Asian and Pacific Islander American men's help-seeking: cultural values and beliefs, gender roles, and racial stereotypes.

Asian and Pacific Islander American (APIA) individuals comprise one of the fastest growing populations in the United States; however, little is know about their health status, and even less is known about the health status and help-seeking patterns of these men. This article provides an overview of APIA men's help-seeking behavior, using an ecological-contextual framework to understand the impact of cultural values and beliefs, gender roles, and racial stereotypes on help-seeking. We consider the influence on their lives of Asian philosophical and religious thought; cultural values of harmony, interdependence, and saving face; alternative views of health based on holism, fatalism, and spiritism; and the impact of racism and the model minority stereotype. Generalizations about cultures and peoples in this group of men are balanced by an emphasis on within-group differences such as ethnic background and acculturation. Implications for culturally responsive services and service providers are discussed.

Keywords: Asian American, Native Hawaiian and Pacific Islander, help-seeking, health, cultural values, men

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Although Asian and Pacific Islander American (APIA) individuals comprise one of the fastest growing populations in the United States (U.S. Census Bureau, 2001b), there remains a dearth of information about their health status (Abe-Kim, Takeuchi, & Hwang, 2002; Amaro, Jenkins, Kunitz, Levy, Mixon, & Yu, 1995; Zhang & Snowden, 1999), and even less is known about the health status and help-seeking patterns of APIA men. Researchers (Gong, Gage, & Tacata, 2003; Leong & Lau, 2001; Liao, Rounds, & Klein, 2005; Yu, Liu, & Williams, 1993) have emphasized the need to focus on the role of culture in shaping the their health. In this article, we review the literature on help-seeking by APIA men, and examine the roles of culture values and beliefs, gender roles, and racial stereotypes in shaping their patterns of help-seeking.

Asian Pacific Islander American is an umbrella term used to represent a number of unique ethnic groups, each with different patterns of help-seeking, cultural values and traditions, and attitudes and beliefs about health and illness. According to the 2000 census, there were over 12.8 million APIA individuals, accounting for 4.5 percent of the U.S. population (Barnes & Bennett, 2002; Grieco, 2001). Of these, 11.9 million were Asian, a racial designation made up of more than 20 ethnic groups, with Chinese, Filipinos, Asian Indians, Vietnamese, Koreans, and Japanese comprising over 88 percent of those who reported only one Asian ethnic group. Other Asian ethnic groups include Cambodians, Hmong, Laotians, Pakistanis, Taiwanese, Thais, Bangladeshis, Indonesians, Sri Lankans, Burmese, Malaysians, Nepalese, Okinawans, Singaporeans, Bhutanese, Indo Chinese, Maldivians, and Iwo Jimans. There were 1.7 million multiracial Asian Americans, and 224,000 multiethnic Asian Americans (Barnes & Bennett, 2002). Pacific Islander Americans numbered 874,000, almost half of whom were Native Hawaiian, the remaining being multiracial. Other Pacific Islander ethnic groups include Samoans, Guamanians or Chamorros, Tongans, Fijians, and over 15 other Polynesian, Micronesian, and Melanesian ethnic groups (Grieco, 2001).

The proportion of APIA individuals who were foreign-born was the highest of any racial group at (61.4 percent or 6.7 million people) (Schmidley, 2001). The average income per household for APIA individuals was more than that for White non-Hispanics ($55,521 vs. $45,904); however, there were more family members per household for APIA individuals than for White non-Hispanics (3.10 vs. 2.45), resulting in lower income per household member in the group than for White non-Hispanics ($22,688 vs. $24,951) (U.S. Census Bureau, 2001a). Despite these income figures, APIA men and women were over-represented among those living in poverty (10.8 percent, as compared with 7.5 percent for White non-Hispanics) (Dalaker, 2001). Taken together, these statistics have important implications for health and help-seeking since poor and foreign-born populations are more likely to not have health insurance coverage (Mills, 2001; Ying & Miller, 1992). Indeed, in 2000, 18 percent of APIA individuals were uninsured, as compared with 9.7 percent of White non-Hispanics (Mills).

Within the APIA group, there exist a multitude of important differences among ethnic groups, including their histories, worldviews, cultural values and traditions, socioeconomic status, geographic residence, acculturation, and patterns of help-seeking for health services. Furthermore, ethnic designations, which primarily designate the countries from which immigrant groups migrated, mask important within-group differences in culture and patterns of help-seeking. For instance, within the Vietnamese American population, not all Vietnamese Americans come from the same ethnic background and there are vast socioeconomic differences between first-wave refugees, who tended to be more urban, educated and well-to-do, and second-wave refugees, who were more often rural, less educated and possessed fewer of the skills necessary to adapt to the U.S. economy (Uba, 1994). There are also differences in help-seeking practices and cultural values and beliefs about health and illness within this group based on ethnic and socioeconomic background (Yee, 1996). A similar picture emerges with South Asian Americans who represent a caste system in which different castes have different cultural beliefs and help-seeking practices. Clearly, it would be a mammoth task to describe each ethnic group comprising the APIA population; thus, we have made an attempt to draw upon the common cultural values and beliefs that shape help-seeking across the subgroups comprising the population as a whole.

Help-Seeking in Asian and Pacific Islander American Men

Viewed from an ecological-contextual framework, help-seeking is the dynamic process by which individuals, within the context of their culture, social structure and health services environment, make decisions about and obtain help for their problems. Seeking help is transactional in that individuals both influence and are influenced by their social and cultural environments (Uehara, 2001). Key components of the cultural milieu are the cultural values and belief system that affect an individual's decision about the nature of his or her problem, whether to seek help, and from whom to seek help.

Although a fair amount of research has examined help-seeking among APIA individuals, most of that research has focused on the mental health services. In general, the research has shown that APIA individuals underutilize mental health services, are more likely to prematurely terminate psychotherapy, and are less likely to reveal mental health problems compared to European Americans (Atkinson, Lowe, & Matthews, 1995; Kung, 2003; Matsuoka, Breaux, & Ryujin, 1997; O'Sullivan, Peterson, Cox, & Kirkeby, 1989; Sue, Fujino, Hu, Takeuchi, & Zane, 1991; Zhang, Snowden, & Sue, 1998). Specifically, Zhang and her colleagues (1998) found that a community sample of Asian Americans were less likely than their White American counterparts to mention mental health problems to a psychiatrist (3.76 percent vs. 25.66 percent, respectively) or other physician (2.66 percent vs. 13.15 percent). They also found that Asian Americans were less likely than White Americans to visit health services during the past six months (35.59 percent vs. 55.97 percent). In addition, research analyzing data from the Chinese American Psychiatric Epidemiological Study, one of the largest community studies of an APIA population, found that only 15 percent of Chinese Americans who had diagnosable psychiatric disorders had reported using mental health services (Kung, 2003). This is less than the 25 percent reported for the general population in the National Comorbidity Study conducted just two years earlier (Kessler, 1994). Similar findings have been obtained with Asian American college students, suggesting they have less positive attitudes toward seeking professional psychological help (Atkinson, Ponterotto, & Sanchez, 1984), are less likely to acknowledge emotional and interpersonal problems (Tracey, Leong, & Glidden, 1986), are more likely to underutilize psychiatric services (Sue & Kirk, 1975), and are less likely to rank mental health professionals as their first choice for help with serious interpersonal and emotional problems as compared with White college students (Suan & Tyler, 1990).

For APIA men, the literature on help-seeking has been rather scant. Most of it has depicted Asian American males as having negative attitudes about seeking help, being difficult to recruit for counseling groups, and having a higher likelihood than females of keeping problems to themselves (Lee & Saul, 1987; Sue, 1996). This portrait is not unlike that for White males (e.g., Johnson, 1988; Rule & Gandy, 1994; Vessey & Howard, 1993). Some research has found that in APIA populations, men are underrepresented in the public mental health system, comprising only 36-42 percent of the APIA population (Ying & Hu, 1994). However, research has not demonstrated a consistent difference in help-seeking attitudes between APIA men and women. Some studies have found women to have more positive attitudes about seeking help than men (e.g., Chang & Chang, 2004; Hom & McNeil, 1998; Komiya, Good, & Sherrod, 2000; Tata & Leong, 1994), while others have not found a difference (e.g., Atkinson & Gim, 1989; Solberg, Ritsma, Davis, Tata, & Leong, 1994; Ying & Miller, 1992). Young (1998), using the Chinese American Psychiatric Epidemiological Study data, found men were less likely than women to seek help from informal sources (for example, friends, relatives, ministers), but that the gender difference disappeared for seeking help from formal sources (mental-health or medical professionals). The inconclusiveness of these findings suggests the need to further explore the more proximal variables in order to tease apart the conditions (such as source of help) under which APIA men will and will not seek help.

For example, Chang and his colleagues (2001) found that Asian American male college students were quite willing to discuss their personal problems in an online support group dealing specifically with issues related to being Asian American men. The researchers pointed out that often service providers are not culturally sensitive to the needs of Asian American men. Depictions of Asian American men as unwilling to seek help need to be understood in this context. The critique of Chang and his colleagues highlights the fact that little attention has been paid to understanding Asian American men's help-seeking behaviors within the contexts of culture, race and gender.

Several variables have been identified to account for Asian American men's less favorable attitudes, relative to White men, toward seeking help from and their subsequent underutilization of mainstream services. Although many of these variables--both at the macro level (lack of accessible and affordable services, lack of staff who are bilingual or from the same ethnic background) and micro level (lack of knowledge about services, language differences)--are barriers to help-seeking and utilization (Loo, Tong, & True, 1989; Sue et al., 1991; Yamashiro & Matsuoka, 1997; Ying & Miller, 1992). This article will focus on cultural, racial, and gender issues that are associated with help-seeking and which ultimately need to be addressed by healthcare providers and services.

Gender Roles, Racial Stereotypes, and Help-Seeking

Adherence to masculine gender roles as defined by both the ethnic culture and the dominant culture plays an important role in shaping APIA individuals' beliefs about health, their patterns of help-seeking, and their well-being (e.g., Liu & Iwamoto, 2006). Traditional Asian values, particularly those that stem from Confucianism and Hinduism, typically place the male higher in the family hierarchy and emphasize among men and women his position as economic provider (Das & Kemp, 1997; Lee & Saul, 1987; Sue, 1996). These traditional masculine gender roles have ramifications for help-seeking. It has been suggested that APIA men view self-disclosure as a sign of personal weakness, making them less likely to seek help, particularly counseling (Johnson et al., 1995; Sue, 1996). Some men view help-seeking as a personal affront to their masculinity, and to avoid being labeled "weak" they mask their physical pain or discomfort to exemplify strength of character (Kernicki, 1997). This practice is closely related to the tenets of Buddhism, in which suffering is considered to be a part of human existence and enduring pain is viewed as a precursor to character development (Kernicki; Yamashiro & Matsuoka, 1997).

Dominant cultural views of masculinity also exert strong influences on APIA men, particularly because these notions conflate masculinity with being a White man and feminize Asian American men (Eng, 2001). Nevertheless, the influence of dominant cultural notions of masculinity on health and help-seeking is largely consistent with the view of APIA men. White men who espouse masculine gender roles have also been found to be less likely to seek mental health services because doing so could be viewed as a sign of femininity (Good, Dell, & Mintz, 1989; Robertson & Fitzgerald, 1992).

Like culture, gender roles are in continual flux, and APIA masculine and feminine gender roles are becoming more equal, particularly in second and subsequent generations and in higher socioeconomic groups (Das & Kemp, 1997; Espiritu, 1997). Moreover, there are many ethnic differences in gender roles. For example, Filipino/a gender roles have been characterized as more egalitarian in terms of employment as well as participation in economic, political, and social activities, both in the Philippines and in the U.S. (Pido, 1986).

The degree to which APIA men espouse the masculine gender role of their ethnic culture has implications for whether and how they seek help for their health problems. How APIA men deal with dominant cultural gender roles may be equally important. Chen (1999) examined strategies used by Chinese American men in negotiating dominant cultural notions of masculinity. He described how some APIA men may attempt to overcome negative stereotypes of themselves by trying to meet the ideals of the dominant cultural masculinity. Another strategy involves diverting attention away from their perceived stereotypical behaviors by overcompensating in other areas. Both strategies can lead to a denial of real health problems in order to avoid negative stereotypes and meet the ideals of White masculinity.

Consistent with masculine notions of appropriate help-seeking behavior, racial representations of APIA individuals, particularly APIA males, as the "model minority" can serve to discourage help-seeking behavior. The classic version of the myth is based on the premise that APIA values include a strong work ethic and moral values that enable APIA families, with the father as the head of household, to attain economic success (e.g., McLoed, 1986). The myth, however, also permeates other aspects of the lives of APIA people, including the physical and mental health. Another version of the myth, which represents APIA individuals as being healthy, both physically and psychologically, was propagated in part by the erroneous interpretation in the 1970s of Asian American health services underutilization as a sign of their superior mental health (Myers, Kagawa-Singer, Kumanyika, Lex, & Markides, 1995; Sue & Sue, 1999).

The "model minority" view of APIA men is consistent with both ethnic cultural and dominant cultural views of men as being good family men who provide for their family and do not ask for assistance (Chua & Fujino, 1999). Although empirical research on the effects of versions of the model minority myth on APIA health and help-seeking behavior is lacking, researchers have suggested that the myth has contributed to the neglect of APIA health issues by policymakers and social planners (Myers et al., 1995; Penn, Kar, Kramer, Skinner, & Zambrana, 1995). At the individual level, others have suggested that APIA individuals may buy into a version of the myth, leading to denial of health-related problems such as alcoholism and domestic violence (Das & Kemp, 1997). Certainly, the denial of such problems would discourage appropriate help-seeking behaviors.

Culture and Help-Seeking

Cultural values and beliefs that shape how the self, illness, health, and help-seeking are conceived such as, interdependence, saving face, stigma associated with personal problems, reliance on family for help, and beliefs that associate health with the environment and the physical with the emotional and spiritual have been thought to play a central role in Asian American men's help-seeking and underutilization of mainstream health services (Liao, Rounds, & Klein, 2005; Loo, Tong, & True, 1989; Morrissey, 1997; Root, 1985; Sue, 1996; Tsai, Teng, & Sue, 1980). The rest of this article will be devoted to understanding these cultural values and beliefs in the hope that health service providers will be more sensitive to the cultural factors that affect APIA men's health, illness and help-seeking behavior.

Interdependence, Saving Face, and Reliance on Familial and Social Resources

Asian culture has been characterized as valuing interdependence and collectivism to a greater extent and independence and individualism to a lesser extent than Western culture. The research literature has consistently supported this cultural difference (e.g., Markus & Kitayama, 1991; Singelis & Sharkey, 1995; Triandis, 1989). Interdependence as an aspect of self is reflected in context-dependent and relational roles, in which one's thoughts, feelings and behaviors are determined in part by those of the group. Interdependence also involves desiring to fit into the group, seeking the goals of the group, and engaging in behaviors appropriate to the group (Markus & Kitayama). Independence, on the other hand, is characterized by self-determined thoughts, feelings, and behaviors, viewing the self as distinct from others, and seeking goals.

Interdependence is thought to influence help-seeking among Asian Americans in a number of ways. First, a collectivist worldview influences how a problem is conceptualized. Specifically, distress is more likely to be construed as a family event, rather than as an individual event. Thus, psychological or physical distress is automatically viewed in terms of how it affects the family and what role the family has in ameliorating the problem. Individuals whose self-construal is interdependent have a sense of connectedness to important others, including family members and close friends, and as a result are more likely to turn to these people for help (Mokuan, 1990; Penn et al., 1995; Yamashiro & Matsuoka, 1997; Yeh, 2002). Yeh and Wang (2000), for example, found that Asian Americans had more positive attitudes toward seeking help for mental health problems from family members (parents and siblings), friends, boyfriends and girlfriends than from counselors.

Interdependence is also thought to interact with other Asian cultural values, particularly saving face and stigma with respect to mental illnesses, by denying the viability of using professional psychological help (Ho, 1991 ; Zane & Yeh, 2002). King and Bond (1985) defined "face" as a collective property, where losing or saving face concerns not only the individual involved, but also his or her family or group. It is related to the concept of group harmony in Taoism as well as interpretations of Confucianism (Johnson et al., 1995; Pedersen, 1991; Yamashiro & Matsuoka, 1997). "Face" reflects on both the individual's achievements as well as on those of his or her family or group, and it is important for individuals to maintain or save face not only to preserve their own prestige, but also that of the family or group. In this way, saving face serves to maintain group harmony. Thus, because of the social stigma attached to mental illness in Asian cultures, individuals are reluctant both to express problems as psychological in nature and to seek professional psychological help. Doing so implies that the individual has a serious problem, which would reflect poorly on her or his group.

There is some research to suggest that concerns about losing face may impede help-seeking among Asian Americans. For example, concerns about loss of face have been found to be negatively correlated with seeking help from mental health professionals (Gong, Gage, & Tacata, 2003). Liao and her colleagues (2005) found that self-concealment, or the tendency to conceal personal information that one perceives as negative, was moderately negatively correlated with attitudes toward counseling for Asian and Asian American college students, but not for White students. They interpreted this finding to indicate that self-concealment may play a more important role in help-seeking for Asian Americans because of the increased salience of shame and loss of face.

On a related note, the factors given above have also been used to explain the expression of somatic, as opposed to psychological, symptoms of distress among APIA individuals, particularly ethnic Chinese (Chang, 2003; Kirmayer, Dao, & Smith, 1998). Kirmayer and his colleagues have theorized that symptoms are expressed somatically, even when distress is experienced both somatically and psychologically, because it is a culturally appropriate means of conveying distress and the need for help. Physical conceptualizations of distress, in turn, are more likely to lead to help-seeking from medical services, rather than mental health services (Ying, 1990).

Cultural Beliefs about Holism, Harmony, Fatalism, Spiritism, and Health

Cultural beliefs exert an enormous influence on the health and health-related behavior of APIA individuals (Mokuau, 1990; Penn, Kar, Kramer, Skinner, & Zambrana, 1995). Many of their commonly held health-related beliefs and help-seeking practices can be traced to views involving bolism and harmony (Penn et al., 1995; Mokuau, 1990; Yamashiro & Matsuoka, 1997), which emphasize the connection between natural and spiritual phenomena (Landrine & Klonoff, 1992; Murdock, 1980; Yamashiro & Matsuoka, 1997). Here, the focus is on the holistic nature of life: that all parts of the world are interrelated, including the body, mind and spirit (Leong & Lau, 2001; Ogawa, 1999; Pachuta, 1993; Ramakrishna & Weiss, 1992; Yee & Mokuau, 1999; Yee, 1999). Physical health to a large extent is the result of a harmonious interaction between the physical and metaphysical worlds. Accordingly, APIA men and women are sensitized to their environment and the cosmos, and strive to maintain harmony and equilibrium in order to preserve good health. Viewed in this light, the environment and the cosmos have significant impact on health and help-seeking practices (Yamashiro & Matsuoka, 1997).

The holistic philosophy of health views the harmony of the whole system as dependent upon the interrelationships among the mind, body and spirit (Pachuta, 1993; Ramakrishna & Weiss, 1992). Physical health is restored by re-establishing a balance within the human being and between the person and the surrounding environment (Ogawa, 1999; Pachuta, 1993; Ramakrishna & Weiss, 1992; Yee & Mokuau, 199; Yee, 1999). For example, many Pacific Islander American cultures view physical health problems as resulting from the disruption of the delicate balance of the natural environment. Maintaining good physical health, therefore, depends on respecting the environment, and acknowledging that spirits and gods are an integral part of nature and could influence one's health (Mokuau, 1990). Other Asian American cultures attribute physical illness to a state of imbalance between the elements in the universe and the individual (Buchwald, Panwala, & Hooton, 1992; Kernicki, 1997).

The belief that physical health is influenced by the environment or external causes originates from the notion that there are five elements in the universe: water, fire, earth, wind and ether (Ramakrishna & Weiss, 1992; Reid, 1995). The roots of this belief can be traced to Ayurvedic and Chinese medicine, in which certain organs in the body are associated with the elements and have analogues in the body as humors. For instance, the element "fire" is associated with the organ "bile." In order to maintain good physical health, the homeostasis of these humors needs to be sustained; conversely, physical health problems are related to humoral imbalance (Nakamura, 1999; Ramakrishna & Weiss, 1992). In traditional Chinese medicine, for instance, illness is viewed as an imbalance between yin and yang, and interventions are aimed at restoring the balance, often with food or herbs with strong yin or yang qualities (Braun & Browne, 1998b).

Physical health also has a spiritual aspect for APIA individuals. Buddhism is central to Asian philosophy and lifestyle (Yamashiro & Matsuoka, 1997). Thus, it is not surprising to note that the health beliefs of Asians are intricately interwoven with spirituality. For example, the belief that physical illness is deserved because of some past impropriety is based on the notion of karma, which suggests that present suffering is a result of bad deeds performed in a former lifetime (Uehara, 2001). This belief is grounded in fatalism in which the individual perceives to have little or no control over life events. The existence of this system of attribution allows individuals to demarcate areas of life, including physical health, that can be improved through an individual's effort from those beyond an individual's control (Uehara, 2001; Walsh, 1989; Yamashiro & Matsuoka, 1997).

In some Southeast Asian cultures, aspects of Buddhism such as karma, reincarnation, and the idea that merit in the present life will earn a better existence in the next life are combined with folk religion based on spiritism, which views physical illness as resulting from punishment by gods, demons or spirits, or magical spells (Buchwald, Panwala, & Hooton, 1992; Uehara, 2001). Disease results from an imbalance that has both natural and supernatural causes, ranging from offended spirits, moral transgressions, diet, behavior, or sorcery. Treatment for milder illnesses can take place within the family and may include pinching, cupping, or coining. When these interventions are ineffective or when the illness is more severe, the next step is to find helpers who are familiar with the ethnic culture and possess the knowledge and skills to remedy the illness. This is where shamans, monks, traditional healers or faith healers come into play (Uehara, 2001). Mainstream service providers, such as mental health professionals. are often considered less credible and effective or a cultural mismatch. Hence the reluctance to use these services (Uehara, 2001; Yamashiro & Matsuoka, 1997).

Spirituality is also a core value among the health beliefs of Pacific Islanders (Mokuau, 1990). Both animate and inanimate objects are considered to be interrelated by the creative force, and physical illness is a result of disharmony between them. Pacific Islanders will resort to various ways of communicating with images of spirits and gods to restore this harmony to prevent physical illness (Mokuau, 1990).

Acculturation, Health, and Help-Seeking

Individuals can differ according to the extent to which they subscribe to cultural values and beliefs related to health. One key factor that influences their endorsement of these beliefs is acculturation, that is, the extent to which they value, behave, and identify with both their ethnic culture and the dominant U.S. culture (Berry, 1989; Sodowsky, Kwan, & Pannu, 1995). For example, individuals who highly endorse their traditional ethnic cultural values and beliefs, but not the dominant cultural values beliefs, would be most likely to view illness and seek help in ways consistent with their ethnic culture. Acculturation, however, must be viewed as a multidimensional variable, whereby individuals may endorse ethnic cultural views in one domain of living (for example, values) and dominant cultural views in another (for example, language) (Chang, Tracey, & Moore, 2005). For example, for Asians and Asian Americans, behavioral assimilation to American culture and identification as American have been found to be positively related to attitudes toward counseling (Atkinson & Gim, 1989; Liao et al., 2005; Tata & Leong, 1994; Zhang, 2000), while adherence to Asian cultural values has been found to be negatively related to attitudes toward counseling (Liao et al., 2005). Thus, any attempt to predict worldview and help-seeking patterns among APIA men would do well to consider specific and relevant domains of living, such as cultural values, and assess cultural orientation toward both the ethnic culture and the dominant culture. In addition, one cannot assume that foreign born APIA individuals would hold more traditional views than U.S.-born individuals who are APIA. Abe-Kim, Okazaki, and Goto (2001), for example, did not find any differences in interdependent or independent self-construal between the two groups.

Implications for Services and Service Providers

For Asian and Pacific Islander American populations, cultural values and belief systems, gender roles, and responses to racial stereotypes can be employed as ways of viewing health and help-seeking. Cultural, gendered, and racial views of health have a powerful influence on help-seeking attitudes and behaviors, and ultimately affect decisions about whether to seek help and from whom to seek it. Thus, understanding the roles of culture, gender, and race in health and help-seeking can serve as building blocks for training healthcare professionals to become more culturally sensitive and provide services that are more culturally responsive to APIA individuals.

D.W. Sue (1994) has pointed out that Western forms of treatment may not always be modifiable to meet the needs of APIA individuals. S. Sue (1994) has recommended that ethnic-specific services be created to respond to the specific needs of APIA individuals. Such services could include indigenous or folk healers to work side by side with mainstream service providers. These services would also employ healthcare professionals who are bilingual and have ethnic backgrounds that are similar to the patients' backgrounds. Evidence suggests that APIA individuals will use mainstream and indigenous services together (Braun & Browne, 1998a). Thus, whether or not ethnic-specific services can be created, it is clear that a comprehensive care model that links mainstream services with indigenous forms of treatment and provides community education about health services is needed to better facilitate the use of health services by APIA men and women (Shin, 2002; S. Sue, 1994).

Mainstream service providers can be trained to be aware of the cultural values and behavior related to APIA individuals' conceptions of health, illness, and help-seeking. For example, understanding that distress may be expressed somatically among some such individuals would enable the healthcare professional to understand the cultural function of the complaints, rather than pathologize them as somatization. This also provides an understanding of the indication in such instances of medical rather than mental health treatment and suggests the need for traditional medical providers to collaborate with psychiatric or psychological healthcare providers. However, mainstream services may not always be appropriate or even desired. In these cases, health providers need to be aware of treatment and coping resources within the client's culture, such as family support or the use of indigenous healers, and be willing to act as a cultural broker in connecting clients to mainstream and indigenous resources. Here, the role of the healthcare professional may best be described as a facilitator of indigenous support services, rather than as a provider who administers treatment (Atkinson, Kim, & Caldwell, 1998). Understanding APIA men's cultural values and belief systems enables the health professional to frame illness and treatment in a manner more congruent with the client's worldview, with the ultimate goal of providing or facilitating effective treatment.

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TAI CHANG

California School of Professional Psychology

Alliant International University, USA

PRITHWI RAJ SUBRAMANIAM

Ithaca College, USA

Tai Chang, California School of Professional Psychology, Alliant International University; Prithwi Raj Subramaniarn, Department of Health Promotion and Physical Education, Ithaca College.

Correspondence concerning this article may be addressed to Tai Chang, California School of Professional Psychology, Alliant International University, One Beach Street, Suite 100, San Francisco, CA 94133; Electronic mail: [e-mail]