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Stigma and Health
Asian Americans’ Intention to Seek Help: The Mediating Influence of Self-
Stigma on the Theory of Planned Behavior
Melissa-Ann Lagunas, Emi Ichimura, Elizabeth M. Mateer, and Joel Jin
Online First Publication, December 14, 2023. https://dx.doi.org/10.1037/sah0000500
CITATION
Lagunas, M.-A., Ichimura, E., Mateer, E. M., & Jin, J. (2023, December 14). Asian Americans’ Intention to Seek Help: The
Mediating Influence of Self-Stigma on the Theory of Planned Behavior. Stigma and Health. Advance online publication.
https://dx.doi.org/10.1037/sah0000500
Asian Americans’Intention to Seek Help: The Mediating Influence of
Self-Stigma on the Theory of Planned Behavior
Melissa-Ann Lagunas, Emi Ichimura, Elizabeth M. Mateer, and Joel Jin
Department of Clinical Psychology, Seattle Pacific University
Asian Americans face challenges in accessing professional psychological services despite their significant
mental health needs. One factor that contributes to this underutilization is self-stigma, which not only
impacts individuals’mental health symptoms but also diminishes their self-efficacy in seeking help. To
address this issue, the present study aimed to examine the relationship between the three variables in the
theory of planned behavior–help-seeking attitudes, subjective norms, and perceived behavioral control–and
intention to seek professional mental health help among Asian Americans, with self-stigma serving as a
mediator. This research contributes to the existing literature by examining these relationships specifically
within the Asian American community. Based on the survey data from 231 Asian American adults, our path
analysis found that all three theory of planned behavior variables predicted intention to seek help. Self-
stigma acted as a mediator between help-seeking attitudes and intention to seek help. However, subjective
norms, perceived behavioral control, and intention to seek help were not mediated by self-stigma. Findings
underscore the importance of developing culturally sensitive outreach programs and resources that focus on
promoting attitude change and addressing self-stigma as means to facilitate mental health help-seeking
behaviors among Asian Americans.
Clinical Impact Statement
This present study analyzes self-stigma’s mediation between theory of planned behavior variables and
help-seeking intentions. Our findings prompt mental health practitioners to tailor interventions,
effectively targeting self-stigma and promoting Asian Americans’use of professional mental health
services. Furthermore, our study delves into how self-stigma intertwines with structural systems
impeding Asian Americans from seeking psychological care. These findings significantly impact
clinical psychological practice, emphasizing the need for culturally sensitive approaches that mitigate
self-stigma, enhance mental health service access, and foster Asian Americans’well-being.
Keywords: Asian Americans, theory of planned behavior, mental health help-seeking, self-stigma, intention
to seek help
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Melissa-Ann Lagunas https://orcid.org/0000-0002-0871-3502
Emi Ichimura https://orcid.org/0000-0001-6221-0423
Elizabeth M. Mateer https://orcid.org/0000-0003-3690-0855
Joel Jin https://orcid.org/0000-0002-5378-3366
This research received no specific grant from any funding agency in the
public commercial or not-for-profit sectors. The authors declare that there are
no conflicts of interest.
The present article is accompanied by the relevant raw data generated
during and/or analyzed during the study, including files detailing the analyses
and the other relevant raw data. These files are available in the Figshare
repository at https://figshare.com/projects/Asian_Americans_Intention_to_
Seek_Help_The_Mediating_Influence_of_Self-Stigma_on_the_Theory_of_
Planned_Behavior/154694.
The positionality statements follow: Melissa-Ann Lagunas identifies
as a Mexican American cisgender woman and was raised by Mexican
immigrants in Southern California. Melissa-Ann Lagunas also identifies as
afirst-generation college and graduate student. Emi Ichimura identifies as a
Japanese American cisgender woman. She was born and raised in Northern
California by her parents, who are both from Japan and have received a
college education in the Pacific Northwest. Elizabeth M. Mateer identifies
as a cisgender American woman. She was born and raised in New York
state and is of Italian and Irish heritage. Joel Jin identifies as Asian
American since immigrating to the United States as a graduate student. He
identifies as Korean Canadian and was raised by Korean immigrants in
Ontario, Canada. Melissa-Ann Lagunas, Emi Ichimura, and Elizabeth M.
Mateer are clinical psychology doctoral students at an urban faith-based
institution located in the Pacific Northwest. Joel Jin is an early career
psychologist and a tenure-track faculty member at an urban faith-based
institution located in the Pacific Northwest.
Melissa-Ann Lagunas played a lead role in writing–original draft and
writing–review and editing and an equal role in formal analysis, project
administration, and visualization. Emi Ichimura played an equal role in writing–
original draft and a supporting role in writing–review and editing and an equal
role in formal analysis, project administration, and visualization. Elizabeth M.
Mateer played a lead role in data curation and methodology, a supporting role in
writing–review and editing, and an equal role in conceptualization. Joel Jin
played a lead role in supervision and a supporting role in conceptualization, data
curation, formal analysis, methodology, project administration, visualization,
writing–original draft, and writing–review and editing.
Correspondence concerning this article should be addressed to Melissa-
Ann Lagunas, Department of Clinical Psychology, Seattle Pacific University,
2130 Dexter Avenue North, Seattle, WA 98109, United States. Email:
lagunasm@spu.edu
Stigma and Health
© 2023 American Psychological Association
ISSN: 2376-6972 https://doi.org/10.1037/sah0000500
1
According to the United States Census Bureau (2021), the Asian
American population has experienced substantial growth, consti-
tuting approximately 6.1% of the total population. This percentage
nearly doubled between 2000 and 2019. Projects from the Pew
Research Center (Budiman & Ruiz, 2021) suggest that the Asian
American population will surpass 46 million by 2060, potentially
becoming the fourth largest racial group in the United States.
Considering the rapid growth of this community, it is of utmost
importance to test existing theoretical frameworks that may enhance
our understanding of mental health seeking behaviors. This may
enable the development of culturally sensitive and accessible
interventions that address the unique needs and barriers faced by
Asian Americans (Hwang, 2006;Suyemoto et al., 2007;Zane &
Yeh, 2002). As such, the present study aims to assess three cognitive
variables from the theory of planned behavior–attitudes, subjective
norms, and perceived behavioral control–to predict the intention of
Asian Americans to seek mental health support. The subsequent
section delves into previous research on mental health seeking
among Asian Americans, the utilization of the theory of planned
behavior in similar studies, and the mediating role of self-stigma in
relation to help-seeking.
Professional Mental Health Help-Seeking
Among Asian Americans
The ongoing mental health treatment disparities between Asian
Americans and their White counterparts bring forth an imperative to
thoroughly examine the cross-cultural application of Eurocentric
theoretical frameworks. Based on a diverse sample of 1,166 university
students from the United States, Asian Americans reported the highest
levels of distress regarding academics, employment, family, peers,
and leisure (Kearney et al., 2005). Despite demonstrating compara-
tively high levels of need, Asian Americans report the lowest use of
psychotherapeutic services (Cheng et al., 2013). They also attended
fewer counseling sessions than European Americans (Kearney et al.,
2005). Estimates based on a sample of 8,762 adult patients
demonstrate that Asian Americans who meet criteria for major
depressive disorder or dysthymia are 14.6% less likely to access care
compared to non-Hispanic White Americans, even after controlling
for economical limitations (Alegría et al., 2008). Similarly, a study
conducted by Le Meyer et al. (2009) revealed that among individuals
who were likely to have Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition disorders, only 28% of Asian Americans
sought specialty mental health services, whereas the rate was 54% for
the general population.
Despite limited research on predictors of help-seeking intentions
among Asian Americans, previous models have explored general
predictors of attitudes, which inform the present study’s hypotheses.
For instance, the intrapersonal-interpersonal-sociocultural framework
(J. E. Kim & Zane, 2016) highlights the underutilization of mental
health services by Asian Americans, linking it to sociocultural factors
like the perpetual foreigner stereotype, which hinders motivation and
comfort in seeking help (Devos & Banaji, 2005;Huynh et al., 2011;
Leong & Lau, 2001). The emphasis on maintaining harmonious
relationships and conforming to societal norms in Asian culture
leads to disapproval of deviations from the norm (Abdullah &
Brown, 2011;Bismar & Wang, 2021). Consequently, Asian
Americans may express depression through psychosomatic symp-
toms, aligning with cultural values like emotional self-control but
inadvertently compromising perceived behavioral control (Chun
et al., 1996;Kim et al., 2005;Kim & Lee, 2014;J. E. Kim & Zane,
2016;Le Meyer et al., 2009). Factors such as limited access to
culturally responsive services, financial constraints, language
barriers, and unfamiliarity with treatment options significantly
impact mental health service utilization among Asian Americans
(Hall et al., 2011;Le Meyer et al., 2009;Yang et al., 2020). However,
there is a research gap in understanding how these determinants
specifically influence help-seeking intentions in this population.
Understanding the Role of Self-Stigma in
Help-Seeking Among Asian Americans
Stigma plays a crucial role in influencing help-seeking behaviors,
and understanding its different dimensions is essential for developing
effective interventions. Stigma can be disaggregated into two
categories: public stigma and self-stigma (P. Corrigan, 2004).
Public stigma refers to the judgment by society that individuals who
seek psychological care are undesirable (Vogel et al., 2013). On the
other hand, self-stigma involves the process of individuals being
aware of stereotypes associated with a stigmatized identity, agreeing
with those stereotypes, and applying them to oneself (Vogeletal.,
2013;C. C. Y. Wong et al., 2019). The impact of self-stigma on
psychological distress among Asian Americans has been confirmed
in the previous studies (Cheng et al., 2013;J. E. Kim & Zane, 2016).
Individuals who apply stigmatizing attitudes are less likely to
seek treatment, which puts them at risk for negative mental health
outcomes (Lannin et al., 2016;Yanos et al., 2015). Eisenberg et al.
(2009) specifically found that personal stigma was highest among
younger, Asian, international, and more religious students, and that
it was associated with low levels of help-seeking. Self-stigma may
impair the provider–patient relationship through concerns regarding
cultural mistrust and perceived substandard care (Bamgbose
Pederson et al., 2022). Consequently, minoritized individuals
may rely on alternative forms of support, as sharing personal
information with a therapist may be perceived as a failure of primary
community support or a lack of willpower, leading to potential
feelings of shame. Previous research has included self-stigma to
expand the explanatory potential of the theory of planned behavior
due to its close association with intention to seek help (Lin et al.,
2017). The heightened stigmatization experienced by Asian
Americans when seeking psychological help makes their experience
with stigma particularly relevant (Cheng et al., 2013). Therefore, it is
important to investigate cognitive factors within existing theoretical
frameworks that may contribute to the decision to seek mental health
help and the role that stigma plays.
The Theory of Planned Behavior
The theory of planned behavior, introduced by Ajzen (1991),is
widely used in research to understand and predict various health
behaviors such as substance use, physical exercise, and the intention
to seek mental health services (Bohon et al., 2016;Hagger et al.,
2007;Kelly et al., 2012;S. H. Lee et al., 2015). This theory focuses
on behavioral intent, which reflects an individual’s intention to
engage in a specific behavior. It posits that intention is influenced by
three cognitive factors: attitudes, subjective norms, and perceived
behavioral control (Boston University School of Public Health, 2019).
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2LAGUNAS, ICHIMURA, MATEER, AND JIN
Attitudes are an individual’s perception of a given behavior
(Boston University School of Public Health, 2019). In the context
of help-seeking, positive attitudes toward seeking mental health
support predict a greater likelihood of engaging in such behavior
(Bohon et al., 2016;Lee & Shin, 2022). For example, Mo and Mak
(2009) employed cross-sectional quantitative analysis to demon-
strate that having positive attitudes toward seeking mental health
assistance predicted intention to use mental health services among
Chinese participants.
Subjective norms involve how an individual perceives others’
opinions of their help-seeking behavior (Boston University School
of Public Health, 2019). S. H. Lee et al. (2015) demonstrated that
subjective norms predict support for South Korean college students
with depression seeking help. This was further confirmed by J. Y.
Lee and Shin (2022), who found that individuals with severe mental
health symptoms perceived less peer approval for seeking help.
While limited research exists on the theory of planned behavior and
help-seeking behavior among Asian Americans in the United States,
similar findings have emerged within other Black, Indigenous, and
people of color (BIPOC) communities (Pinedo et al., 2018).
Perceived behavioral control is an individual’s perception of the
difficulty of seeking help (Boston University School of Public Health,
2019). J. Y. Lee and Shin (2022) found that greater knowledge
of mental health services is linked to higher perceived behavioral
control, showing that having more information positively affects
one’sconfidence in seeking help. Moreover, perceived behavioral
control is linked to self-efficacy, the belief in one’s ability to seek
psychological services. Shi et al. (2020) demonstrated that individuals
with severe mental health symptoms have lower perceived self-
efficacy in seeking help, indicating that self-efficacy strongly
influences the willingness to seek psychological care.
Rationale for Using Self-Stigma as a Mediator
We propose self-stigma as a mediator to demonstrate the
underlying processes through which each theory of planned
behavior variable may influence one’s intention to seek help. A
mediator variable, as defined by Hayes (2017), helps identify the
intermediate process or mechanism through which the relationship
between two variables occurs. Self-stigma reflects the emotional
and psychological impact of internalized negative beliefs, which
can shape individuals’attitudes, norms, and perceived control over
help-seeking behavior. Nichols and Newhill (2023) similarly
integrated the theory of planned behavior and stigma theory model
by amalgamating self-stigma into the construct of attitudes and
incorporating public stigma within the framework of subjective
norms. The present study explores the possibility that unfavorable
mental health attitudes, subjective norms, and perceived behavioral
control predicts intention to seek help through the internalization of
stigmatizing beliefs, suggesting that it takes on a mediating role.
The connection between attitudes and intention can be elucidated
by examining self-stigma, where individuals internalize negative
attitudes due to societal stigma, consequently influencing their
decision-making processes (Lin et al., 2017). Stigmatizing views
held by young individuals toward a peer with a mental disorder, such
as notions of being “weak-not-sick,”might be internalized as self-
stigma should they personally experience a similar condition
themselves; this, in turn, affects their intention to seek help (Yap et
al., 2011). As such, we suggest that self-stigma is a more proximal
antecedent to intention to seek help and that it plays a more pivotal
role in mediating how attitudes shape one’s intention, outweighing
the influence of factors like moderators.
Likewise, we propose that subjective norms exert influence
through an awareness of stigmatizing stereotypes. While there are
cultures with a prevailing emphasis on individualism and the pursuit
of personal goals and beliefs, the impact of perceived judgment from
significant others is notably heightened within the collectivistic
settings frequently encountered by Asian individuals (Zay Hta et al.,
2023). In these settings, group and familial identities hold greater
significance, and the concern that mental health challenges could be
perceived as detrimental to their community is a pertinent concern
(Masuda et al., 2009). A pattern identified in the research carried out
in non-Western Asian cultures, such as South Asian and Chinese
cultures, is that self-stigma resulted from feeling blamed by the
majority group, ultimately leading to a diminished sense of control
over one’s quality of life (Zay Hta et al., 2023). This underscores our
interest in investigating the role of self-stigma as a mediator between
subjective norms and the intention to seek help.
The connection between perceived behavioral control and the
intent to seek help may be mediated by self-stigma. Self-stigma has
been previously associated with ego depletion and immobilization
(Inzlicht et al., 2006), hindering individuals’proactive pursuits of
fulfilling their mental health needs. On the other hand, “coming out of
the closet”with mental illness has been associated with motivation to
move toward achieving one’s life goals and reduced negative effects
of self-stigmatization (P. W. Corrigan & Rao, 2012). Researchers
speculate that openly discussing one’s condition can lessen the
burden of secrecy, potentially leading to the discovery of supportive
peers or family members and a sense of empowerment and control
over one’slife(P. W. Corrigan & Rao, 2012). Consequently, we
hypothesize that an increase in perceived behavioral control can lead
to the dismantling and disintegration of self-stigmatizing beliefs,
which increases one’s intent to seek mental health assistance. As
such, we propose that perceived behavioral control plays a pivotal
role in shaping one’s intentions to seek help through the absence of
internalized stigmatizing messages.
Generally, in the United States, Asians were seen to experience
higher self-stigma compared to non-Asians during the COVID-19
pandemic (M. Kim et al., 2022). By including self-stigma as a
mediator in the theory of planned behavior framework, we capture the
complex interplay between mental healthhelp-seeking stigmatization
and intrapersonal help-seeking processes among Asian Americans.
This approach allows for a deeper exploration of the mechanisms
through which the theory of planned behavior variables influence
intentions to seek help, ultimately informing interventions to address
self-stigma and promote help-seeking behavior among the target
population.
Research Objectives
The existing knowledge gap in the literature concerning the
relationship between the three factors of the theory of planned
behavior–attitudes, subjective norms, and perceived behavioral
control–and mental help-seeking among Asian Americans in the
United States highlights the need for further investigation (Cheng
et al., 2013;J. E. Kim & Zane, 2016;Vogel et al., 2013;Yanos et al.,
2015). Previous research has demonstrated the effectiveness of the
theory of planned behavior in predicting mental help-seeking among
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ASIAN AMERICANS’INTENTION TO SEEK HELP 3
Asian populations globally and BIPOC communities in general
(Pinedo et al., 2018). However, limited research exists specifically
on the relationship between the theory of planned behavior and
mental help-seeking among Asian Americans in the United States
(Vogel et al., 2013). This knowledge gap suggests the necessity to
examine the applicability and predictive power of the theory of
planned behavior within the unique sociocultural context of Asian
Americans in the United States (Vogel et al., 2013;Yanos et al.,
2015). Furthermore, the lack of diverse samples that predominantly
focuses on White populations highlights the need to investigate
leading theories among diverse groups to support inclusive and
culturally sensitive approaches to promoting mental health seeking
(Cheng et al., 2013;J. E. Kim & Zane, 2016).
Therefore, the research objectives of this study are to examine (a)
how each cognitive factor of the theory of planned behavior predicts
intention to seek mental help, (b) how each cognitive factor of the
theory of planned behavior predicts self-stigma for seeking help, and
(c) how self-stigma mediates the relationship between the theory of
planned behavior variables and intention to seek help among Asian
Americans. Specifically, we hypothesize that (a) the theory of
planned behavior variables will significantly predict intention to
seek help among Asian Americans, (b) the theory of planned
behavior variables will be associated with lower levels of self-
stigma related to seeking help, and (c) self-stigma will mediate the
relationship between each theory of planned behavior variable and
intention to seek help among Asian Americans.
Method
In Spring 2021, prior to commencing data collection, we obtained
approval from the institutional review board (IRB). We employed a
nonexperimental cross-sectional design to collect data for this
study. Graduate research assistants (GRAs) from an urban faith-
based university in the Pacific Northwest were responsible for
gathering data. Data collection was carried out through Qualtrics, an
online survey platform. This process commenced after we received
IRB approval. The survey consisted of a 180-item self-report
questionnaire, and participants were invited to complete it online.
To enhance participant engagement while minimizing survey
fatigue, the survey was designed with an anticipated completion
time of 15–20 min. Participants were not excluded based on the
duration they took to complete the survey. For the present study, we
focused on analyzing a subset of 39 items from the original
questionnaire (Mateer et al., 2023).
Procedure
To enhance the comprehensiveness and diversity of our
participant pool, participant recruitment relied on two methods.
Initially, we employed convenience sampling to augment our
sample size, focusing on the Asian American undergraduate
community within our institution. Our graduate research assistants
(GRAs) collaborated with the Office of the Registrar to acquire a
comprehensive list of Asian American undergraduate students in
2021. The received list included 560 students, with 81 of them
responding, constituting a response rate of 14.46%. Following this,
the GRAs initiated contact with these students via email, introducing
the study and requesting their participation. To enhance response
rates, a maximum of three email reminders were sent. Additionally,
the dissemination of the study’s details occurred through social
media platforms, facilitated by campus organizations such as the
Asian American Association and the Filipino American Student
Association. This combined approach contributed to 35.06% (n=
81) of the total participants.
As our initial sample primarily consisted of data from an
undergraduate demographic, we leveraged Prolific, an online
research participant platform, to expand our reach to a broader
spectrum of Asian Americans. Through this platform, participants
were selectively chosen based on specific criteria, including their
ethnicity, geographical location, and student status. To be eligible,
individuals were required to self-identify as Asian American, reside
in North America, and not have student status. Qualified participants
were directed to the study and received compensation upon
successful completion. This methodology accounted for 64.94%
(n=150) of the overall sample.
Participants
A total of 231 self-identified Asian Americans participated in the
study (M
age
=27.00, SD =9.13). For full demographics of our total
sample, see Table 1.
Measures
Self-Stigma
We assessed self-stigma using the Self-Stigma of Seeking Help
scale (SSOSH; Vogel et al., 2006), which comprises ten items rated on
a Likert scale ranging from strongly disagree to strongly agree.The
SSOSH has demonstrated excellent internal consistency (α=.90) and
satisfactory test–retest reliability (α=.72) in the previous research
(Vogel et al., 2006). In our study, we reversed the scoring for Items 2,
4, 5, 7, and 9 to ensure consistency in interpretation. An example item
from the scale is “I would feel inadequate if I went to a therapist for
psychological help.”The SSOSH exhibited strong reliability in our
study (α=.85), indicating the consistency of responses to the
scale items.
Attitudes, Subjective Norms, Perceived
Behavioral Control, and Intention
We used the Mental Health Seeking Attitudes Scale (MHSAS;
Hammer et al., 2018) to assess participants’help-seeking behaviors
through the three cognitive variables of the theory of planned
behavior and intention. The MHSAS consists of four subscales
including attitudes, subjective norms, perceived behavioral control,
and intention.
The attitudes subscale comprised nine items, wherein participants
were presented with a definition of “mental health professionals”
and asked to indicate their opinion regarding seeking help from such
professionals. Response options ranged from useless to useful. The
attitudes subscale demonstrated excellent reliability (α=.92;
Hammer et al., 2018), which was consistent with the reliability
observed in our study (α=.93).
To measure subjective norms, participants rated their responses to
two questions on a 7-point Likert scale, indicating the extent to
which they felt important individuals in their lives would expect
them to seek help from a professional for a mental health problem.
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4LAGUNAS, ICHIMURA, MATEER, AND JIN
An example item was “If I had a mental health problem, most people
who are important to me would think that I should seek help from a
professional.”The subjective norms subscale demonstrated good
internal consistency (α=.81; Hammer et al., 2018), which aligned
with the reliability observed in our study (α=.71).
The perceived behavioral control subscale consisted of four
questions, each rated on a 7-point Likert scale. Participants assessed
their perceived ability to seek help from a professional for a mental
health problem, ranging from impossible to possible. For instance,
one of the questions asked participants to rate the possibility of
seeking help from a professional if they had a mental health
problem. The perceived behavioral control subscale demonstrated
adequate reliability (α=.78; Hammer et al., 2018), which was
consistent with the reliability observed in our study (α=.85).
Intention was measured using a 7-point Likert scale ranging from
extremely unlikely to extremely likely. Participants indicated their
intention to seek help from a mental health professional if they had
a mental health concern. An example item was “If I had a mental
health concern, I would try to seek help from a mental health
professional.”The intention subscale demonstrated good internal
consistency (α=.95; Hammer et al., 2018), which aligned with our
study (α=.95).
Demographics
The survey included an author-constructed seven-item demo-
graphic questionnaire. For a full item list see Table 1.
Data Diagnostics
A total of 247 individuals opened the questionnaire. Of those, 238
granted consent and completed the survey. Skew and kurtosis values
fell below the values of 3 (skew) and 8 to 20 (kurtosis) which Kline
(2023) suggests are concerning. Shapiro–Wilk test of normality
indicate that our variables assessing mental help-seeking attitudes
(W=0.95, p<.001), subjective norms (W=0.98, p<.001),
perceived behavioral control (W=0.95, p<.001), intention (W=
0.95, p<.001), and self-stigma (W=0.99, p=.045) are
significantly different than a normal distribution.
Using the outlier function in R’s psych package, we conducted a
Mahalanobis distance test to evaluate multivariate normality with all
continuous variables. As the quantiles on the Quantile-Quantile plot
increased, the plotted line strayed from the theoretical normal
distribution, suggesting that the data did not exhibit multivariate
normality. We appended the Mahalanobis distance scores as a
variable to the data and found that 8, 230 exceeds 3 standard
deviations beyond the median. With the appended outliers, we
assumed multivariate normality and proceeded with analysis.
Visual inspection of residual plots indicated that all three mental
health variables followed linear trends, endorsing the assumption
of linearity. After creating scatterplots with each variable of the
theory of planned behavior and its unstandardized residuals, we
found that besides attitudes toward seeking mental help, plots for
subjective norms and perceived behavioral control presented a slight
downward trend, indicating unequal variances across which violated
the assumption of homoscedasticity. Using recommendations
outlined by Hayes and Scharkow (2013) for unmet assumptions
for regression analysis, we proceeded by deriving 95% confidence
intervals and unstandardized indirect effects of 1,000 bootstrapped
samples.
Results
Preliminary Analyses
Parent’s (2013) available item analysis (AIA) is a method for
handling missing data by utilizing the existing data for analysis and
excluding cases with missing data points only when those data points
are directly involved in the analysis. Parent (2013) suggested that AIA
is comparable to more intricate techniques like multiple imputation
across various scenarios, including variations in sample size, strength
of associations among items, and the extent of missing data. Therefore,
we adopted Parent’s recommendations to guide our approach to
managing missing data. We conducted missing data analyses using
tools in base R, as well as the R packages psych (Version 1.0.12) and
mice (Version 3.13.0). Among the cases that met the inclusion/
exclusion criteria, the percentage of missing data ranged from 0.00%
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Table 1
Total Sample Demographics (N =231)
Characteristic n%
Subethnic heritage
East Asian 114 49.35
Multiethnic Asian 42 18.18
South Asian 26 11.26
Southeast Asian 49 21.21
Gender identity
Cisgender woman 118 50.87
Cisgender man 105 45.45
Gender nonconforming/genderqueer 6 2.59
No response 2 0.86
Highest level of education
Some high school 2 0.86
High school diploma 19 8.23
Some college 2 0.86
Associate’s degree 53 22.84
Bachelor’s degree 22 9.48
Master’s degree 101 43.53
Applied doctorate (e.g., MD) 25 10.78
PhD 5 2.16
Vocational training 2 0.86
Annual income
−$15,000 17 7.36
$15,000–29,999 20 8.66
$30,000–44,999 28 12.12
$45,000–59,999 32 13.85
$60,000–74,999 26 11.26
$75,000–89,999 27 11.69
$90,000–104,999 26 11.26
$105,000–119,999 12 5.19
$120,000+40 17.32
Born in the United States
Yes 175 75.76
No 56 24.24
Acculturation of those born outside the
United States by year immigrated
2021–2012 6 2.60
2011–2001 20 8.66
2000–1990 15 6.49
1989–1970 11 4.76
No response 4 1.73
Previous mental health help
Yes 83 35.93
No 148 64.07
ASIAN AMERICANS’INTENTION TO SEEK HELP 5
to 12.5%. Across the entire data set, only 0.15% of cells contained
missing data, while 95.3% of cases had complete data.
At this stage of the analysis, cases with less than 85% missing data
were allowed to proceed to the scoring phase. Following Parent’s
(2013) AIA approach, scales consisting of five items were scored if at
least four items were complete, and the scale with 12 items was scored
if it contained at least 10 complete items. Additionally, a missing
completely at random (MCAR) analysis based on Little’s(1988)test
revealed an insignificant chi-square statistic, χ
2
(2.85), p=.72,
indicatingthat the data followed the MCAR pattern. Furthermore, the
data met the criteria for univariate normality (skewness <3, kurtosis
<8; Kline, 2012).
We conducted independent samples ttests to evaluate if differences
between our university sample and Prolific sample existed. Results
indicated no statistically significant group differences in attitudes,
subjective norms, perceived behavioral control, intention to seek
help, and self-stigma. See Table 2 for complete statistical details
(Figure 1).
We conducted Pearson product–moment correlations and found
significant correlations between mental health attitudes, subjective
norms, perceived behavioral control, intention to seek mental help,
and self-stigma. Intention to seek mental help was positively
correlated with all three theory of planned behavior subscales—
attitudes (r=.58, p<.01), subjective norms (r=.52, p<.01),
perceived behavioral control (r=.57, p<.01). Intention to seek help
was negatively correlated with self-stigma (r=−.47, p<.01).
Path Analysis
To explore the direct relationships between latent factors and
observed variables, a path analysis was conducted using the
“lavaan”package in R (v. 0.6–7; Rosseel, 2012). Path analysis is a
technique within structural equation modeling that allows for the
examination of hypothesized causal relationships between variables.
The specified path model was fitted to the data set using the cfa
function, which estimated the coefficients representing the paths
between the latent and observed variables. The parameter Estimates
function was utilized to obtain the estimated path coefficients,
offering insights into the direct relationships and interactions among
the variables. In this study, path analysis was employed to assess the
fit of the proposed model to the data and to evaluate the strength and
direction of relationships among the observed variable “intention to
seek help”and other observed variables “self-stigma,”“subjective
norms,”“perceived behavioral control,”and “attitudes.”This path
analysis approach facilitated the examination of the hypothesized
relationship between each component of the theory of planned
behavior and intention to seek help, mediated by self-stigma. See
Figure 2.
Model Fit Indices
In the path analysis using lavaan 0.6–9, the estimation process
concluded normally following 21 iterations. The maximum likeli-
hood estimator was employed, utilizing the nlminb (i.e., Nonlinear
Minimization subject to Box Constraints) optimization method for
parameter estimation. The model encompassed a total of nine
parameters and was assessed against a user-specified model. For the
user model, the test statistic yielded a value of 0.000, with 0 degrees
of freedom. Comparatively, the baseline model yielded a test statistic
of 244.669, accompanied by 7 degrees of freedom ( p=.000).
Comparison of the user model to the baseline model revealed
perfect fit indices, with a comparative fit index of 1.000 and a
Tucker–Lewis Index of 1.000. The model selection criteria included
an Akaike information criterion of 1060.569, a Bayesian informa-
tion criterion of 1091.512, and a sample-size adjusted Bayesian
information criterion of 1062.987. Further evaluation of model
adequacy included a root-mean-square error of approximation
(RMSEA) of 0.000. Additionally, the analysis reported a standard-
ized root-mean-square residual value of 0.000, indicating an optimal
fit of the model to the data. These findings indicate a robust fit of the
proposed path model to the observed data.
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Table 2
Independent Samples t-Tests Comparing University and Prolific Sample on Attitudes, Subjective
Norms, Perceived Behavioral Control, Intention to Seek Help, and Self-Stigma
Variable
University Prolific
df t value pvalueM(SD)M(SD)
Attitudes 5.62 (1.18) 5.47 (1.06) 229 1.03 .31
Subjective norms 4.82 (1.37) 5.50 (1.17) 229 −1.34 .18
Perceived behavioral control 5.36 (1.23) 5.44 (1.15) 229 −0.52 .60
Intention to seek help 4.58 (1.62) 4.93 (1.43) 229 −1.70 .09
Self-stigma 2.08 (0.72) 1.93 (0.66) 229 1.55 .12
Figure 1
Path Analysis Using Intention to Seek Mental Help and Self-Stigma
as the Criterion
Note. Direct paths are depicted in grey, while indirect paths are depicted in
black.
6LAGUNAS, ICHIMURA, MATEER, AND JIN
The path analysis revealed that Asian Americans who have more
positive mental health attitudes tend to score higher in intention to
seek help; B=0.319, 95% CI [0.136, 0.503], SE =0.094, p=.001.
Additionally, subjective norms predicted higher intention to seek
help; B=0.287, 95% CI [0.145, 0.428], SE =0.072, p<.001. Last,
perceived behavioral control also positively predicted help-seeking
intentions; B=0.331, 95% CI [0.169, 0.492], SE =0.083, p<.001.
The path coefficient between self-stigma and intention was
negative, suggesting that higher levels of self-stigma was associated
with lower intention to seek help; B=−0.316, 95% CI [−0.579,
−0.052], SE =0.134, p=.019. To assess the robustness of this
negative relationship, we conducted bootstrapping analysis with
1,000 resamples using the full information maximum likelihood
(FIML) approach. The bootstrapped 95% confidence interval for the
path coefficient between self-stigma and intention did not include
zero, supporting the statistical significance of this association (95%
CI [1.238, 1.562]). Furthermore, better mental health attitudes were
estimated to be associated with lower levels of self-stigma (B=
−0.300, SE =0.042, p<.001), in line with our hypothesis.
However, subjective norms (B=−0.027, SE =0.035, p=.439)
and perceived behavioral control (B=−0.068, SE =0.040, p=
.093) did not reach statistical significance. The robustness of these
parameter estimates was consistently supported by the boot-
strapping procedure. Results indicate that self-stigma played a
mediating role in linking attitudes toward seeking mental help with
the intention to seek assistance. However, self-stigma did not act as a
mediator for the relationship between the other two variables,
namely, subjective norms and perceived behavioral control, and
their influence on the intention to seek mental help.
Discussion
In this study, we aimed to assess the usefulness of the theory of
planned behavior in understanding the underlying factors influencing
mental health help-seeking behaviors among Asian Americans, with
a particular focus on the mediating role of self-stigma. The findings
revealed that attitudes, subjective norms, and perceived behavioral
control, as components of the theory of planned behavior, were
associated with Asian Americans’intention to seek mental health
help. Specifically, positive attitudes toward seeking help, perceived
normality in seeking help, and greater ease to seek help were all
positively associated with help-seeking intention. These results are
consistent with previous studies conducted among Asian populations
globally (J. Y. Lee & Shin, 2022;S. H. Lee et al., 2015), suggesting a
path for future research to develop outreach services that promote
positive beliefs about professional mental health care (Mo &
Mak, 2009).
Additionally, results supported the negative association between
mental help-seeking self-stigma and help-seeking intention,
indicating that higher levels of self-stigma predicted a lower
tendency to seek help. Moreover, self-stigma played a significant
mediating role between attitudes and intention but did not mediate
the relationship between subjective norms or perceived behavioral
control and help-seeking intention. This discovery may be situated
within the broader context of the model minority myth (MMM), a
pervasive belief system attributing the achievements of Asian
Americans to their work ethic and determination, thereby
reinforcing the misguided perception that they are “too well-off
to seek help”(D. Kim, 2021;Yoo et al., 2010). The MMM could
plausibly contribute to the internalized stigma experienced by Asian
Americans, who are not only compelled to silently endure stress by
shouldering hardships alone (Lian et al., 2020) but might also be
hesitant to openly address mental health challenges out of concern
for “losing face”within their communities (Kim & Yon, 2019;F.
Wong & Halgin, 2006). Furthermore, this amplifies the significance
of earlier research that emphasizes the role of emotional self-control
as a relevant factor within Asian American groups, which in turn
heightens the challenge of seeking mental health support (P. Y. Kim
et al., 2015). As advocated by Hall’s work (2011), it is imperative for
future research to make therapeutic experiences personally relevant
for minoritized individuals. This aspiration aims to gradually shift
away from Eurocentric treatment models and promote awareness
about therapy as an inclusive, multicultural resource. Effective
approaches involve interventions that are informed by etiological
beliefs (e.g., biological, religious/spiritual) and a conceptual
framework cultivated with adaptability and receptiveness (P. Y.
Kim et al., 2015).
This revelation is coherent with earlier studies that have
emphasized the impact of stigmatization within Asian social contexts
on the inclination to engage with psychological services (Cheng et al.,
2013). While these findings offer valuable insights, additional
research is necessary to discern whether these trends persist under
varying circumstances. Future research could encompass a range of
Asian American subgroups and delve into the interplay between self-
stigma, external perceptions, and culturally nuanced factors. This
expanded exploration would contribute to a more comprehensive
understanding of forces thatmay shape help-seeking behaviors within
the Asian American community.
Moreover, results did not support self-stigma mediating the
relationship between subjective norms and intention to seek help.
This may be attributed to the fact that our assessment focused solely
on self-stigma rather than public stigma, which encompasses the
negative attitudes and discriminatory behaviors individuals may
face from others when seeking help for mental health issues (Cheng
et al., 2013). Future research should expand the scope of stigma to
include public stigma, as it may provide a more comprehensive
understanding of how different types of stigma impact help-seeking
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Figure 2
Path Analysis Using Intention to Seek Mental Help and Self-Stigma
as the Criterion
Note.N=231. Direct paths are depicted in grey, while indirect paths are
depicted in black.
*p<.05. ** p<.01. *** p<.001.
ASIAN AMERICANS’INTENTION TO SEEK HELP 7
behaviors among Asian Americans (Mateer et al., 2023). Exploring
other types of stigma may provide valuable insights into the
multifaceted nature of stigma and its role in shaping individuals’
attitudes toward seeking mental health support.
Of note, our findings indicated an insignificant trend in which
perceived behavioral control predicted lower levels of self-stigma,
suggesting the potential for stronger mental help-seeking intentions.
These results align with the study by Mo and Mak (2009), which
found that perceived behavioral control was not a strong predictor
of stigma in seeking professional mental health services. This might
be associated with potential collectivistic tendencies that have been
noted in certain Asian communities, where the focus is placed on the
contributions of the family or group rather than individual efforts
(Ting & Hwang, 2009). Asian Americans who hold collectivist
values could potentially prioritize broader communal concerns
over individual perceptions of seeking mental help, which might
influence their intention in this regard (Ting & Hwang, 2009).
Future research should consider incorporating within-group and
across-group comparisons specific to Asian American culture, along
with cultural measures such as collectivism, to generate stronger
statistical evidence for this explanation.
Overall, our study significantly contributes tounderstanding mental
help-seeking intention and self-stigma among Asian Americans by
utilizing the theory of planned behavior. Consistent with prior
research, our findings confirm the theory of planned behavior’s
predictive power in determining intention to seek psychological
services among Asian Americans, with attitudes, subjective norms,
and perceived behavioral control playing crucial roles. We also find
that self-stigma acts as a mediator between attitudes and intention to
seek help. These results underscore the importance of addressing
negative attitudes and stigma surrounding mental help-seeking in
Asian American communities. Future research should focus on
developing culturally sensitive interventions that promote positive
attitudes toward mental health resources, considering the unique
sociocultural context of Asian Americans, to eliminate barriers and
foster a supportive environment for seeking mental health support.
Limitations
Our study has several limitations that should be considered. First,
we did not include measures of acculturation nor enculturation in
our study. These constructs are important factors to consider, as our
findings suggest that they may influence each factor in the theory of
planned behavior (Min & Kim, 2000;Sun et al., 2016). Future research
should implement these measures to gain a more comprehensive
understanding of how cultural factors may impact mental help-seeking
intentions and self-stigma among Asian Americans.
Second, participant recruitment relied on two methods, one of
which involved a student sample that allowed for voluntary
participation. This recruitment strategy may have influenced our
results by attracting individuals who are personally impacted by
self-stigma related to mental health help-seeking. Consequently, our
findings may not comprehensively reflect the entire Asian American
population. Since Asian Americans are a highly diverse group,
encompassing individuals from different ethnic backgrounds and
cultural traditions is significant. This diversity among Asian
populations can significantly shape their attitudes toward and
utilization of mental health services. Another limitation of our study
lies in its cross-sectional design, which introduces potential
reporting bias and complexities arising from bidirectional relation-
ships among constructs. The distinction between dependent and
independent variables, as well as the possibility of the mediator
being the independent variable, becomes less clear. Moreover, our
study’s cross-sectional design hinders our capacity to indicate
stronger causal inferences. To address this limitation, future research
could employ experimental data to better examine causality. For
instance, implementing experimental designs could shed light on
whether there was a shift in stigma among Asian Americans before
and after the COVID-19 pandemic, thus enhancing the empirical
basis of the causal mechanisms. This approach has the potential to
deepen our understanding of mental help-seeking patterns and the
dynamic interactions among theory of planned behavior factors,
self-stigma, and intention to seek help.
Fourth, the present study does not addressthe diverse and complex
nature of Asian communities by grouping them into a single entity
(refer to Table 2, for a comprehensive breakdown of ethnic
identification). The landscape of mental health and help-seeking
behaviors among Asian Americans is shaped by sociocultural factors,
such as historical legacies and help-seeking customs (S. B. Kim &
Lee, 2022). Consequently, the integration of ethnic identification is
imperative for the creation of culturally responsive resources,
informed policy choices, and pertinent services. As such, future
research couldaim for data disaggregation based on ethnic subgroups,
enabling practitioners, policymakers, and researchers to attain a more
precise and comprehensive understanding of the prevalent patterns
in mental health-seeking behavior among the Asian American
community.
While the theory of planned behavior variables explain a
significant portion of the variance in intention and self-stigma, it is
important to acknowledge the doubts raised about the necessity and
theoretical significance of self-stigma as a mediator. Statistical
significance does not necessarily equate to theoretical importance or
substantive significance. Therefore, additional steps can be taken to
further support the role of self-stigma as a mediator. This may involve
exploring potential alternative mediators or moderators that could
influence the relationship between the theory of planned behavior
variables and intention to seek help. Additionally, incorporating
participant narratives or qualitative feedback may provide a richer
understanding of the role of self-stigma in influencing intentions.
Qualitative evidence can offer insights into the subjective experiences
of individuals (Nápoles-Springer & Stewart, 2006) and highlight the
underlying mechanisms linking the theory of planned behavior
variables, self-stigma, and intention to seek help.
Finally, it is worth noting that the Mental Health Seeking Attitudes
Scale (MHSAS) used in our study has primarily been used in selective
populations and has not been culturally adapted specifically for our
study. Future researchers should assess the psychometric strength of
the MHSAS on diverse racial/ethnic populations to ensure its validity
and reliability. Despite these limitations, our findings align with
previous literature indicating that stigmatizing attitudes may hinder
Asian Americans’willingness to seek mental health resources
(Ibrahim et al., 2019;C. C. Y. Wong et al., 2019).
Conclusion
Our findings provide valuable insights for the development of
culturally adaptive early interventions and prevention strategies by
highlighting the influence and relevance of cognitive factors that
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8LAGUNAS, ICHIMURA, MATEER, AND JIN
contribute to help-seeking behaviors among Asian Americans.
While our research focused on intrapersonal factors, it is crucial to
acknowledge the impact of social and community entities in
providing informal support for the well-being of Asian Americans.
Institutions such as schools, religious and spiritual centers, ethnic
and language centers, and primary care providers have a significant
role in promoting mental health help-seeking, particularly in
communities where mental health may be stigmatized (Kent et al.,
2020). It is essential for leaders in these organizations to facilitate
access to both informal and formal mental health resources, while
also crafting engaging opportunities for psychoeducation that are
tailored to the specific needs of cultural groups (Han & Pong, 2015;
Kent et al., 2020;Nguyen & Anderson, 2005;Shea & Yeh, 2008).
In conducting stigma research among minoritized groups, it is
important for scholars to refrain from inadvertently placing blame
on the population of interest. Instead, we acknowledge and honor
the experiences of people who have been negatively affected by the
debilitating effects of mental health stigma. Our aim is not to portray
adeficit in Asian Americans’ability to seek mental health resources,
but rather to emphasize the systemic role that institutions,
organizations, and policymakers must play in making mental
help-seeking approachable and destigmatized. By recognizing and
addressing these systemic barriers, we can create an environment
that supports the mental well-being of Asian Americans and other
marginalized communities.
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Received July 24, 2023
Revision received November 6, 2023
Accepted November 6, 2023 ▪
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