Denise Saint Arnault

Cultural determinants of help seeking: a model for research and practice.

Increasing access to and use of health promotion strategies and health care services for diverse cultural groups is a national priority. While theories about the structural determinants of help seeking have received empirical testing, studies about cultural determinants have been primarily descriptive, making theoretical and empirical analysis difficult. This article synthesizes concepts and research by the author and others from diverse disciplines to develop the midrange theoretical model called the Cultural Determinants of Help Seeking (CDHS). The multidimensional construct of culture, which defines the iterative dimensions of ideology, political economy, practice, and the body, is outlined. The notion of cultural models of wellness and illness as cognitive guides for perception, emotion and behavior as well as the synthesized concept of idioms of wellness and distress are introduced. Next, the CDHS theory proposes that sign and symptom perception, the interpretation of their meaning, and the dynamics of the social distribution of resources are all shaped by cultural models. Then the CDHS model is applied to practice using research with Asians. Finally, implications for research and practice are discussed.

Somatic and depressive symptoms in female Japanese and American students: a preliminary investigation.

The present study examined the relationship between common somatic symptoms and depression in samples of Japanese and American college students. Fifty Japanese and 44 American women completed the Beck Depression Inventory (BDI) and rated 56 somatic-distress items for 7 days. Japanese had higher levels of somatic distress than Americans. ANOVA of somatic distress by BDI-level revealed that the High BDI Japanese group reported 26 somatic symptoms (including stomach ache, dizziness, and shoulder pain) with significantly higher means when compared with the low BDI group. High BDI Americans had a significantly higher mean for joint pain compared to the Low BDI group. The importance of the body in transcultural psychiatry is explored, and implications for primary and mental health care are discussed.

Help-seeking and social support in Japanese sojourners.

Research shows that social support is essential for healthy psychological functioning. Help seeking and social support are social processes shaped by cultural understandings about how need should be expressed, to whom, and in what circumstances. This study used grounded theory methodology to examine how cultural factors regulate help seeking and social support in a sample of 25 Japanese sojourners’ wives living in America. Culturally based social edicts such as mutual responsibility and in-group solidarity were found to promote help seeking and social support. In contrast, culturally specific factors such as enryo (polite deference), hierarchy, and the cultural rules governing reciprocity inhibited these behaviors. From these data, a cultural model of social exchange, allowing for cultural diversity, is proposed. This model can increase the effectiveness of nursing interventions aimed at community-based health promotion.

The Clinical Ethnographic Interview: A user-friendly guide to the cultural formulation of distress and help seeking

Transcultural nursing, psychiatry, and medical anthropology have theorized that practitioners and researchers need more flexible instruments to gather culturally relevant illness experience, meaning, and help seeking. The state of the science is sufficiently developed to allow standardized yet ethnographically sound protocols for assessment. However, vigorous calls for culturally adapted assessment models have yielded little real change in routine practice. This paper describes the conversion of the Diagnostic and Statistical Manual IV, Appendix I Outline for Cultural Formulation into a user-friendly Clinical Ethnographic Interview (CEI), and provides clinical examples of its use in a sample of highly distressed Japanese women.

RO1 Funding for Mixed Methods Research Lessons Learned From the “Mixed-Method Analysis of Japanese Depression” Project

Mixed methods research has made significant inroads in the effort to examine complex health-related phenomena. However, little has been published on the funding of mixed methods research projects. This article addresses that gap by presenting an example of a National Institute of Mental Health–funded project using a mixed methods qualitative–quantitative triangulation design titled “The Mixed-Method Analysis of Japanese Depression.” The authors present the Cultural Determinants of Health Seeking model that framed the study, the specific aims, the quantitative and qualitative data sources informing the study, and overview of the mixing of the two methods. Finally, the authors examine reviewers’ comments and the authors’ insights related to writing mixed methods proposals for successfully achieving RO1-level funding.

Social networks and the maintenance of conformity: Japanese sojourner women

Most of the literature about Japanese social relationships focuses on men in organizational settings. However, this study used intensive interviewing to examine the nature, structure and function of social relationships among the spouses of Japanese expatriates. The Japanese women in these samples were found to engage in complex, highly regulated, complicated and obligatory relationships through their primary affiliation with other “company wives”. Traditional cultural norms of ryoosai kenbo (good wives and wise mothers) were expected from modern women, and the enactment of these roles was enforced through scrutiny, gossip and the possibility of ostracism. Understanding the social organization and support within the Japanese womens community is central to understanding how culturally specific social networks can both give support, as well as create social constraints to help seeking. Health oriented prevention programs must consider these social factors when evaluating the immigration stressors faced by these families.

Testing the influence of cultural determinants on help-seeking theory.

Despite increased risks for mental health problems, East Asian immigrant women have the lowest overall service-utilization rates of any cultural group in the United States. Although the influence of cultural processes as the cause of low service use is widely speculated, no empirical study has tested cultural determinants (including culturally specific idioms of distress, culture-based illness interpretations, or concerns about social consequences), social contextual factors, perceived need (PN), and help-seeking (HS) behaviors. In the present study, we examined how cultural determinants, such as symptom experience, beliefs and interpretations, and perceptions about the social environment, affect PN and HS type for Japanese women living in the United States. Increasing physical symptom severity increased the predicted probability of endorsing PN. For those participants with PN, 48.6% of them used medical HS (&khgr;2 = 11.27, p = .00), and 12.5% of them used the psychological HS (&khgr;2 = 7.43, p = .01). Multivariate logistic regression revealed that, when PN is considered with the other cultural variables while controlling for structural variables, PN increases the odds of medical HS (OR = 2.78, 95% CI [1.0–5.8], p < .01). The odds of medical HS are also increased with higher social support (OR = 1.07, 95% CI [1.0–1.1], p < .01). Finally, the presence of interpersonal stigma beliefs decreased the odds of medical HS (OR = 2.4, 95% CI [1.1–5.3], p < .03). Clinical and research implications are discussed.

Construct Validity and Reliability of the Beliefs Toward Mental Illness Scale for American, Japanese, and Korean Women

Purpose: The aim of this study was to evaluate the psychometric properties of the Beliefs Toward Mental Illness Scale (BMI) across women from the United States, Japan, and South Korea. Methods: A cross-sectional study design was employed. The sample was 564 women aged 21–64 years old who were recruited in the United States and Korea (American = 127, Japanese immigrants in the United States = 204, and Korean = 233). We carried out item analysis, construct validity by confirmatory factor analysis (CFA), and internal consistency using SPSS Version 22 and AMOS Version 22. Results: An acceptable model fit for a 20-item BMI (Beliefs Toward Mental Illness Scale–Revised [BMI-R]) with 3 factors was confirmed using CFA. Construct validity of the BMI-R showed to be all acceptable; convergent validity (average variance extracted [AVE] ≥0.5, construct reliability [CR] ≥0.7) and discriminant validity (r = .65–.89, AVE >.79). The Cronbach’s alpha of the BMI-R was .92. Conclusion: These results showed that the BMI was a reliable tool to study beliefs about mental illness across cultures. Our findings also suggested that continued efforts to reduce stigma in culturally specific contexts within and between countries are necessary to promote help-seeking for those suffering from psychological distress.

The Importance of Perceived Need in Help Seeking for Japanese Women: A Preliminary Investigation of Sociocultural Contributions

This research was funded by the NIH Office of Behavioral and Social Sciences, the Office of Womens Health and the National Institute of Mental Health under grant number MH071307. Research has shown that the general American adult population underutilize mental health services despite having high objective need (Corrigan, Watson, Warpinski, & Gracia, 2004; Kimerling & Baumrind, 2005; Klimidis, Hsiao, & Minas, 2007). Most research on service underutilization focuses on structural barriers to access, and the convergence of risks and vulnerabilities for that account for mental health disparities (Alegria et al., 2014). However, research that examines how sociocultural aspects of illness, including symptom experience, cultural beliefs and values, and sociocultural context interact to influence both perceived need and help seeking strategies is needed (Kimerling & Baumrind, 2005). Reports that culturally responsive approaches in psychiatry have shown that it can improve patient satisfaction (Callan & Littlewood, 1998; Owiti et al., 2015), treatment engagement (Ineichen, 1990; Lee, Ayers, & Kronenfeld, 2009; Lewis-Fernández, 2009; Yasui & Henry, 2014), and help seeking behavior (Dixon, Holoshitz, & Nossel, 2016; Hwang & Myers, 2013). Our research program was prompted by a crisis in Detroit in the mid-1990s that involved tragedy for a Japanese National with postpartum depression. For a host of interacting reasons, the woman, her family, her community, and the health care system did not recognize or adequately respond to her escalating distress, resulting in her drowning her baby during her psychosis. This young woman was part of a substantial community of Japanese families living in Michigan related to the Japanese automobile industry in Detroit. A mismatch between Japanese and American symptom experiences and illness interpretations may be at the heart of this tragedy (Benish, Quintana, & Wampold, 2011). Since appropriate nursing intervention relies on the assessment of cultural variables that influence mental illness experience and expression, our research has examined those cultural factors that are known to influence mental health help seeking, including somatic symptom experiences, illness interpretations, and culturally based beliefs aboutmental illness for distress in a sample of Japanesewomen living in the US.