Engaging Asian Americans for Mental Health Research: Challenges and Solutions

Journal of Immigrant Health, Vol. 7, No. 2, April 2005 ( C© 2005)DOI: 10.1007/s10903-005-2644-6

Engaging Asian Americans for Mental Health Research:Challenges and Solutions

Hongtu Chen,1,4 Elizabeth J. Kramer,2 Teddy Chen,3 and Henry Chung3

Asian American communities have important and unmet mental health needs, but there iscomparatively little research data on process and outcomes that can guide evidence-basedapproaches to mental health care. This paper describes our experience of building researchprograms in a community-based health care facility, some of the challenges we faced, andbarriers that were overcome. We have learned that a) mental health services research can becarried out in a community health center with minimal intrusion on usual patient flow; b) theeffort must be shared between the health center and the community; c) barriers to participa-tion in mental health research programs are multifactorial ranging from conceptual, cultural,and attitudinal biases to practical concerns inherent in the ethnic minority population; and d)resistance can be overcome by working with participants’ cultural and social needs and usingtheir explanatory belief models when developing and pursuing studies.

KEY WORDS: research; Asian; barrier; participation.

INTRODUCTION

Asian Americans are the fastest growing racialgroup in the United States. According to the 2000census, 10,242,998 individuals (3.7% of the totalpopulation) were Asian American, a number that isexpected to double by 2025. Asian Americans aredistinguished from other racial groups by severalcharacteristics: they include at least 43 ethnic groupswho speak more than 100 languages and dialects; ap-proximately 71% are foreign born, with Asian im-migrants accounting for 2.6% of the total US pop-ulation, and limited English speaking proficiency iswidespread.

The number of effective strategies to overcomethe tremendous stigma and suspicion that Asian

1Brigham and Women’s Hospital, Harvard Medical School, 1249Boylston Street, 3rd Floor, Boston, Massachusetts 02215.

2931 S. Duke Street, York, Pennsylvania 17403.3Charles B. Wang Community Health Center, 268 Canal Street,New York 10013.

4Correspondence should be directed to Hongtu Chen, Brighamand Women’s Hospital, Harvard Medical School, 1249 BoylstonStreet, 3rd Floor, Boston, Massachusetts 02215; e-mail: [email protected].

Americans have toward mental health is limited(1, 2). Established mental health services lack thecapacity to meet the mental health needs of manyAAPI people (3, 1), and Asian Americans have dif-ficulty seeking, accepting, or remaining in availablemental health treatment programs (4–7, 19) and par-ticipating in health services research (8–10).

In 1997, with grant support from the RobertWood Johnson Foundation and a number of localfoundations, the Primary Care and Mental HealthServices Bridge Program was founded at the CharlesB. Wang Community Health Center, a neighborhoodhealth center located in the heart of Manhattan’sChinatown, in New York City. The Clinic’s bilingual,bicultural staff, many of whom reside or were raisedin the neighborhood, serves a patient population con-sisting primarily of new immigrants and older resi-dents who have been in the United States for a longtime but have never learned English or acculturatedto life in this country. For the most part their be-liefs about health and health care are fairly tradi-tional, particularly when it comes to mental health.Staff are well attuned to these beliefs and the issuesthey can encounter. The goals of the Bridge pro-gram are 1) to improve access to mental health care

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110 Chen, Kramer, Chen, and Chung

by providing mental health services in primary care;2) to improve community treatment capacity by en-hancing the skills of primary care providers to iden-tify and treat mental disorders commonly seen in pri-mary care; and 3) to raise community awareness byproviding education on mental health and illness.

A mental health research program began in 1998as an evaluation component of the Bridge Program.Later, a number of research projects were developed,including the Primary Care Research in SubstanceAbuse and Mental Health for Elders (PRISM-E)Study, a clinical trial testing the efficacy of an antide-pressant on neurasthenic Asian American patients,and a survey study assessing emotional distress in theNew York Asian American community after the 9/11terrorist attack. These projects enabled expansionof the research program and allowed the researchteam to fully experience the challenges and explorethe strategies of recruiting Asian American patientsand their families into mental health research stud-ies. This paper highlights our experience in engagingthe Asian American community for mental health re-search, and shares some of the solutions we found tobe informative for researchers working with similarpopulations.

CHALLENGES AND SOLUTIONS

Collaborating With Clinical Staff

Studies that must be done in clinical settings in-evitably cause a certain degree of intrusion or inter-ruption to the normal clinical flow. Given the produc-tivity requirements and incentives to keep patientsmoving through the system, it is important to gaincooperation and support from the providers who willbe impacted by the study, as well as their supportpersonnel. The relative dearth of evidence concern-ing both the delivery of mental health care and thetypes of treatments available for Asian Americans,particularly in health centers where providers mayexperience some of the same stigma as patients (11),behooves research staff to stress the uniquely poten-tial impact of certain elements of the study on boththe medical staff and the patients. It is particularlyimportant to stress: 1) how the study might benefitpatient care in the future, and the compelling clinicalneed for such research; 2) any known or suspectedrisks, especially those that are unique to the popu-lation; 3) whether the existing clinical flow may bealtered; 4) the clinical staff’s respective roles in thestudy; and 5) how the study can best be communi-

cated to patients. It is extremely important to empha-size the cultural competence elements of the studyand how findings are expected to improve patientcare. A pamphlet that reinforces the verbal presen-tation can be very helpful, both as a reference andas a tool that can help to gain cooperation from lessenthusiastic members of the medical staff.

Having physicians and nurses participate in thedesign and planning of the study and review proto-cols as they are developed can be extremely helpfulin devising ways to minimize the impact of the studyon patient flow and clinic operations. Staff also canhelp to identify the best times and ways to recruitstudy participants. Simple protocols and study de-scriptions also should be provided to the clinical staff,with an emphasis on the types of participants beingrecruited for each specific study. This will better en-able physicians and nurses to identify possible can-didates and expedite referrals to the research team.It is important to be aware of the existing workloadof clinical staff and the extra burden that the researchprocedure will add. Especially in situations where thephysicians do not obviously benefit from the researchproject, a conscientious discussion with them aboutthe best strategies to reduce their burden is a win-winsolution for all parties involved.

The physicians’ direct support of the study is of-ten the most influential factor to prospective studyparticipants. Physicians, particularly primary careproviders, are considered important authority figuresto Asian patients, and a physician’s recommendationor encouragement usually has an important influenceon changing the patient’s attitude toward participat-ing in a research program. If a physician expresseshis understanding of the patient’s stigma and his viewthat mental illness is the same as physical illness thatneeds to be treated and is treatable, a patient usuallywill agree to give it a try. Therefore, the physiciansmust be convinced that the study will potentially oreventually benefit participating patients. Most pri-mary care providers who work with Asian Americanpopulations are aware of the stigma associated withmental disorders.

In order to reduce stigma, we trained the pri-mary care providers to emphasize the linkage be-tween stress and general health, state that this topicwas important to the patient and community, andthen bring in the more diagnostically defined issuesof mental health after buy-in is achieved. This sup-ports the mind-body dualism model of health withwhich many Asians are familiar and then allowsfuller discussion of risks and benefits of participation.

Engaging Asian Americans for Mental Health Research 111

A physician who comments that the patient seemsto be under some “pressure” and that the researchproject is a good opportunity for further exami-nation, is much more persuasive than a researchstaff member who says the exact same words to thepatient.

Finally, enthusiastic endorsement of the pro-gram and individual studies by the clinic’s executivestaff, especially the Medical Director, can go a longway toward obtaining support and cooperation fromthe medical staff. Although, some of these experi-ences may not be unique for Asian Americans, issuessuch as staff participation, physician authority figure,and stigma toward mental health seem to be partic-ularly pronounced in Asian American communities,given their limited exposure to research and their im-migrant and cultural background.

Using Culturally Appropriate Instruments

Most of the psychometric scales and instrumentsused in mental health research are developed andavailable only in English. Fortunately many of thescales have been translated and validated in someAsian languages, while others may only be translatedinto Asian languages but have not been validated.The instruments we have used include: The GeneralHealth Questionnaire (GHQ-12) (12, 13); the Mini-Mental Status Examination (MMSE) (14); MINI In-ternational Neuropsychiatric Interview (MINI) (15);the Center for Epidemiological Study-Depression(CES-D) (16); and the Geriatric Depression Scale(GDS) (17). A thorough literature search of instru-ments that have already been developed and ob-tained linguistic and cultural validity is the first stepone should take before exerting any elaborate effort.

Even if some of the instruments have alreadybeen validated in an Asian population, it is a goodidea to pretest all instruments on the study popula-tion to determine the need for adaptations due todifferences in dialect or literacy level. Sometimes, awrong choice of words can cause serious underre-porting or overreporting by the patient. For instance,we were using the Blessed Orientation-Memory-Concentration Test (18). One item asked the respon-dent to learn the name and address of a person, andrecall the information a few minutes later. The ver-sion we received was a word-for-word translationof English names of person, street, and city (JohnBrown, 42 Market Street, Chicago) into Chinese.When we used it to screen elderly patients for poten-

tial cognitive disorders, many monolingual Chinese-speaking patients screened positive for a disorder be-cause these names were all strange to them. Afterwe modified the translation by using familiar Chinesenames to replace the English ones, the test becamemore appropriate to match the respondent’s linguis-tic background and therefore valid for screening forcognitive disorders, rather than mere learning ability.

When no appropriate and or even imperfectlyadapted instrument can be found, one may have totranslate an existing instrument originally developedfrom other linguistic contexts, if one does not planto carry on another study validating the desired in-strument. In translating a survey instrument, not onlyshould the items and questions be accurately trans-lated, the response choices of each question also mustbe culturally appropriate. In one screening questionwe asked patients to report their drinking behavior todetermine whether they have more than two drinksper day. Several weeks into the study, we realizedthat some Chinese people made their own rice winewhich contains much less alcohol than regular com-mercial wine. To avoid overreporting we had to adda new item to the list of alcoholic beverages to coverthis situation and to adjust the criterion for a “drink”of such wine.

Working With the Community

The concepts of both “research” and “men-tal health” are still new especially to immigrants ofSouth-Eastern Asian origins. Overemphasizing theacademic needs of research could be interpreted asa sign of self-serving intent that is irrelevant to acommunity’s need. Service-based community agen-cies are very sensitive to whether a project can bringany benefit to the community in general and patientsin particular.

The Supplement to the Surgeon General’s Re-port, Mental Health: Race, Culture and Ethnicity,cited stigma as the major barrier for Asians to access-ing mental health care. In Asian communities thereare different degrees of stigma associated with dif-ferent types of mental disorders. For example, de-pression is generally less stigmatizing than psychosis.The less stigma that is linked to a project, the moresupport a community is likely to give. Without de-tailed knowledge, people tend to overgeneralize andoversimplify, possibly misrepresenting reality in theprocess (e.g., regarding everyone with mental healthproblems as “crazy”). We found that most Asian


community leaders appeared to be understandingand sympathetic regarding the mental health aspectsof research projects. They all agreed with the needfor services but also believed that the stigma wouldpotentially obstruct the project.

Explaining study procedures also was difficult.For example, it was very hard for us to frame ran-domization in a manner that was both understand-able and acceptable to potential study participants.Our consumer advisory group suggested we tell peo-ple exactly what would happen to a patient, ratherthan dwelling on the name of the procedure. This re-sulted in our simply saying, “. . . afterwards, the pa-tient will have an equal chance of going to either ofthe following two treatment models . . . .” This provedto be less of a problem for all parties than we origi-nally had anticipated.

In a dual effort to recruit study participants andto educate the community about mental illness, weemployed intensive community outreach. Activitiesincluded lectures on depression and anxiety at sev-eral local senior centers, home care agencies, and so-cial service centers, public education articles on men-tal illness in the local newspapers, and distributingbrochures on the prevention, diagnosis, and treat-ment of depression, anxiety, and alcohol disorders.

We also used radio programs, which have theadvantage of wide and regular access. The radio of-ten is played all day in many places of employment.We found that the anonymity of a radio dialogue be-tween a patient and a clinician, or an engaging con-versation between a clinician and an audience, is avery effective way to introduce a new topic. A series,of programs is an excellent way to raise awareness ofcertain health issues and increase the normalcy of astigmatized topic. The factors that usually make ra-dio programs successful are an interesting topic, anexperienced speaker (or clinician), and presentationwith interesting and representative symptoms or casediscussion. An interactive radio program may gener-ate phone calls from an audience who are eager toask questions about themselves.

Based on the number of phone calls it gener-ated, we found that a good newspaper article that isbased on a case study written in the patient’s voice isthe most effective method for reaching elderly AsianAmericans with mental health needs. Articles thatfocus solely on institution-based announcements ofnew programs attract the least attention.

Printed material other than newspaper articlesmay not be helpful because many Asian Americanimmigrants, especially elders, have relatively lower

literacy levels. Although we have developed a num-ber of pamphlets and flyers, they seldom generatephone calls to inquire about or request mental healthservices. In sharp contrast, the printed materials de-veloped for infant care and pregnant women are of-ten read and used by their target audience.

A consumer advisory group that meets regularlycan be a good source of opinion, as well as a fo-rum for hypothesis testing, and brain-storming forstrategizing and planning for the community educa-tional campaign. For one of the research projects,a consumer advisory council was established whosemembership was comprised of mental health con-sumers, pastors of Chinese churches, caregivers ofmental health patients, and home attendants. Themajor functions of the consumer advisory councilwere to: 1) ensure that community interests were rep-resented in the design and implementation of thestudy; 2) provide consultation and support in the de-velopment of materials needed for community ed-ucation and outreach; 3) advise on how to effec-tively recruit and retain elderly Chinese patients’participation in the study and 4) assist in dissemi-nating the lessons and knowledge gained from thestudy.

The research team and the consumer advisorycouncil had a number of meetings to capture con-sumers’ and advocates’ thoughts about the currentmental health status of the community; the majorbarriers to seeking mental health services among el-ders and the solutions to improve the mental healthstatus and health seeking habits of elders in the com-munity. The discussions generated many valuableideas regarding ways of presenting the study to el-derly Chinese and the community served by the clinicas well as ways of recruiting study participants.

Although we were successful in initiating andmaintaining the consumer-researcher collaborationthroughout the project, we did encounter somechallenges over the years. For example, while theconsumer-researcher collaboration was a success, wewere unsuccessful in our efforts to find a consumerleader to help us mobilize the community and playthe role of advocate to promote mental health. Withone exception, we also found it difficult to find peoplewho could help us improve the community’s aware-ness of mental health and reduce stigma toward men-tal health services. Another challenge is to sustain theconsumer advisory council activities after grant sup-port ends. Despite willingness and enthusiasm, ex-tra resources are needed to organize consumer-basedactivities.


Working Through Enrollment Problems

Low-income immigrants may be hesitant to in-cur any additional expense that results from par-ticipation in a treatment study, and undocumentedimmigrants may fear they will be deported if theychoose to participate. Others, particularly elders,may be responsible for rearing children or grand-children thus precluding their ability to commit thetime required for the study. Offering patients reim-bursement for their inconvenience such as babysit-ting service and transportation can be helpful. Wepaid nominal transportation costs and reimburse-ments for their completion of various phases of a lon-gitudinal observation.

Because the traditional Asian view of healthdoes not separate body and mind, Asian Americansmay seek alternative explanations for their symp-toms rather than accept psychiatric diagnoses andtreatment. When we tried to recruit Asian patientsfor a study of depression, denial was a typicalresponse—some patients simply do not consider de-pressed moods a medical condition that requirestreatment. Many also doubt the treatability of men-tal problems. For instance, a patient attributes herdepressive symptoms to her relationship with a bad-tempered daughter-in-law, and she believes thatthere is no way that this can be changed as long asthey live together. Another patient may attribute hisanxiety to a housing problem, and believe that onlygiving him a decent place to live, rather than par-ticipating in a treatment study program, can solvehis problem. Many Asian Americans simply do notbelieve that talk therapy can help or that takingmedicine can solve emotional problems that aredeeply rooted in a social context.

A key strategy in explaining the essentiallyWestern concepts of mental disorders and psychiatrictreatment to a patient is to employ a culturally com-petent person who will be viewed by the patient asan “insider” or “the same people.” That person canbe a nurse, a clinician, a research assistant, or a com-munity volunteer who can think and behave on thepatient’s behalf, thus building the fundamental trustbetween a skeptical patient and a health service pro-gram, between a cautious and distrustful immigrantand a culturally and conceptually challenging experi-ence. Our Research Assistants, who were recruitedfrom the community, played this important rolefor us.

Several strategies were employed to reduce therefusal rate. The most useful one was research team

meetings. Discussing issues and sharing experienceswith experienced mental health clinicians was themost helpful way to improve research assistants’skills of engagement. Community education, espe-cially Chinese radio programs, newspaper articles,and presentations at the senior centers also probablywere helpful.

To improve the retention rate, we also employeda number of strategies: a) we made it very clear to pa-tients that they would be compensated for time spenton assessments; b) we sent a greeting/reminder letterafter the baseline assessment, in order to both con-solidate the established rapport and prepare the pa-tient for the upcoming follow-up assessments; c) theresearch assistants emphasized that the follow-up as-sessment would not be contingent on participatingin the recommended clinical treatment; d) at the ini-tial assessment, the research assistants would requestalternative contact information in case the patientmoved away or could not be reached; e) we man-aged to catch the patients in the clinic at the timeof their next appointment with their primary careprovider if the appointment was within the windowof the follow-up assessment; f) we carefully moni-tored the follow-up assessment “windows” for eachstudy participant and tried to schedule them into theearly part of the window; g) we flexibly arranged in-terview time and used evenings or weekends whensubjects could not be reached during the week; andh) we made sure that timely compensation was sentto the patients interviewed on the phone.

In addition, most Asian American immigrantpatients, especially elders, have a wide range of needsfor help, the most prevalent of which are interpret-ing medical test results, assistance with applying forhealth or housing benefits, or just reading a few com-plicated English sentences. The most successful men-tal health clinicians are those who are willing eitherto provide some of these concrete services or to helpfind the right person to do them for the patient. Be-cause the need for better moods is as important asthe need for lessening the burdens of living a nor-mal life, the best mental health service for this pop-ulation seems to be truly integrated services, broadlydefined.

By using these strategies, we have greatly im-proved our chance for involving Asian Americanpeople in mental health research. In the PRISM-Estudy, for example, a total of 1500 primary care pa-tients aged 65 and older were screened for psycho-logical distress, suicidal ideation, and alcohol misuse.Based on our review of the literature, we calculated


that about 6.4% of primary care patients would qual-ify and agree to participate in the study. Of those1500, 109 participants were enrolled in the study, afigure slightly higher than we expected. We expectedour attrition rate to be around 30%. During the first3 months of longitudinal follow-up it was 19.3%, andbetween 3 and 6 months it was very minimal. Overall,the Asian American participants in this study had arelatively low drop-out rate throughout the longitu-dinal follow-up observations.

Handling Polite Refusals

A patient is unlikely to tell the researcher thathe does not want to participate in a mental healthresearch program because it is embarrassing andshameful to see a mental health clinician, especiallyif his relatives and friends find out. Rarely wouldan Asian patient tell a researcher that he stronglydoubts the effectiveness of psychotherapy, althoughhe might comfortably share this opinion with a nursewho he knows.

A more likely response is, “Let me think aboutit,” “Let’s discuss it later.,” or, “I’ll try my best (tomake the appointment), but I cannot guarantee.”Another common answer is, “I will discuss it with mychildren, and let you know later.” Refusal or no showis often implied in most of these responses.

We found that the best strategy is to accept themat face value, and ask the patient if he or she wouldschedule another appointment with the researcherto discuss the possibility of participation again. Itis common for a patient to feel hesitant or cautiousabout participating in a new activity. However, aslong as the researcher believes that the project isvaluable or that participation is a worthwhile experi-ence for the patient, his or her persistence will oftenbe rewarded by the patient’s gratitude later.

Obtaining Informed Consent

Obtaining informed consent from an AsianAmerican immigrant patient can be a challengingtask for two major reasons. Asians are not accus-tomed to the process of giving written informedconsent for treatment, and they are relatively inex-perienced in participating in research trials, whichthey may view with suspicion. Study protocols ap-proved by Institutional Review Boards typically re-quire translation of consent forms into languages

other than English, and the wording must be as closeto that in the original document as possible. How-ever, the relatively formal language and tone canseem quite intimidating. After reading the translatedconsent form, many immigrant adults refused to par-ticipate in a study because of their suspicion of a pos-sible scam behind any legal documents. In our expe-rience the best way to handle this is to go over theinformed consent document with patients, summa-rizing and explaining every paragraph at a pace slowenough for them to process the information.

We also sought to obtain consent immediatelyafter the physician indicated the patient’s willingnessto take part in the study and approved for partici-pation. For those patients who verbally agreed butcould not stay any longer that day, the research assis-tant scheduled another appointment with the patientwithin 1 week to explain the study, obtain the con-sent, and conduct the eligibility interview.

Even when patients verbally agree to partici-pate after going through the consent document, somemay still refuse when they get to the signature page.A common concern among immigrants is that anysignature may have legal consequences that mightpotentially affect their immigration process. The re-searcher who is soliciting the signature needs to re-iterate the confidentiality of the study. The signa-ture form should be presented to the patient in aprofessional and confident manner. We have foundthis an effective way to improve their willingness toparticipate.

Sometimes, even after patients have signed theconsent, they later realize that participation in thestudy involves more than they originally expected be-cause of transportation, the time required, or finan-cial costs associated with participation. These factorscan easily cause them to change their minds. Somepatients will call back after they discuss the projectwith their family members and decide to withdraw.Withdrawal can be reduced by clarifying the proce-dures with key family members and reinforcing themodest reimbursement for patient inconvenience. Itis often helpful to have a family member present atthe time consent is obtained.

Using Incentives

Many Asian American patients have little expe-rience participating in research and show clear sur-prise at what they receive. They typically will com-ment that they always pay in clinical settings and


have never received any money or souvenirs frommedical staff. In one of our studies of mental healthservice experiences, the hour-long interview was of-ten perceived as a rare and valuable service concern-ing the patients’ emotional situations. They believethat they are the ones who should pay for our ser-vice, not the other way around. In addition, patientsand their families may feel puzzled and raise suspi-cion about the intent of the project. Some patients,especially elderly ones, may not fully understand themeaning of the incentive they have received. Whenthey bring it back to their families, family membersmay call back to request a further explanation, or askus to allow them to return the money but still agreeto participate in the program. They do not want to bepressured by the extra obligation caused by money.Some older Asian patients may feel uncomfortableaccepting money, because it reminds them that partof them (e.g., the information) has been sold as partof a cheap material exchange. They will only expressthis discomfort by saying ritualistically, “No. It’s tooembarrassing.” To ease the awkwardness, and createthe perception of a decent gift or token of gratitude,rather than a wage for the information, we were ad-vised to put the money into a red envelope that iscustomarily used as a gift-wrap among Chinese.

Clinical and moral incentives also have beenfound to be moderately effective in engaging somepatients in the research process. The clinical incen-tive emphasizes a potential benefit of the treatmentto the patient’s condition. Its goal is to raise thepatient’s awareness of his need for treatment andconvince the patient of the possible effects of thetreatment.

The moral incentive, or the altruistic approach,emphasizes how participation in the study may even-tually help other people who have similar conditionsor the community in general. This approach can ef-fectively persuade many Asian people to participateand it is sometimes necessary in order to convincesome patients who have a general distrust of anyonewho asks them to join a program. In either approach,it is important that the interviewer truly believe thatthe research program will be beneficial.

Making the First Visit

The no-show rate for the first visit to a mentalhealth clinician is high among Asian American pa-tients. A telephone reminder prior to the appoint-ment is necessary to ensure that the patient will

show up at the scheduled appointment. Such a re-minder call often will become a mini counseling ses-sion to persuade and encourage the hesitant patient.Therefore, mental health clinicians should make suchphone calls themselves, rather than asking a supportperson to handle this important engagement step. Al-ternatively, the individual making the calls must bewell trained and prepared to deal with contingenciesthat may arise in the course of the conversation.What happens at the first visit will weigh heavilyin determining whether an Asian patient will con-tinue the recommended treatment. With the stigmaof mental health services and doubt about the effec-tiveness of therapy, an Asian patient may come intothe mental health clinician’s office only to confirm hisor her preexisting disbelief that “this won’t help.”

What would give those patients a sense that“this might help”? Clinical social workers who haveworked with Asian American patients for many yearsbelieve that the most effective strategy is to presentthe clinician’s view of the patient’s problems to thepatient and to make it clear that it is only the clini-cian’s point of view. The clinician can then summa-rize the patient’s view of his or her problems, anddiscuss the difference between the two viewpoints. Itis also important to point out the potential negativeconsequences if these problems are not dealt with.Although there is no guarantee that such a cogni-tive set-up with sensible communication will ensurethe patient’s continuation of the visit, it seems to bean effective way to engage a highly stigmatized andskeptical Asian patient.

CONCLUSION

Despite the success in improving general healthstatus of Asian Americans over the last decade, com-munity participation in mental health services andresearch remains low due to stigma and variationsin knowledge, attitudes, and beliefs about mentalhealth care. One effective way to overcome such lim-itations is to accumulate more knowledge throughthe development of colocated research and serviceprograms. Through our experience of building a re-search program in a community-based health facility,we have learned that: a) Establishing a successfulresearch program in an Asian American commu-nity relies on both clinical and community-based sup-port from various groups both within and outside thehealth care system. b) The barriers to participationin mental health research programs span knowledge,


attitudes, beliefs, and health care seeking behav-iors, as well as practical concerns inherent to eth-nic minority populations such as fears of deportation.c) Overcoming resistance requires research organiz-ers to employ culturally and socially sensitive strate-gies at every step of the research process, from plan-ning through evaluation. We have learned that themany challenges of doing in vivo research in a clinicalsetting are more than offset by the knowledge gainedabout the community. Further, the issues relating todesign and implementation, especially those relatingto impact on the clinical staff, are generalizable toall settings whose primary mission is to provide clin-ical service. We believe that well-planned clinical re-search programs in ethnic minority communities canprovide a firm foundation for health care practition-ers, participating consumers, and policy makers, toadvance the state of knowledge and to provide highquality, culturally competent care.

ACKNOWLEDGMENTS

The authors are grateful to the Charles B.Wang Community Health Center in New York City,the Substance Abuse and Mental Health ServicesAdministration (SAMHSA), and the Health Re-sources and Services Administration (HRSA) fortheir support.

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Engaging Asian Americans for Mental Health Research: Challenges and Solutions