61,63].

Research into the use of services among immigrants should also address the diversity in the experience of immigrants, such as demographic variables, such as the diversity of race, ethnic, religious, old age and sexuality, and the variety of social assistance, acculturation, and acculturation experiences in pre-and post-migrations and mental health schemes in nations Understanding such heterogeneousness may lead to disagreements [28,62)]. For instance, discrepancies in the rates of use by Latino immigrants could result from a combination of findings from a variety of different ethnic groups. Some Latino groups (e.g. Puerto Ricans) showed greater mental health service usage levels than other Latino groups; other groups (e.g. Mexicans) showed reduced rate [40]. In order to recognize underserved subgroups and comprehend the factors affecting the use of mental health services, it is essential to emphasize heterogeneity within migrant groupings [55,57]. Four methodological suggestions are explained below in order to build on recent information and create a more detailed empirical explanation of the connection between migration and the use of services.

First, study should break up both immigrant and non-immigrant samples. Aggregate samples may obscure distinctions vital to the comprehension of patterns of service use. To promote understanding it is essential to disaggregate specimens according to foreign-born status and other migration variables [51].

Second, study should concentrate on under-represented categories of population — specifically immigrants from non-documented regions like Africa, Middle East, migrants, migrants and asylum seekers, males, young people and elders and geo-district immigrants [60].

Third, potential scientists should apply heterogeneity techniques like mixture modeling or qualitative techniques. Longitudinal research on the application of immigrant mental health services would also promote the comprehension of the shift in the use of services over time [63].

Fourth, standardized measures should be taken on the variables associated with immigration. This literature is not compatible in terms of conception and operationalization of the immigration variables. The measures on immigration included both premigrant indicators, including the birthplace or childhood, the age of migration, the nation of origin and year of immigration, and postmigration problems such as years in the United States, generational status, discrimination experiences, acculturation, family reunification, social contacts, cultural identity, and immigration sentiments. Other prevalent immigration policies included English and native language skills, main and preferred language, and immigrant status measures, such as whether the person had citizenship or legal documents [68,69]. More standardized measurements are required to improve our ability to capture the varied experience of a broad spectrum of immigrants. For instance, the collapse of fresh immigrant experiences with those of long-established immigrant societies may partially underlie the divergent results on service use.

In this research paper, many things are discused which are given below:

Culture influences many aspects of mental illness, including how patients from a given culture express and manifest their symptoms, their style of coping, their family and community supports, and their willingness to seek treatment. Likewise, the cultures of the clinician and the service system influence diagnosis, treatment, and service delivery. Cultural and social influences are not the only determinants of mental illness and patterns of service utilization for racial and ethnic minorities, but they do play important roles.

In all populations, regardless of race or ethnicity, mental disorders are very common. The causes of mental health are caused by cultural and social variables, although their input differs with each disease. The result of the complicated interaction between biological, psychological, social and cultural variables is regarded mental illness. Depending on the particular disease, the function of any of these significant variables can be greater or weaker.

In the United States, mental illnesses in general are very comparable in most minority organizations to white ones. This overall conclusion is not applicable to vulnerable, needy sub-groups with greater prices and who are not often caught in community studies. The rates of mental disorder are not adequately investigated to allow for definitive findings for many smaller racial and ethnic groups, mainly Americans, Alaskan Natives, Asian Americans, Pacific Islanders.

Ethnic and racial minorities in the United States face a social and economic environment of inequality that includes greater exposure to racism and discrimination, violence, and poverty, all of which take a toll on mental health. Living in poverty has the most measurable impact on rates of mental illness. People in the lowest stratum of income, education, and occupation are about two to three times more likely than those in the highest stratum to have a mental disorder.

Racism and discrimination are stressful occurrences affecting mental and health. Minorities, such as depression and fear are at danger for mental disorders. It is less obvious that racism and discrimination alone can trigger these disturbances, but study is deserved.

The stigma does not encourage the search for assistance in large sections of the population, both majority and minority. Attitudes towards minority mental illness are as bad or even worse than those held by white people.

A major reason for deterring minorities from seeking therapy is a misconception of mental health facilities. They are strengthened by proof of clinical prejudice and stereotypes, both direct and indirect. It is not understood to what extent clinician bias and stereotyping account for the disparities in the facilities of mental health.

The cultures of ethnic and racial minorities alter the types of mental health services they use. Cultural misunderstandings or communication problems between patients and clinicians may prevent minorities from using services and receiving appropriate care.

Conclusion

In this article, some of the key considerations of working with diverse cultures in mental health have been explored and the point made that there can be severe repercussions on individuals and communities if systems and processes are not in place to enable mental health providers to work effectively across cultures. Each of these considerations in turn provides opportunities for new ways of engaging across cultures that can empower all parties involved rather than disempower and marginalize some groups while empowering others. Rather than approach the considerations from a deficit approach, where each of these is a problem, they can provide new avenues for developing integrated and holistic approaches toward working with mental health. A few of these avenues have been discussed in the paper, and some of these are already beginning to make inroads into mainstream mental health services, such as the emphasis on integrative services and the recovery approach. Others, which have been delineated in greater detail in this paper, such as working with positive resources in the community and cultural partnerships, are those where very small one-off projects have been embarked on and where arguably there is much more opportunity for broad based research and practice.

Effectively addressing mental health disparities requires consideration of the unique service use experiences of immigrants. Research addressing immigrant mental health care has demonstrated important unmet mental health needs and factors related to service use. Future research should focus on understudied groups and seek to understand heterogeneity and longitudinal relationships between immigrants and mental health service use in order to explain differing service use patterns and inform effective interventions. To increase mental health service use and effectiveness among immigrants, intervention programs that integrate formal and informal service sectors should be examined and mechanisms that explain the relationship between social support and service use should be explored.

References

C. Liu, A. Sbiti, and V. Huijbregts, Verdriet style: Gezondheid Chinese Migrants, Mikado, Rotterdam, The Netherlands, 2008. 

Centraal Statistiek voor office: Statistics CBS, http:/statline.cbs.nl / StatWeb / dome / default.aspx.

Endo et al., 2008, Greenberg et al., 2003, Kohn et al., 2004, Phillips et al., 2009, Richa et al., 2009

Berry, J.W. (1990). Acculturation and adaptation: General context. In W. H. Holtzman & T. H. Bornemann (Eds.), Immigrant and Refugee Mental Health (pp. 90–102). Austin, TX: Hogg Mental Health Foundation.

Y. Cheung as well as P. Lam, Vallende Bladeren op Nieuwe Wortels, Rotterdam Wah Fook Wui, Rotterdam, The Netherlands, 2006.

J. C., Del Castillo. (1970). The impact of language in foreign-born patients on symptomatology. Psychiatric American Journal, 127(2), 242–244.

AK, Ejesi K, García Coll C. Understand the childhood and adolescence paradox of U.S. immigrants. Perspectives for the development of children. 2014;8(2):59. Review the paradox of immigrants in the context of studies on child development. Recommends the use of time-varying approaches to longitudinal modeling to better comprehend how these procedures work out over the lifetime of an individual. Highlights the distinctions between the methods based on strengths / resilience and risk factor, and argues for both modeling.

Portes A, Rumbaut RG. Introduction: Longitudinal study of second generation and immigrant kids. Studies of ethnicity and raciality. 2005;28(6):983–99.

Vega William A, Aguilar-Gaxiola Sergio, Kolody Bohdan. Help Mexican Americans search for mental health problems. Immigrant Health Journal. 2001;3(3):133–40.

Wight RG, Aneshensel CS, Botticello AL, Sepúlveda JE. A multi-level analysis of racial variation in adolescent depressive symptoms in the United States. Sociology & medicine. 2005;60(9):2073–84.

Jargowsky PA. Concentrated poverty immigrants and neighborhoods: assimilation or stagnation? Ethnics and Migration Studies Journal. 2009;35(7):1129–51.

Sentell Tetine, Snowden Lonnie, Shumway Martha. English language skills and race / ethnicity access to mental health treatment. Journal of Internal Medicine General. 2007;22(2):289–93.

Vega William A, Aguilar-Gaxiola Sergio, Kolody Bohdan. Help Mexican Americans search for mental health problems. Immigrant Health Journal. 2001;3(3):133–40.

William Lloyd, Warner, Srole Leo. American Ethnic Groups ' Social Systems. New Haven, CT: Press from Yale University; 1945.

Wadsworth T, Kubrin CE. U.S. Metropolitan Hispanic suicide: examining the impacts of immigration, assimilation, affluence, and disadvantage. American Sociology Journal. 2007;112:1848–1885.

Abe-Kim J, Takeuchi D, Hwang WC. Help predictors among Chinese Americans seeking mental distress: family issues. Consulting Journal and Clinical Psychology. 2002;70:1186–1190.

Aguilar-Gaxiola S, Vega WA, Kolody B, et al. Lack of service usage with mental health issues by Mexican Americans. American Psychiatric Journal. 1999;156:928–934.

Vega WA, Kolody B, et al. Aguilar-Gaxiola S. Mexican Americans ' lack of service use with mental health problems. American Journal of Psychiatry. 1999;156:928–934.

Yang LH, Kotabe H, Purdie-Vaughns V, Link BG, Saw A, Wong G, et al. Culture, danger, and mental disease stigma: Chinese-American organizations identify culture-specific danger. 2013;88:56–67. Soc Sci Med. doi: 16/j.socscimed.2013.03.036.

Leong FTL, Lau ASL. Barriers to offering Asian Americans with efficient mental health services. Res. 2001;3(4):201–214 Ment Health Service. doi: 10.1023/A:1013177014788.

A cohort survey: Jenkins GR, Hale R, Papanastassiou M, Crawford MJ, Tyrer P. Suicide rate 22 years after parasuicide. BMJ. 2002;325(7373):1155. doi: 10.1136/bmj.325.7373.1155.

J. Zimmermann, C. Benecke, S. Hörz, M. Rentrop, D. Peham, A. Bock, G. Dammann Validation of a 16-point German-language inventory of Diagnostica, 59(1)(2013), pp. 3-16.

W. Hwang Adapting psychotherapy to better satisfy the requirements of American psychologist of ethnic minorities, 61(7) (2006), pp. 702-715

M.G. Weiss, D.R. Doongaji, S. Siddhartha, D. Wypij, M. Bhatawdekar, S. Pathare, et al. The Explanatory Model Interview Catalog (EMIC) of the British Journal of Psychiatry, 160 (1992), pp. 819-830 Contribution to cross-cultural research methods

P. Werner Knowledge of Alzheimer's disease symptoms: correlates and connection to behavior-seeking International Journal of Geriatric Psychiatry, 18 (2003), pp. 1029-1036

Zhu, Y., & Blachford, D. (2012). Economic expansion, marketization, and their social impact on china's ethnic minorities in xinjiang and tibet. Asian Survey, 52(4), 714-733. doi:http://dx.doi.org/10.1525/as.2012.52.4.714

BRAWLEY, MARK R. “globalization.” The Princeton Encyclopedia of the World Economy. Ed. Kenneth A. Reinert and Ramkishen S. Rajan. Vol. 1. Princeton, NJ: Princeton University Press, 2009. 555-561. Gale Virtual Reference Library. Web. 24 Feb. 2014.

Fang, T. (1999). Chinese business negotiating style. Thousand Oaks, CA: Sage Publications. Retrieved from http://books.google.com.ezproxy.liberty.edu:2048/books (Original work published 1999).

G. Yeo, N. Hikoyeda Cultural problems in end-of-life decision-making between Asians and Pacific Islanders in the United States K.L. Braun, J.H. Pietsch, P.L. Blanchette (Eds.), Sage Publications, Inc., Thousand Oaks, CA (2000), pp. 101-125.

G.A. Fava Can long-term antidepressant therapy aggravate the course of depression? Clinical Psychiatry Journal, 64 (2003), pp. 123-133

H.C. Fibiger Psychiatry, the pharmaceutical industry and the Schizophrenia Bulletin on better therapy, 38 (2012), pp. 649-650

https://www.sciencedirect.com/science/article/pii/S2214782915300269  Effectiveness of MH-Guru, a brief online mental health program for the workplace: A randomised controlled trial

Combining education and video-based contact to reduce stigma of mental illness: “The Same or Not the Same” anti-stigma program for secondary schools in Hong Kong https://www.sciencedirect.com/science/article/abs/pii/S0277953609001002

A. Frances Psychiatric News (2009, June 26) (Retrieved February 18, 2012, fromhttp:/www.psychiatrictimes.com / dsm-5/content / article/10168/1425378) A warning sign on the way to DSM-V: Beware of its unintended effects.

K.I. B.W. Oppenheimer, Berger, J. Reibman, et al. World Trade Center catastrophe lessons: chest-limiting airway illness, 144 (2013), pp. 249-257

S. Ando, S. Yamaguchi, Y. Aoki, G. Thornicroft Japan Psychiatry Clin Neurosci Review of Mental Health Related Stigma, 67 (2013), pp. 471-482

Hardie SM, McKinley IG. Remediation of Fukushima: status and summary of future plans [e-pub before printing]. J Radioactive Environment. http:/dx.doi.org/10.1016/j.jenvrad.2013.08.002, made available on 13 September 2013.

A.S. Bryk, S.W. Raudenbush Sage, Newbury Park, California (1992)

C. Cefai, L. Camilleri Building school children's resilience. Maltese elementary school students University of Malta: European Center for Emotional Resilience and Socio-Emotional Health (2011)

I.G.N. Darmawan, J.P. Keeves Using C.R. assessment of multiple levels. Aldous, I.G.N. Darmawan, J.P. Keeves (Eds.), Change over time in rural and remote school teaching of numeracy and literacy, Shannon Research Press, Adelaide (2009), pp. 48-60

S. Eden, T. Heiman, D. Olenik-Shemesh The attitudes, views and issues of the British Journal of Educational Technology, 44 (2013), pp. 1036-1052, 10.1111/j.1467-8535.2012.01363.x

M. Fullan, S. Stiegelbauer Teachers College Press, New York, NY (1991) The new significance of instructional change (2nd ed.).

N. Humphrey, A. Lendrum, M. Wigelsworth Social and emotional elements of secondary school teaching (SEAL) program: national assessment (2010) Taken from http:/www.education.gov.uk/publications/eOrderingDownload/DFE-RB049.pdf, 18 May 2013

R.M. Klassen, M.M. Chiu Self-efficacy and job satisfaction of educators: sex educators, years of experience and work stress Journal of Educational Psychology, 102 (2010), pp. 741-756,

E. Melhuish, J. Belsky, A. Anning, M. Ball, J. Barnes, H. Romaniuk, NESS Research Team Variation in Community Intervention Programs for Children and Families: Sure Start Local Programs Journal of Child Psychology and Psychiatry, 48 (2007), pp. 543-551.

H. Munby, T. Russell, A.K. Martin Teachers ' understanding and how it grows V. Richardson (Ed.), American Educational Research Association, Washington, DC (2001), pp. 877-904.

M.D. Pullmann, E.J. Bruns, B.P. Daly, M.A. Sander Improving the assessment and effect on educational results of learners of mental health and other supporting school-based programs Advances in School Mental Health Promotion, 6 (2013), pp. 226-230

M.C. Shediac-Rizkallah, L.R. Bone Planning for Community-based Health Program Sustainability: Conceptual Frameworks and Future Directions for Research, Practice, Policy on Health Education Research: Theory and Practice, 13 (1998), pp. 87-108,

T. Slade, A. Johnston, H. Whiteford, M. Teesson, P. Burgess, J. Pirkis, et al.

Australians ' Mental Health Report 2 (2009) on the 2007 National Mental Health and Wellbeing Survey. Retrieved from http:/www.health.gov.au/internet/main/publication.nsf/content/mental-pubs-m-mhaust2/ on 22 October 2013

Multilevel analysis by T.A.B. Snijders, R.J. Bosker (2nd ed.), Sage, London (2012)

Habib, M., & Zurawicki, L. (2001). Corruption in the context of international business: Conceptual and methodological issues. Journal of Transitional Management, 6(3-4), 167-80

Harrison, L.E., & Huntington, S.P., (2000), Culture Matters, How Values Shape Human Progress. StudyMode.com. Retrieved January 24, 2014, from http://rx9vh3hy4r.search.serialssolutions.com

James H. Bookbinder, Global logistics, Transportation Research Part E: Logistics and Transportation Review, Volume 41, Issue 6, November 2005, Pages 461-466, ISSN 1366-5545, http://dx.doi.org/10.1016/j.tre.2005.07.001.(http://www.sciencedirect.com/science/article/pii/S1366554505000529)

Lu, X. (2009). A Chinese perspective: Business ethics in China now and in the future. Journal of Business Ethics, 86(4), 451-461. doi:10.1007/s10551-008-9857-2

Newport, F. (2012, December 24). In U.S., 77% Identify as Christian; Eighteen percent have no explicit religious identity. Gallup Poll News Service. Retrieved from http://go.galegroup.com.ezproxy.liberty.edu:2048/ps/i.do?id=GALE%7CA313967232&v=2.1&u=vic_liberty&it=r&p=AONE&sw=w&asid=d4d90a6ec2ea13a82aaae0bb99b776e5

Ogden, H., & Shen, C. (2011). Cultural dimensions and materialism: Comparing canada and china. Asia Pacific Journal of Marketing and Logistics, 23(4), 431-447. doi:http://dx.doi.org/10.1108/13555851111165011

Sandberg, Jared. “Language barriers (Even with the same language).(Report on Business: Globe Careers)(COMMUNICATION).” Globe & Mail [Toronto, Canada] 30 Jan. 2008: C8. Global Issues In Context. Web. 2 Mar. 2014

Sardy, M., Munoz, J. M., Sun, J. J., & Alon, I. (2008). Emerging dimensions of business ethics in china. Competition Forum, 6(2), 305-327. Retrieved from http://search.proquest.com/docview/214846060?accountid=12085

St Clair, N. S., & Norris, J. T. (2012). Business ethics and social responsibility in contemporary china. Journal of Academic and Business Ethics, 5, 1-9. Retrieved from http://search.proquest.com/docview/1011487477?accountid=12085

SourceOECD General Economics & Future Studies, Volume 2005, Number 42, November 2005 , pp. 129-168(40)

Su, C., & Littlefield, J.E. (2001). Entering guanxi : A business ethical dilemma in mainland China? Journal of Business Ethics, 33: 199-210.

SWOT Analysis. (2009). In Encyclopedia of Management (6th ed., pp. 915-918). Detroit: Gale. Retrieved from http://go.galegroup.com.ezproxy.liberty.edu:2048/ps/i.do?id=GALE%7CCX3273100290&v=2.1&u=vic_liberty&it=r&p=GVRL&sw=w&asid=a3440aea4ea1d8a24a9cd170320b511e

Svensson, Jakob, “Eight questions about corruption,” Journal of Economic Perspectives, 19:3 (Summer 2005), 19-42. http://www.jstor.org.ezproxy.liberty.edu:2048/stable/4134971

Wang, H., & Hong, Y. (2012). Globalization and its impact on china's technology innovation system. Journal of Technology Management in China, 7(1), 78-93. doi:http://dx.doi.org/10.1108/17468771211207367

S. Genomics and the company Paabo. The genome of the human being and our perspective. Science: 291 (2001):1219–1220.                    

K. G., Richter, K., & K. G. (2000) A guide for Native Americans to behavioral health management. , Tucson, AZ. Center for Native American Health, Arizona University.              

Rumbaut, R. G. The crucible inside of the Children of Immigrants: Ethnic Identity, Self-Esteem, and Segmented Assimilation. 28, International Review of Migration (1994):748–94.

A. Harvey, E. Watkins, W. Mansell, R. Shafran Cognitive behavioural processes across the psychological disorders: A transdiagnostic approach to research and treatment Oxford University Press, New York (2004)

D. Healy The anti-depressant era Harvard University Press, Cambridge, MA (1997)

T.R. Insel Testimony during the hearing, Mental Illness and brain disease: Dispelling myths and promoting recovery through awareness and treatment. Subcommittee on Health of the Committee on Energy and Commerce, United States House of Representatives Retrieved August 2, 2012

P.S. Jensen, L.E. Arnold, J.M. Swanson, B. Vitiello, H.B. Abikoff, L.L.Greenhill, et al.3-Year follow-up of the NIMH MTA study Journal of the American Academy of Child and Adolescent Psychiatry, 46 (2007), pp. 989-1002

-Hall V, Petersen I, Bhana A, Mjadu S, Hosegood V, Flisher AJ. Collaboration between traditional practitioners and primary health care staff in South Africa: developing a workable partnership for community mental health services. Trans Psychiatry (2010) 47:610–28. 10.1177/1363461510383459 

 Kirmayer LJ, Gomez-Carrillo A, Veissiere S. Culture and depression in global mental health: An ecosocial approach to the phenomenology of psychiatric disorders. Soc Sci Med. (2017) 183:163–168. 10.1016/j.socscimed.2017.04.034

 Isaacs AN, Pyett P, Oakley-Browne MA, Gruis H, Waples-Crowe P. Barriers and facilitators to the utilization of adult mental health services by Australia's Indigenous people: Seeking a way forward. Int J Mental Health Nurs. (2010) 19:75–82. 10.1111/j.1447-0349.2009.00647