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Differences in Asian and white drinking: consumption level, drinking contexts, and expectancies.

Despite the heterogeneous nature of interethnic drinking differences within racial groups, research has demonstrated that cautious generalizations can be made when comparing Asian and White drinking patterns. Persons in the United States who identify their race as "Asian" drink much less than their White counterparts, and they report fewer problems. Some have speculated that drinking patterns between racial groups are mediated by culturally influenced social learning. To date there has been very little research examining the expectancy of reinforcement from drinking between different racial, cultural or ethnic groups. The current study of 637 white and 179 Asian university students examined differences in alcohol consumption and problem levels, the social context of drinking, and alcohol expectancies. Results show considerable differences between Asian and White drinking and level of associated problems, as well as similarities and differences in social drinking contexts. It also appears that Asians expected greater tension reduction from drinking despite drinking less overall. Implications for further research are suggested that would link racial, and more specifically, ethnic drinking differences with culturally defined alcohol expectancies.

Adult↗

Indian Asian men have less peripheral arterial disease than European men for equivalent levels of coronary disease.

OBJECTIVES: Indian Asians have high rates of heart disease and stroke, but risks of peripheral arterial disease appear to be low. This paradox, and reasons for it, have not been explored. We compared ethnic differences in peripheral arterial disease for a given level of coronary disease. METHODS: We studied 83 European and 84 Indian Asian men with a range of coronary disease. Extent of coronary atheroma was quantified by coronary artery calcification score on multislice CT. Femoral intima-media thickness (IMT) was measured by ultrasound. RESULTS: Femoral IMT was 1.58, 2.06, 2.12, and 2.69 mm in Europeans, and 0.61, 1.41, 1.81 and 2.29 in Indian Asians by increasing categories of coronary atheroma (p=0.003 for ethnic difference, adjusted for age and lumen diameter). Adjustment for smoking and systolic blood pressure, the only risk factors adversely distributed in Europeans, only partly accounted for this ethnic difference (p=0.05). Other risk factors, including lipids, obesity, insulin and glycaemic status, more adversely distributed in Indian Asians, could not account for ethnic differences. Prevalence of abnormal ankle brachial index and lower limb atherosclerotic plaque was also greater in Europeans. CONCLUSIONS: For a given level of coronary disease, Indian Asians have less lower limb atherosclerosis than Europeans, unexplained by established risk factors. Further study of these populations would help tease out relative contributions of risk factors to atherosclerosis in different vessel beds.

Aged↗

Chemoprevention of breast cancer among Asian women--its perspective and problems.

Chemoprevention of breast cancer employing tamoxifen and others has been demonstrated to be effective in reducing the frequency of developing breast malignancy in Western countries. In Asian countries, the frequency of breast cancer as well as its premalignant lesions has recently increased. Therefore, the possible chemoprevention may benefit those women with potential high risks of developing breast cancer and with premalignant lesions. However, the details of these findings of chemoprevention in Western countries have not been available for women with Asian descendant. In addition, risk factors of developing breast cancer in healthy women have not been established in Asian countries compared to Western countries with relative paucity of familial breast cancer cases. Thus, possible chemoprevention of breast cancer in Asian countries may be targeted toward those with established premalignant breast lesions such as ductal carcinoma in situ and/or atypical ductal hyperplasia. However, due to their recent increment of their incidence, biological and/or clinical features of these premalignant breast lesions have not been extensively characterized in Asian women and further investigations are required for wide spread chemoprevention.

Animals↗

Suppression of ovulation by a new subcutaneous depot medroxyprogesterone acetate (104 mg/0.65 mL) contraceptive formulation in Asian women.

BACKGROUND: A new progestin-only, nondaily depot medroxyprogesterone acetate (DMPA) SC injectable contraceptive suspension (104 mg/0.65 mL) has been developed. Clinical trials (including dose-ranging, pharmacokinetic/pharmacodynamic, and contraceptive efficacy studies) indicating the effectiveness of this new formulation were conducted primarily in white women. However, results of an early study by the World Health Organization suggested that in Thai women, medroxyprogesterone acetate (MPA) may be metabolized in <91 +/- 7 days (the range for effective suppression of ovulation established in clinical trials), resulting in a faster return to ovulation in this population. OBJECTIVES: This study was designed to determine the duration of ovulation suppression and investigate the pharmacokinetic profile of MPA after a single SC injection of DMPA 104 mg/0.65 mL in Asian women. It also assessed the effect of ethnicity and injection site on the duration of ovulation suppression. METHODS: : This was a single-center, single-dose, open-label outpatient trial conducted in Singapore in Asian women aged 18 to 40 years. After 1 control cycle, women with confirmed ovulation were randomized in a 1:1 ratio to receive an SC injection of DMPA 104 mg/0.65 mL in either the anterior thigh or the abdomen. Serum concentrations of MPA, progesterone, estradiol, luteinizing hormone, and follicle-stimulating hormone were measured during the 91-day dosing interval and for an additional 15 days thereafter. RESULTS: Twenty-four Asian women (mean [SD] age, 33.8 [43] years; range, 22.7-40.1 years; mean [SD] body mass index, 22.4 [3.0] kg/m(2)) belonging to 5 ethnic groups (Chinese, Filipino, Indian, Malaysian, and Thai) were included in the study Ovulation suppression was maintained throughout the 91-day dosing interval, regardless of ethnicity or injection site. Ovulation was suppressed for at least 112 days after injection in 23 (95.8%) women, as evidenced by maintenance of serum progesterone concentrations <4.7 ng/mL. The pharmacokinetic parameters for MPA in these Asian women were similar to those previously reported in white women. The most frequently reported adverse events were flulike symptoms and headache, all of mild to moderate intensity. No serious adverse events were reported. CONCLUSIONS: In this study, SC DMPA 104 mg/0.65 mL provided effective suppression of ovulation for at least 91 days in Asian women. Ethnicity and injection site had no effect on MPA profiles.

Adult↗

Rosuvastatin pharmacokinetics and pharmacogenetics in white and Asian subjects residing in the same environment.

BACKGROUND: Systemic exposure to rosuvastatin had been observed to be approximately 2-fold higher in Japanese subjects living in Japan compared with white subjects in Western Europe or the United States. The organic anion transporting polypeptide 1B1 contributes to the hepatic uptake of rosuvastatin. Polymorphisms in the SLCO1B1 gene can lead to reduced transport function in vitro (T 521>C). This study was conducted to determine whether the pharmacokinetic differences between Japanese and white subjects extended to other Asian ethnic groups and to determine whether polymorphisms in the SLCO1B1 gene contribute to any pharmacokinetic differences observed. METHODS: Rosuvastatin pharmacokinetics was studied in an open-label, parallel-group, single-oral dose (40 mg) study in 36 white, 36 Chinese, 35 Malay, and 35 Asian-Indian subjects living in Singapore, Singapore. Plasma concentrations of rosuvastatin and metabolites were determined by HPLC-mass spectrophotometry. Two SLCO1B1 polymorphisms (A 388>G and T 521>C) were genotyped. RESULTS: Ratios for rosuvastatin area under the plasma concentration-time curve from time 0 to the time of the last quantifiable concentration were 2.31, 1.91, and 1.63 and ratios for maximum plasma concentration were 2.36, 2.00, and 1.68 in Chinese, Malay, and Asian-Indian subjects, respectively, compared with white subjects. Similar increases in exposure to N-desmethyl rosuvastatin and rosuvastatin-lactone were observed. SLCO1B1 genotypes did not account for the observed pharmacokinetic differences between Asians and white subjects. CONCLUSIONS: Plasma exposure to rosuvastatin and its metabolites was significantly higher in Chinese, Malay, and Asian-Indian subjects compared with white subjects living in the same environment.

Adult↗

The low incidence of surgery for non-cardiac vascular disease in UK Asians may be explained by a low prevalence of disease.

AIMS: Firstly, to compare rates of surgery for non-cardiac vascular disease in Caucasians and Asians and secondarily to assess the prevalence of peripheral arterial disease (PAD) and abdominal aortic aneurysm (AAA) in the male UK Asian population. METHODS: Analysis of a prospective database followed by an epidemiological survey of 100 unselected Pakistani males, in which demographic and anthropometric data were collected alongside aortic ultrasonography and measurement of ankle: brachial pressure index (ABPI). RESULTS: Although 14.1% of our catchment area is Asian, after correction for age, they only accounted for 64/2268 (2.8%) of procedures for PAD and AAA. Specifically, Asians were 10 times less likely to undergo AAA repair and 3 times less likely to undergo procedures for lower limb peripheral bypass, amputation and endovascular intervention. In the epidemiological study, 26 subjects had a significant history of ischaemic heart disease, 21 were diabetic, 32 had hypertension and 60 were current or ex-smokers. Median aortic diameter [IQR] was 17.6 mm [16.3-19.1 mm] and no subject had an AAA. In 200 limbs, median ABPI [IQR] was 1.12 [1.04-1.21]. Only 2 patients had an ABPI < 0.9. CONCLUSION: Despite a high prevalence of cardiovascular risk factors and ischaemic heart disease, the prevalence of PAD and AAA is much lower than would have been expected in an age- and sex-matched Caucasian population. These data suggest that the reduced incidence of surgery for PAD and AAA in UK Asians is due to a low prevalence of disease.

Aged↗

Raised leptin concentrations among South Asian patients with chronic heart failure.

BACKGROUND: The disease presentation of chronic heart failure (CHF) is considered to progress with metabolic deterioration, underlined by changes in adipose associated hormones (adipocytokines). However, little is known about ethnic variations of adipocytokines amongst CHF patients, in particular South Asians, who are at an increased risk of CHF. METHODS: Using a cross-sectional study, South Asians (n=106) and Caucasians (n=105) living in the UK were compared by CHF status. We investigated ethnic differences in adipocytokines (leptin, adiponectin, tumor necrosis factor (TNF)alpha), and their association with CHF. Patients with mild to moderate CHF were recruited from heart failure clinics (47 Caucasian, 54 South Asian), and compared to healthy controls. Metabolic parameters (including insulin resistance using HOMA modelling), echocardiography and brain natriuretic peptide (BNP) were measured amongst patients and healthy controls, and compared across and within ethnic groups. RESULTS: Mean (log transformed) plasma leptin concentrations were highest amongst South Asian patients, being 5.25% (95%CI: 1.50-9.02) higher than Caucasian patients (P=0.007), and similarly raised with respect to controls (P< or =0.04). Indices of insulin resistance were higher amongst CHF patients compared with controls, with no ethnic variation. In addition to age, female gender and body-mass index, levels of leptin were also associated with South Asian ethnicity (P<0.001), insulin resistance (P=0.02), smoking habit (P=0.01) and HDL cholesterol (P=0.004). Levels of adiponectin showed no ethnic variation, but were associated with CHF and a previous history of myocardial infarction (P<0.001). On multivariate regression analysis of patients and healthy controls, CHF was independently associated with smoking habit, adiponectin and insulin resistance (all P<0.01). CONCLUSION: Metabolic abnormalities are present in CHF, which in turn, are influenced by ethnicity. The role of adipocytokines in CHF pathophysiology and prognosis merits further study.

Adiponectin↗

Development of a food frequency questionnaire to estimate calcium intake of Asian, Hispanic, and white youth.

OBJECTIVE: To develop a food frequency questionnaire (FFQ) that estimates calcium intake of Asian, Hispanic, and white youth living in the western United States. DESIGN: A list of 80 foods was assembled to create an FFQ to measure calcium intake. Evaluation of the FFQ spanned four consecutive weeks. An FFQ was completed during Week 1 and Week 4, and a 24-hour dietary recall was completed during Week 2 and Week 3.Subjects/setting A convenience sample of 162 Asian, Hispanic, and white youth ages 10 to 18 years was selected. Statistical analyses performed Percent agreement, paired t tests, Pearson correlation coefficients of cube-root transformed values, and deattenuated Pearson correlation coefficients of cube-root transformed values were used to evaluate the FFQ. RESULTS: The correlation between calcium intake estimates, when measured by first and second administrations of the FFQ, was 0.68 (Pearson's r) for the total sample. Correlations differed by age, sex, and ethnic subgroups as follows: 10 to 13 years (r=0.62), 14 to 18 years (r=0.73), male (r=0.73), female (r=0.64), Asian (r=0.77), Hispanic (r=0.72), and white (r=0.48). The correlation between calcium intakes as estimated by the second FFQ vs the average of the two 24-hour dietary recalls was 0.54 (deattenuated Pearson's r) for the total sample. This correlation differed by age, sex, and ethnic subgroups as follows: 10 to 13 years (r=0.46), 14 to 18 years (r=0.59), male (r=0.65), female (r=0.45), Asian (r=0.64), Hispanic (r=0.18), and white (r=0.57). CONCLUSIONS: A unique dietary survey has been developed to estimate calcium intake among Asian, Hispanic, and white youth in the United States.

Adolescent↗

Asians in the United States: substance dependence and use of substance-dependence treatment.

Clinicians have often observed that Asians are unlikely to utilize substance-dependence treatment services but few have reported empirical data examining this phenomenon. This study used data from the National Household Survey on Drug Abuse, 2000-2002, and tested whether Asians in the United States have relatively low rates of drug and alcohol dependence and whether substance-dependent Asians use treatment services less than Caucasians. Subsequent analyses were undertaken to identify factors that explained these racial differences. Of the 5,118 Asians, 159 met criteria for past-year drug or alcohol dependence. Asians with past-year substance dependence were significantly less likely than substance-dependent Caucasians to report past-year treatment (odds ratio 0.42, 95% confidence interval 0.19-0.96). Differences in past-year substance-dependence prevalence appear to be partially explained by between-group differences in ever using substances; differences in past-year treatment use appear to be in part related to differences in levels of acculturation and education.

Adolescent↗

Effectiveness and safety of olanzapine in the treatment of schizophrenia among Asian patients switching from conventional antipsychotics.

OBJECTIVES: The objectives of this study were: (1) to investigate, in a clinical practice setting, the effectiveness of olanzapine in the treatment of schizophrenia among partially-responding, symptomatic Asian patients who switch from conventional antipsychotic treatment, (2) to assess the safety of olanzapine and (3) to assess the change in quality of life in Asian patients with schizophrenia who switch to olanzapine. METHODS: Effectiveness, safety and quality of life were assessed in outpatients with schizophrenia (n=1267) who lacked symptomatic control with conventional antipsychotics and were switched to olanzapine therapy. Data for this prospective, observational study were collected for 12 months from Asian patients in China, Hong Kong, the Philippines, South Korea and Taiwan. RESULTS: Significant clinical improvements (P<0.05) were observed following 12 months of olanzapine treatment and 87.3% of the subjects responded to treatment at endpoint (i.e. Brief Psychiatric Rating Scale Total score reduced by > or =30% relative to baseline; last observation carried forward). Abnormal involuntary movements (mean change in Abnormal Involuntary Movement Scale: -3.20, P<0.001) and quality of life were significantly improved in patients treated with olanzapine. However, some patients experienced significant weight gain (3.60+/-4.50 kg, P<0.001) with olanzapine treatment, relative to baseline. CONCLUSIONS: This study shows that switching to olanzapine may be effective in improving symptoms, may be well-tolerated and may improve the quality of life in Asian patients who are only partially responsive to treatment with conventional antipsychotics. The pragmatic design and naturalistic setting of this large study make the findings relevant for treating patients from some Asian countries in routine clinical practice.

Adult↗

South Asians and epilepsy: exploring health experiences, needs and beliefs of communities in the north of England.

PURPOSE: To examine the beliefs and experiences of South Asians with epilepsy and the extent of provision of appropriate information and accessible services for them by health professionals. METHODS: Qualitative interviews with 30 South Asians with epilepsy, 16 carers and 10 health professionals. In addition, two focus groups were held with 16 South Asians without epilepsy recruited from community centers. The interview sample was divided by religious groupings (Hindus, Sikhs and Muslims). Fieldwork was conducted in Bradford and Leeds (England). RESULTS: Beliefs that epilepsy is caused by spirit possession (Muslims) or attributable to sins committed in a past life (Sikhs and Hindus) were reported as being widely held among South Asians living both in the UK and the Indian subcontinent, although few informants themselves subscribed to such views. Compliance with conventional medication was high; however, those who experienced seizures most often were most likely to turn to traditional South Asian therapies. Most informants used both treatments simultaneously. The main issues regarding the provision of services were: lack of appropriate information and advice; language and communication barriers; problems in interaction with health professionals. Also discussed were the potential merits of attending support groups. Greatest dissatisfaction was expressed in relation to primary care, whereas the highest praise was reserved for specialist epilepsy nurses. CONCLUSIONS: Our findings show both similarities and differences between participants' experiences, where gender, age or other aspects of personal biography can be as important as religion, culture or country of origin. Furthermore, the impact of being diagnosed with epilepsy can be exacerbated by structural impediments to accessing information and appropriate services.

Adolescent↗

Perceptions of risks of smoking among Asian Americans.

BACKGROUND: Tobacco use is the single most preventable cause of illness and death in the United States. Few studies focus on Asian Americans, one of the fastest growing but underserved populations in the United States. METHODS: A cross-sectional survey method was used for this study. The study sample was identified by using a stratified-cluster proportional sampling technique. A questionnaire was developed in English, translated into the four Asian languages (Chinese, Koreans, Vietnamese, and Cambodians), and back-translated. The sample consisted of 1174 individuals, distributed as follows: Chinese, 34.9%; Korean, 37.1%, Vietnamese, 16.7%; Cambodian, 8.4%; and others, 2.7%. RESULTS: Findings indicated that attitudes toward tobacco-related dangers were associated with smoking status: former and never smokers held more negative perceptions regarding smoking compared to current smokers. Further, results indicated that the Asian American subgroups differed in their respective attitudes. The study is the first to compare attitudes toward tobacco-related dangers among racial/ethnic and language subgroups of Asian Americans. CONCLUSION: The growing body of empirical data on smoking among Asian Americans indicates that smoking cessation programs should take into account variations in smoking-related perceptions and attitudes across the ethnic subgroups.

Adolescent↗

Cultural factors in preventive care: Asian-Americans.

The Asian-American population in the United States continues to grow rapidly. In 1990, there were 6.6 million Asian Americans in this country, representing 2.7% of the population. The 2000 Census showed the Asian population has grown to 10.1 million, now 3.6% of the population. A breakdown of the major ethnic groups revealed: Chinese 24%, Filipino 18%, Asian-Indians 16%, Vietnamese 11%, Koreans 10%, and Japanese 8%. According to the 1990 Census, 66% of the Asian-American population was foreign-born, 40% reported that they do not speak English 'very-well', and 25% were in linguistically isolated households. Due to the differences in their ethnic background, language barriers, cultural beliefs, socioeconomic status and distrust in Western medicine, providing care to this population constitutes a formidable challenge for primary care clinicians.

Asian↗

Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies.

A WHO expert consultation addressed the debate about interpretation of recommended body-mass index (BMI) cut-off points for determining overweight and obesity in Asian populations, and considered whether population-specific cut-off points for BMI are necessary. They reviewed scientific evidence that suggests that Asian populations have different associations between BMI, percentage of body fat, and health risks than do European populations. The consultation concluded that the proportion of Asian people with a high risk of type 2 diabetes and cardiovascular disease is substantial at BMIs lower than the existing WHO cut-off point for overweight (> or =25 kg/m2). However, available data do not necessarily indicate a clear BMI cut-off point for all Asians for overweight or obesity. The cut-off point for observed risk varies from 22 kg/m2 to 25 kg/m2 in different Asian populations; for high risk it varies from 26 kg/m2 to 31 kg/m2. No attempt was made, therefore, to redefine cut-off points for each population separately. The consultation also agreed that the WHO BMI cut-off points should be retained as international classifications. The consultation identified further potential public health action points (23.0, 27.5, 32.5, and 37.5 kg/m2) along the continuum of BMI, and proposed methods by which countries could make decisions about the definitions of increased risk for their population.

Absorptiometry, Photon↗

Epigenetic differences between Wilms' tumours in white and east-Asian children.

BACKGROUND: Variations in the international incidence of Wilms' tumour might be due to genetic factors. The maternal insulin-like growth factor 2 gene (IGF2) is imprinted in normal tissues, whereas in some Wilms' tumours and other tumour types the imprint is lost, leading to biallelic transcription of IGF2. We investigated whether the difference in incidence of Wilms' tumour between children of east-Asian descent and white children is due to variations in proportion of tumours with loss of IGF2 imprinting (IGF2 LOI). METHODS: We assessed IGF2 LOI by use of an ApaI polymorphism in IGF2 exon 9 or quantitative PCR measuring DNA methylation of the H19 and KvDMR1 alleles. The frequencies of perilobar nephrogenic rests associated with Wilms' tumour were assessed histologically in Japanese children and children of white and east-Asian descent. FINDINGS: IGF2 LOI was present in Wilms' tumours from predominantly white children from New Zealand (13 of 41 tumours) but absent in tumours from Japanese children (0 of 21 tumours; difference in proportions 0.32, 95% CI 0.07-0.52). Frequency of perilobar nephrogenic rests accompanying tumours from white American children (1192 of 5002, 24%) was significantly higher than in Japanese (one of 56, 1%, difference in proportions 0.22, 95% CI 0.14-0.25) and east-Asian American children (seven of 92, 8%, 0.16, 0.09-0.21). INTERPRETATION: Wilms' tumours in the east-Asian population rarely arise from the IGF2 LOI mechanism frequently noted in white patients. Our findings that IGF2 LOI and perilobar nephrogenic rests associated with this mechanism arise at low frequency in Japanese and east-Asian American children lend support to this conclusion. Variation in frequency of this epigenetic mechanism provides one explanation for the difference in incidence of Wilms' tumour between populations.

Asian People↗

Genetic link between Asians and native Americans: evidence from HLA genes and haplotypes.

We have been studying polymorphisms of HLA class I and II genes in East Asians including Buryat in Siberia, Mongolian, Han Chinese, Man Chinese, Korean Chinese, South Korean, and Taiwan indigenous populations in collaboration with many Asian scientists. Regional populations in Japan, Hondo-Japanese, Ryukyuan, and Ainu, were also studied. HLA-A, -B, and -DRB1 gene frequencies were subjected to the correspondence analysis and calculation of DA distances. The correspondence analysis demonstrated several major clusters of human populations in the world. "Mongoloid" populations were highly diversified, in which several clusters such as Northeast Asians, Southeast Asians, Oceanians, and Native Americans were observed. Interestingly, an indigenous population in North Japan, Ainu, was placed relatively close to Native Americans in the correspondence analysis. Distribution of particular HLA-A, -B, -DRB1 alleles and haplotypes was also analyzed in relation to migration and dispersal routes of ancestral populations. A number of alleles and haplotypes showed characteristic patterns of regional distribution. For example, B39-HR5-DQ7 (B*3901-DRB1*1406-DQB1*0301) was shared by Ainu and Native Americans. A24-Cw8-B48 was commonly observed in Taiwan indigenous populations, Maori in New Zealand, Orochon in Northeast China, Inuit, and Tlingit. These findings further support the genetic link between East Asians and Native Americans. We have proposed that various ancestral populations in East Asia, marked by different HLA haplotypes, had migrated and dispersed through multiple routes. Moreover, relatively small genetic distances and the sharing of several HLA haplotypes between Ainu and Native Americans suggest that these populations are descendants of some Upper Paleolithic populations of East Asia.

Alleles↗

Is South Asian ethnicity an independent cardiovascular risk factor?

People of South Asian origin constitute a large, visible minority in Canada and are known to be at heightened risk for premature coronary artery disease. Conventional risk factors clearly confer risk in South Asians but do not adequately explain their excess risk compared with other populations. Rates of smoking, hypertension and levels of low density lipoprotein-cholesterol tend to be similar or lower in South Asians, although diabetes is more prevalent. Recent studies have suggested that the metabolic syndrome and abdominal obesity may play a causative role in both the prevalence of diabetes and the premature atherosclerosis noted in South Asians. It is possible that genetically susceptible individuals develop abdominal obesity and insulin resistance when exposed to a toxic environment of reduced energy expenditure and increased caloric consumption. This pattern is increasingly noted in parallel with urbanization, suggesting that the increased cardiovascular risk in South Asians may be preventable through lifestyle interventions and the judicious use of medicines to attain optimal levels of blood pressure, lipids and glucose.

Asia↗

Barriers to providing effective mental health services to Asian Americans.

Using the research framework recommended by L. Rogler, R. Malgady, and D. Rodriguez (1989), the current paper examines the barriers to providing effective mental health services to Asian Americans. Beginning with the recognition that Asian Americans consists of numerous heterogeneous subgroups, the issue of the stereotype of Asian Americans as the "model minority" was also discussed. The primary focus of the paper is on Stages 2, 3, and 4 within the Rogler et al. (1989) model and the identification and discussion of cultural factors that hinder the delivery of mental health services to Asian Americans. The paper is therefore organized into these three sections: (a) help-seeking or mental health service utilization, (b) evaluation of mental health problems, and (c) psychotherapeutic services. In each of the sections, not only are the barriers to delivery of effective mental health services discussed but so are the research and methodological problems as well as some directions for future research. This critical review of the literature has been prepared with the goal of serving as a "blueprint" for us to pursue rigorous but relevant research to identify and reduce these cultural barriers to providing effective mental health services to Asian Americans.

Asian↗