Background

The Auckland region is superdiverse with more than 200 ethnic groups settled in the region. In this resource, the term ‘Asian’ refers to the collective set of Asian ethnic groups, who although not homogeneous in nature, share certain value orientations, health beliefs and practices. These groups represent many diverse cultures, languages, religions, socio-economic status, education levels and migration experiences. Asian peoples in New Zealand come from countries in West Asia (Afghanistan and Nepal), South Asia (covering the Indian sub-continent), East Asia (covering China, North and South Korea, Taiwan, Hong Kong and Japan), and South East Asia (Singapore, Malaysia, the Philippines, Vietnam, Thailand, Myanmar, Laos and Kampuchea) (Mehta, 2012).

‘Asian’ groups include every category of immigrant: skilled migrants; refugees; those on temporary work visas, foreign fee-paying students on fixed term visas; and New Zealand-born Asians (third and fourth generation New Zealanders).

New Zealand-born Asians and 1.5 generation Asians (who were born overseas and relocated to New Zealand at a young age) are generally more acculturated to New Zealand culture, than newcomers. Within a family, the degree of acculturation may vary between the younger generation and the older generation or between those who have longer residence in New Zealand and those who are new arrivals.

Asian, Middle Eastern and African populations have much younger age structures than European populations, with relatively high proportions at the child and childbearing ages, and low proportions at the older ages (SNZ, 2015).

Annually, the New Zealand government accepts a UNHCR mandated refugee quota of 750 places. In 2018, this number will increase to 1000 quota refugees per annum. Refugees also arrive as asylum seekers and through the refugee family sponsored category. A quarter of refugee populations are under the age of 15 years (McLeod & Reeve, 2005). Rungan et al’s (2013) study of refugee children under five, arriving in New Zealand includes: children from: Myanmar (40%), Bhutan (10%), Afghanistan (8%), Congo (6%), Eritrea (4%); Colombia (13%) and Iraq (7%); with Sudan, Burundi, Sri Lanka, Iran, Indonesia, Palestine, Mauritius. Rwanda, Nepal, Somalia and Bangladesh each less representing less than 2% of children arriving from January 2007 to January 2012.

Asian people

The Asian population in the Auckland Region was over 402,000 in 2016 representing 23% of Auckland’s total population (SNZ, 2015). The most predominant Asian ethnicities in the region are Chinese (38.5%); Indian (34.6%), Korean (7.2%) and Filipino (7.0%) peoples. Close to a quarter of Asian peoples in the Auckland region have lived in New Zealand for less than 5 years (Walker, 2014).

Asian peoples in New Zealand come from: South Asia: India, Sri Lanka, Nepal, Pakistan, Bangladesh, Afghanistan, Bhutan, the Maldives and Fijian Indians. East Asians include people who have migrated from China, Japan, Taiwan, Mongolia, South Korea, North Korea and Macau. South East Asians include people from Vietnam, Cambodia, Malaysia, Singapore, Indonesia, Thailand, Philippines, Burma, Brunei, East Timor, and Laos (Mehta, 2012).

Middle Eastern and African people

Middle Eastern and African (MEA) populations consist of extremely diverse groups with dissimilar cultures, religions and backgrounds. In 2013, 2% (44, 259) of the New Zealand population identified as Middle Eastern, Latin American and African (MELAA) and half lived in the Auckland region (Walker, 2014).

Middle Eastern people

Middle Eastern people are the largest of the MELAA groups in Auckland. Middle Eastern peoples in New Zealand come from: Algeria, Egypt, Iran, Iraq, Israel, Jordan, Lebanon, Libya, Morocco, Oman, Palestine, Syria, Tunisia, Turkey, Yemen, Kuwait, the United Arab Emirates, Turkey, Saudi Arabia and Bahrain.

Since 1994, refugees from Iran and Iraq have formed a large proportion of New Zealand’s refugee intake and overall these groups make up the largest Middle Eastern populations (Perumal, 2011). These ethnic groups represent many diverse languages, religions and ethnic affiliations.

African people

African people are the second largest MELAA group in Auckland. Similar to Middle Eastern people, many came to New Zealand as refugees from the late 1980s (predominantly from the Horn of Africa). By the early 2000s, the majority came as migrants from South Africa and Zimbabwe (Perumal, 2011).

African peoples in New Zealand are from: Jamaica, Kenya, Nigeria, the USA, Uganda, The Caribbean, Somalia, Eritrea, Ethiopia, Ghana, South Africa, Zimbabwe, Democratic Republic of Congo, Republic of Congo, Tanzania, Rwanda, Burundi, Nigeria, Sierra Leone, Djibouti and Sudan. African peoples come from diverse cultural and religious backgrounds and ethnic affiliations.

Migrant children and young people are at risk of mental health problems. The migration process causes stress, not only because migration entails extensive loss of family and friends, culture and community, but also because migrants have to adapt to a new cultural environment, often including different social norms, values and standards and a new language (Berry, 1990). The New Zealand Youth 2007 study found that mental health issues were a significant concern among Asian youth, especially among female students (Parackal, Ameratunga, Tin Tin, Wong & Denny, 2011).

Research shows that refugee youth are at considerable risk of developing mental illness and experiencing co-morbid disorders, such as depression and anxiety (Pumariega, Rothe & Pumariega, 2005; Schweitzer, Melville, Steel & Lacherez, 2006; Te Pou, 2008). Refugee children and young people are at increased risk of mental illness due to: pre-migration experiences, including: war, physical injury and sexual assault, family separation, refugee camp life with its daily struggle for survival, disempowerment and decreased safety, violence and atrocities, extreme poverty and deprivation. Re-settlement experiences can also be traumatic including: being in an alien culture, a new education system, learning a new language, a lack of social support, ongoing life stressors and manoeuvring between home and school.

Intergenerational conflict between children, parents and grandparents due to the incompatibility between the home culture and the host culture is common in migrant and refugee background families. Asymmetric acculturation within families is a pattern in which children acquire the host country culture and language much faster than their parents and grandparents, resulting in conflict and stress in migrant families (Matsuoka, 1990; Potocky-Tripodi, 2002).

The negative impact of racism and discrimination on the mental health of Asian, migrant and refugee youth is documented in a number of New Zealand studies (Ameratunga & Horner, 2011; Scragg, 2016; Wong et al., 2015). Belonging to a coherent and supportive family culture protects against the development of mental health problems (Hackett, Hackett & Taylor, 1991; Harker, 2001).

The experience of migration and settlement may impact directly and indirectly on children’s mental health. As children are migrants themselves, the migration stressors mentioned may apply to them but they may also have to cope with inadequate support from their parents owing to their parents’ preoccupation with their own migration stresses (Hicks et al., 1993). As well, children may have to support their parents, for example interpreting for them and explaining the new way of life, such as the school system.In the early settlement phase, migrant and refugee families may be confronted with financial hardship, unemployment and housing problems.

This resource will review common mental health disorders presentating to Child and Adolescent Mental health Services (CAMHS) for Asian, migrant and refugee background children including: depression and anxiety; problem gambling; internet Game Addiction; drug and alcohol abuse; eating disorders; posttraumatic stress disorder; sexual identity issues and suicide risk. Cultural presentations of distress and cultural formulation and help-seeking behaviours will be discussed. Issues in regard to assessing migrant and refugee children include: intergenerational issues and using appropriate cultural assessment tools, cultural formulation tools and validated screening tools. Psychosocial interventions and their application will be demonstrated in case studies. Case scenarios demonstrate CALD culturally competent mental health practice. A section on resources provides information on referral agencies and culturally and linguistically appropriate pycho-education resources for health practitioners and consumers.

Current experience and research conducted in New Zealand shows that Asian, and MELAA migrants and refugees are encountering difficulties in accessing New Zealand health services. In addition to the many wider systemic barriers, it has been found that language and cultural issues are the two most widely experienced barriers to service utilisation, adversely affecting equitable access to appropriate and quality care (Ho, Au, Bedford, & Cooper, 2002; Mehta, 2012; Ngai, Latimer, & Cheung, 2001; Walker, Wu, Soothi-O-Soth & Parr, 1998).

Asian and MELAA migrant populations are unfamiliar with New Zealand health and disability systems and many experience access barriers due to low English proficiency levels and a lack of knowledge of what services are available. Many migrants have difficulty understanding the roles and functions of different agencies and health professional roles within the NGO, primary, secondary care and social service sectors.

Asian and MELAA migrant populations are vulnerable. Research on service utilisation in New Zealand shows that Asian and MELAA populations are not accessing health services equitably with other populations and present late to services (Mehta, 2012; Perumal, 2011). The stigma associated with poor mental health is a significant factor in poor engagement with mental health services (Honey et al., 2014). There is a need for Mental Health and Addiction services to assist Asian/MEA service users and carers, (in particular non-English speaking service users) to navigate the network of services provided.

The following is a list of system or service barriers that can impact on the care of the child or a young person:

Cross-cultural skill refers to the ability to implement cultural awareness, sensitivity and knowledge in practice when working with CALD children, adolescents/ families, and the needs/issues they present with.

CALD cultural competence involves, being competent with:

• Addressing language barriers in clinical encounters (knowing how to use interpreters is essential). You can learn how work with interpreters by undertaking the following training which is available on line: CALD 4: Working with Interpreters (Waitemata DHB, eCALD® Services, 2014b).
• The Cultural-Awareness – Assessment – Negotiation Technique (Campinha-Bacote, 2011), which involves:
  • Being aware of the ethno-medical beliefs of the clients/family/ communities you serve.
  • Assessing the likelihood that a particular client/family may act on these beliefs during a particular mental health episode.
  • Negotiating between biomedical and ethno-medical belief systems.
  • Emphasising common goals (e.g. helping your child/young person to get better), while acknowledging differences.
  • If necessary or possible, incorporating non-harmful remedies in the treatment plan.
  • Not assuming that the family knows how to use the New Zealand health and disability system.
  • Referring to available culturally appropriate support services when required.

(Waitemata DHB, 2016b)

Many Asian, Middle Eastern and African gestures and greetings differ significantly from Western ones. To develop good rapport and show respect, here are some essentials for greetings and communication.

• Ask clients if they wish to be addressed using a title and surname, especially at the initial engagement (premature familiarity may be considered disrespectful (eg they may also address the health practitioner as Dr, Madam, Sir to show their respect).
• A nod or slight bow is customary when greeting East Asian families (Chinese, Korean, Japanese).
• Older people should be greeted first and last before leaving.
• Avoid prolonged or direct eye contact.
• Over-familiar touch is not appreciated.
• It is acceptable to shake hands with men.
• Muslim women may refrain from shaking hands with men.
• Preferably use customary greetings with women.
• When in doubt, a smile and a slight bow of the head will always be appreciated.
• Using hand gestures to summon someone is considered insulting.
• In most Asian cultures it is disrespectful to touch another’s head (except for medical examination).
• Many Asian/MEA clients will avoid saying ‘no’ as it is considered impolite, so ‘yes’ may be ambiguous and may indicate that the listener is paying attention; it does not necessarily indicate agreement.
• Showing respect, especially for elders, is appreciated (eg greeting the elders first, the practitioner being on time for appointments and greeting them in their traditional way)
• Showing an interest in the culture and practices will likely enhance the relationship with the practitioner, and compliance.
• Health practitioners are usually highly regarded and clients may not ask questions, and may not answer in the negative as it is considered disrespectful. It would be helpful to invite the client and their family to ask questions, especially when working through an interpreter.
• In most Asian cultures, ‘Saving Face’ is a strong principle and will be used over confrontation or questioning of those in authority. It is also important not to put a person in a position where they will be seen to ‘lose face’.
• Ask clients about their expectations of the service. Some migrant families may expect medications, injections, practical help, and solutions rather than just a visit/consultation. For some migrants discussion alone may be seen as a waste of time.
• Explain the treatment process and timeframe, immediately after diagnosis. Some Asian clients are distressed by uncertainty and may choose to return to their home country for treatment if they are anxious.
• Explain confidentiality and privacy especially when using interpreters. Confidentiality becomes an issue in smaller communities or recently arrived groups. Migrants may be reluctant to use an interpreter because he/she knows the interpreter and/or fears that details of the matter will be made public. At the beginning of the interview, reassure the client/family that you and the interpreter will respect his/her rights to confidentiality (unless there are serious safety concerns).
• Explain your services and roles clearly and provide information in the client’s language. Many migrants are not familiar with New Zealand health and social services, legal rightsand policies eg the New Zealand definition of child neglect or family violence or the “no smacking” law, and they don’t know what services are free of charge eg interpreting services etc. Newcomers are not familiar with the routine and practical details of New Zealand health, mental health and disability services. It is most important to provide interpreters or support people to explain what is happening, to answer questions and to discuss any fears or worries with parents/grandparents.
• Assess health literacy and English language proficiency. Do not assume someone who can respond with Yes or No answers understands English or comprehends medical terminology or information. Also do not assume someone can read in English or in their own native language.
• Use professional interpreters where practical: Avoid using a family member or a child to interpret. NB Many Asian/MEA families refuse the use of interpreting services because they are not aware that it is free of charge, and are not aware of the roles, responsibilities and confidentiality required of interpreters. They may expect interpreters to provide additional support or transport for them. It is important to explain the roles of interpreters to avoid misunderstanding.
• Give instructions in a clear, logical sequence so that families understand eg providing step-by-step instructions or using pictures/visual information.
• Being culturally competent is not about learning everything about a specific culture. It is better to learn about the values of collective cultures and to learn some of the more common cultural beliefs and practices of the groups you serve rather than to try to learn a list of ‘do’s and don’t’s’ for working with CALD clients and families.
• At the engagement stage, an awareness of alternate models of mental illness and efforts to find common ground can promote the development of rapport with CALD parents. Enquiry regarding preferences for treatment modality may result in enhanced adherence. The Culture and Health-belief Assessment Tool (CHAT) (see the Assessing Migrant and Refugee Children and Adolescents section will assist you to understand diverse health beliefs and explanatory models of mental health and client/family preferences for care.

An overview of collective cultures and traditional Asian, Middle Eastern and African (MEA) family values, health beliefs and practices is discussed in this section.

“Culture influences how culturally and linguistically diverse (CALD) communities from Asian and MEA backgrounds explain their health and wellbeing or respond to health and sickness, their behaviours, attitudes as well as their health seeking patterns.”

Families from Asian, Middle Eastern and African (MEA) backgrounds are very (extended) family oriented with a high priority placed on family, unity, dignity, respect, spirituality and humility. There are significant differences between collectivist and western individualist views about decision-making, family structure, gender roles and parenting.

Asian and MEA cultures, religions and languages have a significant impact on health beliefs and practices, influencing the way in which families explain their health and illness, and how they respond to and access health services. Cultural backgrounds also influence patient’s and family’s behaviour, family structure, decision-making, child rearing practices, caregivers’ roles, dress codes and dietary preferences.

Cultural groups have different ways of understanding illness and will attribute different causes to the origin and symptoms of mental health disorders/disabilities. How illness/disability is explained is strongly influenced by families’ cultural/religious backgrounds.  To a large degree, these values also define the acceptable symptoms of the illness/ disability as well as the behaviour, expression and role of the child and young person. Health beliefs are often complex and may change overtime with acculturation. For some CALD groups, after a long period of settlement in New Zealand, there may be little or no reliance on traditional practices. Some families will revert back to traditional health practices when they find that illness/disability is not responding well to Western medicine. CALD younger people who are New Zealand born or the 1.5 generation may not hold any traditional health beliefs and practices. To assess acculturation levels and to avoid stereotyping, individual assessment is essential.

Traditional Family Values

The following table provides a comparison of traditional collectivist family values with Western family values. NB The information is generalized and is intended to highlight cultural differences and to enhance cultural understanding for health providers.

(Waitemata DHB, eCALD® Services, 2016f).

Family Structure

In this section, additional information about Asian/MEA traditional family structures, family-based decision-making, gender roles, parenting, intergenerational and other cultural expectations are provided. The suggested cultural approaches or considerations are included to expand health providers’ cultural understanding and to enhance engagement with families.

In New Zealand, Asian/MEA families who have extended family members often live together as a single-family unit, which includes grandparents, parents and children.

• The grandparent’s role in raising the children is a highly valued link to culture, religion and heritage.
• For traditional families with multiple sons, the parents or grandparents usually choose to live with the eldest son.
• Asian/MEA families value family ties and have a strong sense of obligation to and respect for seniors, loyalty and honour as well as duty to the family.
• It is a traditional belief that children have to give a lot of respect to parents and take care of parents when they get old.

Suggested approaches:

• Explore family dynamics and relationships.
• Find out who is the primary caregiver for the child.
• Explore the level of acculturation of the family members and their service expectations.
• Ask the client if he/she has family or community who can help the family in practical ways.

Decision-making

• The father or the husband is usually the decision-maker for bigger family issues. However, mothers are usually the main caregivers of the children and older persons.
• Some Chinese and Korean mothers may have difficulties with taking on the role of making decisions on serious health matters for their children, because their husbands are working in their homeland. While they may have to be the main decision-makers they may still need to discuss decisions with their husband first. This may lead to a lot of stress.
• Because of the value placed on interdependence and privacy in Asian/MEA cultures and the desire to “save face”, family issues including healthcare decisions, are frequently discussed within the immediate family before seeking outside help.

Suggested approaches:

• Establish the main decision-maker(s) for healthcare matters (including informed consent).
• For communication, convey information to both (father or the husband or the mother of the children or caregivers of the children or older persons) to avoid communication breakdowns.
• Find out if there is anyone overseas that needs to be contacted for healthcare decisions.

Gender roles

The roles of Asian/MEA men and women are distinct. Women manage the home by keeping all finances, family, and social issues in order. Women are more passive and men typically are the bread-winners and managers of issues requiring interaction with individuals in the community, eg health care. This type of behaviour implies that men have a dominant and authoritative role because they are the primary point of contact with society. However these roles are beginning to change among educated Asian/MEA families and among immigrants in progressive or permissive societies.

Suggested approaches:

• Ask who the primary care giver is for the child and who is responsible for decision making.

Parenting and grand-parenting

• In many Asian/MEA cultures, parents expect their children to be obedient, well-disciplined and to achieve high academic qualifications. Asian parents employ a “training” mode of upbringing, organizing children to attend different tutorials or interest groups, even after school and during holidays.
• Failure to meet expectations (eg academic) brings shame and “loss of face” to the child and the family.
• Some parents are concerned about their children losing their native language ability and being unable to maintain traditional values. Children may be stressed by their parents’ traditional expectations and face conflict between traditional and western cultural values and peer group norms.
• In most instances in Asian/MEA communities, the whole family is involved in the care of the children. Grandparents play an important role in rearing children.
• Children often sleep with parents from the time of birth to early childhood. If the grandparents are part of care taking, the children may be as attached to the grandparents as to their parents. This may cause some attachment issues between the child and their parents.
• Respect for elders is highly valued and children, including grandparents, older siblings, teachers, and family friends. The discipline of children is thought to come naturally. In some families, a child is responsible for many of the adult tasks, such as finance, legal forms, and interpretation/translation. Children from refugee backgrounds in particular may be responsible for adult tasks including the care of younger children.
• China’s one child policy was introduced in 1979. This has resulted in the development of the 4-2-1 This refers to the first generation of law-enforced only children becoming parents themselves. The adult child has two parents and four grandparents. Consequently, some Chinese parents and grandparents may over-indulge their only child or grandchild resulting in a child who may lack self-discipline and the ability to cooperate with others. The Chinese media refers to these traits as the “little emperor syndrome”. (Wikipedia, 2017). The impact of the one-child policy may result in some Chinese young couples having limited parenting skills. 

Suggested approaches:

• Assess parents’ views about the importance they place on the child’s education and the child’s ability to cope with parental expectations of high achievement.
• Assess the child (if he/she can speak for himself/herself) on their own to determine stressors and issues (eg cultural identity issues, educational expectation, etc). Explain to the parents the importance of assessing the child on their own (if parents are not comfortable to have their child assessed without them).
• Ask the child for their choice for support: grandparents or parents – or better, both.
• Advise parents/grandparents against using their children as interpreters.
• Assess the effects on the child of having adult responsibilities.
• Explore the couple’s parenting skills and encourage parenting education or incredible years’ education. (If grandparents are involved as primary care givers, encourage them to attend parenting education programmes together with the parents).