Stakeholder views on factors influencing the wellbeing and health sector engagement of young Asian New Zealanders

New Zealand’s demographic profile is changing with notable increases in the diversity of the youth cohort with respect to ethnic and cultural affiliations, languages spoken at home, and countries of birth.¹ In 2013, people identifying with Asian ethnicity comprised the third largest and fastest growing ethnic category and had a higher proportion of youth aged 15–24 years than any other broad ethnic category.² Acknowledging the changing ethnic profile in New Zealand, the Medical Council of New Zealand and the Royal New Zealand College of General Practitioners promote the creation and maintenance of culturally competent doctors and medical practices to facilitate better care, more comfort with the health care system and better health outcomes.^3–5 These efforts largely relate to the Treaty of Waitangi and the Whānau Ora policy, highlighting the relative vacuum of Asian-specific national health policy.

The national youth health surveys conducted among secondary school students in New Zealand identified that although high proportions of Asian students enjoy good health and positive connections with families and schools, disproportionately higher proportions (compared with other major ethnic groups) report depressive symptoms, engaging in unsafe sex, and being victims of bullying and ethnic discrimination.^1,6–11 Asian youth also experience significant difficulties accessing health care,⁸ a finding corroborated by health service providers who acknowledge that Asian families face major challenges negotiating health, ACC and disability support services for their children.¹² Stigmatisation and concerns regarding discrimination and social exclusion due to some health issues, such as mental illness and disability, are also likely to compound these difficulties.^13,14

The ‘Asian’ category is referred to in popular discourse in New Zealand to mean East and South-east Asian, while in the United Kingdom it refers to South Asian peoples. Statistics New Zealand (and the health sector) categorises people from East, South and South-east Asia as ‘Asians’. With countries of origin accounting for more than half the global population, this generalised construction masks the vastly different cultural norms, taboos and degrees of conservatism that exist among Asian cultures. In addition, the migration experiences, social and economic determinants, cultural affiliations, and sources of risk and resilience that could influence their health and wellbeing are highly heterogeneous. Yet routine statistics and published reports typically refer to ‘Asian’ data in aggregate form, denying the opportunity for a more nuanced understanding of the complexities involved.⁷ Consequently, available data are inadequate to inform health service and public policy, and the implications of national health strategies for this increasingly diverse and growing population remain largely invisible.⁷

Current efforts to address healthcare access issues facing Asian communities include cultural competency training for health professionals¹⁵ and the provision of interpreter services.^16–18 To promote and protect consumer rights and meet the vision of the Office of the Health and Disability Commissioner of a consumer-centred healthcare system,¹⁹ a greater understanding of the factors influencing health and healthcare needs of young Asian New Zealanders is required.

The strengths-based philosophy that underpins the Youth Development Strategy for Aotearoa encourages youth-oriented and youth-led research to contribute to youth development.²⁰ In a parallel study conducted among Asian youth in New Zealand, young people expressed particular interest in engaging in processes that can inform more responsive health services.²¹

The current study sought to understand stakeholder views on the key issues that would be most useful to explore in relation to health and wellbeing of young ‘Asian’ New Zealanders and best approaches to research processes that would foster engagement of Asian youth in research that can inform more responsive health services. The findings are discussed in relation to themes identified in the parallel study with similar objectives conducted with Asian youth.²¹

Qualitative methods were used to explore key informants’ views on investigating Asian youth health. A purposive sampling frame drawing on the researchers’ networks was used to identify participants from stakeholder groups. The six stakeholders were selected with the expectation that each participant with defined interests in the health of Asian or migrant communities will provide unique and rich information to the study (Table 1). Given the study aims, expert sampling was used.

Table 1. Participant demographics

The interviews were primarily focused on the health and wellbeing of young Asian New Zealanders and ways to engage Asian youth in research that seeks to address gaps in current health services. In-depth face-to-face semi-structured interviews were conducted using the following prompts: What information do you think would be most useful to explore?; What would help recruit and engage Asian youth in research?; What would be the expected outcomes?; What would be the best approach to disseminate findings?

Interviews lasting 60 to 90 min were audio-recorded and transcribed by an external transcriber. The transcripts were coded and analysed using the general inductive approach to reflect frequently reported patterns.²² The inductive approach enables extensive and varied raw data to be condensed into a brief summary format and to establish links between the research objectives and the summary findings. This approach was selected as it was considered important that the analysis of qualitative study data was guided by the focused evaluation objectives.

Two authors (RP-J, AS-M) reviewed and coded the transcripts to identify key themes. Specific themes that captured the stakeholders’ perceptions of core elements as relevant to conducting research on health and wellbeing of Asian youth in New Zealand are presented with anonymized illustrative quotes.

Ethical approval for the study was obtained from the Human Participants Ethics Committee, University of Auckland (Reference 8778). Participants provided informed written consent.

Six interviews were conducted with stakeholders (two South Asian, three East Asian and one New Zealand European). The six stakeholders included opinion leaders in the Asian academic field, key decision-makers in planning health services and leaders in Asian community organisations. The analyses identified priority areas for research on ‘Asian’ youth health (cultural identity, integration and acculturation, and barriers to help-seeking) and approaches to research (youth voice, empowerment and participatory approach to research; parental influence and involvement in health research; confidentiality and anonymity; capacity building and informing policy).

Difficulties faced in relation to cultural identity and finding a balance between cultures was an overarching influence on the health of young Asians. Most stakeholders discussed these in terms of conflicts faced by young Asians during socialisation, particularly having to balance parental expectations with living among other cultures in New Zealand, as demonstrated in the comment below:

I think friction, perceptions, understanding, rules, expectations from parents’ generation to children who may have come as infants or slightly older.... and there’s enough information around, that talks about kids being one person at home and then another person out in the community. (#2)

Negative consequences of acculturation (the process by which members of one cultural group adopt the beliefs and behaviours of another group) were discussed in terms of changes in dietary habits and the consequent increase in non-communicable disease, alcohol use, and smoking habits among Asian youth.

Young people living with disabilities and their parents were identified as among the most marginalised and vulnerable families, needing extra support to navigate health services:

Even to mainstream families disability is a foreign language ...... and Asian parents from different cultural background and as non-native speakers of English have a double whammy as it is called, so in most cases they are not quite included in the service. (#6)

Sexual health issues among young Asians were emphasised by all stakeholders and discussed in terms of intergenerational issues they face, sexual freedom that comes with living in a Western society, accessing sexual and reproductive health services, and abortion. Sexuality and sexual health are not talked about openly in most Asian homes and the consequences of young people being unable to talk to their parents about it when faced with issues was observed. One participant identified poor access to sexual health services to have an impact on the abortion rates among young Asians:

We are seeing disproportionate prevalence of termination of pregnancy among Asian women which suggests poor access to sexual and reproductive health services. (#2)

Commenting on likely explanations, one of the inter-generational influences on poor access to sexual, reproductive and mental health services among Asian youth was perceived to be a lack of awareness brought about by difficulties parents face due to language barriers and their inability to navigate an unfamiliar health care system in New Zealand.

Poor access among youth was also attributed to issues around privacy and confidentiality of information within the context of relatively small and close-knit communities that are also aspiring to live up to ‘model minority’ concepts, being commonly perceived as hardworking, high achieving, and free of psychological problems. One participant noted:

There’s of course the community face and maintaining a community face..... if you go into services these days we’ve got a number of Asian people working in our services, which is positive, but also there’s that thing of oh my gosh I’ve run into her she’s going to report back to my aunty, the network is alive and kicking in the Asian communities. (#3)

A key concept that came across all interviews is to involve young people throughout the duration of the research, building rapport, gaining trust and empowering them in the process.

A participatory action approach is really useful.... give them some skills around being in the interviews and maybe doing some of the interviews themselves, helping with some of the analysis, writing up some of the reports. (#3)

Just making sure the participants are walking alongside you in that journey, that you’re kind of not doing the leading and the dragging. (#3)

Some stakeholders also noted the need to use innovative approaches, keeping it simple and fun and using incentives that promote youth engagement. While some suggestions were financial or in-kind support (e.g. coupons), opportunities for networking (with peers, researchers and wider groups), skills development, and receiving job references were suggested as important means of engaging youth.

Providing an opportunity to hear youth voices at all stages was emphasised. Youth research participants need opportunities to validate and reflect on findings as well as to disseminate findings to community and policy makers:

It would be quite interesting to hear young people’s reflections on the findings of the research too. You’ll sort of triangulate the study and kind of check that this is reflecting what they’re saying and what they think are the priorities. (#2)

I think if we really want to make change and get this stuff disseminated then it’s about using the youth and using their voice because they’re active, they do want to make themselves heard. (#3)

While not countering the importance of actively engaging youth in research, one participant added a cautionary note on the need to manage expectations of quick response to findings:

They expect to see change now and you know, you get that in the technological age where everything does happen so quickly, so I think, it’s just being mindful of working with youth that that’s probably not going to happen so quickly, but it doesn’t mean that the voice is being lost or that it’s not important or that they’re not going to benefit from this in some ways. (#3)

The relationships with and influences of families were perceived to play an important role in young people’s health and wellbeing. The need to involve parents in research and the need to disseminate findings to parents was therefore considered to be particularly important.

I think it’s really ideal to have parents involved because they’re the other side of the intergenerational issues. (#2)

We need to let their parents know what some of the concerns and issues are, integration issues, the problems that they have with their peers and so on. (#1)

However, the need to involve youth in making the decision to engage parents in the study in a way that is safe and respectful to them was highlighted by most stakeholders.

Having the discussion and saying well these are our reasons why we think it (involving parents) would be useful, how would we go about doing that, and again being transparent. (#3)

All participants observed that confidentiality and anonymity were likely to be important concerns for Asian youth who perceive their communities to be small and close-knit. Selection of who will conduct the interviews was considered important to gain the confidence of young participants. Providing participants a choice about who will conduct the interviews was suggested as a way forward:

Because if they’re in a small community and it’s a sensitive issue like mental health, sexual health, family violence, they absolutely do not want that person, even though that person’s bound by confidentiality, to know what’s going on in their family....The participants have to be reassured that their information is anonymised and strictly confidential. (#2)

To balance these concerns while exploring their difficulties, a clear plan to protect youth and manage disclosure was indicated as a key priority:

Peer pressure, esteem, the stigma, the bullying, all of that stuff can go on so I think it’s just about being really mindful about, how youth are going to be protected but still be able to have that voice, so that this is robust research that goes out there and says look this is the real need. (#3)

There’ll be a subset of youth who are at risk for various reasons: who have sensitive issues, who might be at risk of teenage pregnancy, who are in home situations where there’s violence going on, sexual abuse possibly. So you’re going to have to have a clear plan for how you manage disclosure that’s at risk ..... you will need to have counselling backup, you’ll need to refer on, you need to know about plan of safety for those young people. (#2)

The main research outcomes envisaged were building community leaders and change makers, identifying gaps or unmet needs, heightening awareness and developing recommendations to inform policy.

I think it is about ...... building communities who are wanting to action change as well through the youth by engaging them in this process and getting them to drive some of this research, and bringing parents on board, bringing in the community so I think it can have real community growth as well. (#3)

Well I think more broadly across society, it’s about heightening awareness, actually saying look this is a growing community within our population and wider society. Asian youth are growing in numbers and these are their needs and this is their voice so I think it is about bringing societal awareness to the issue. (#3)

While racism and racial discrimination was not identified as a key theme, one participant referred to associated experiences in commenting:

They have challenges, especially their mental health, in terms of the perceptions people have in the wider society, so again that notion that ....... so you look Chinese or you look Indian... and they always look a bit surprised when gosh you speak with a kiwi accent, so you’re challenged with that stuff all the time and that can wear you down after a while. (#3)

The themes identified in this qualitative study of stakeholders experienced in responding to the needs of Asian youth reveal several areas that deserve greater attention when providing responsive primary health care and community-based preventive services. Issues of particular concern were complexities relating to cultural identity, challenging social relationships, and unmet needs in disability, mental and sexual health. Engaging Asian youth in research that is respectful of their privacy, cultural norms and health needs was considered integral to obtaining robust knowledge while also empowering youth to speak up, building capacity to action change and influence policy and decision-making.

The influences on health and wellbeing of Asian youth identified in this study, such as cultural and other barriers to help seeking and health service utilisation including primary health services affirm evidence from national surveys of secondary school students^1,8,9 and reports on Asians living in Auckland¹⁴ and in New Zealand.^23,24 The findings from this study are also broadly consistent with themes identified in a parallel study with similar objectives conducted among Asian youth.²¹ In particular, young Asians advocated for and expressed a strong interest in engaging in health research addressing current barriers to accessing services. Both studies directly or indirectly highlighted challenges relating to cultural identity and issues around acculturation, difficulties in addressing mental health concerns, the importance of including parents in the discussion and the need for breaking down barriers and the unhelpful concept of the ‘model minority’ forced on young people and their families.

Stakeholders in this study raised concerns related to intergenerational issues and accessing sexual and reproductive health services among Asian young people. The lack of knowledge of New Zealand’s health care system and concerns around access to private and confidential healthcare in the context of relatively small and close-knit communities were perceived to contribute to poor health care access. The statistics and explanations about abortion rates among Asians in New Zealand is a highly contested topic.^25,26 However, the need for recognising a multiplicity of perspectives and addressing unmet health service needs is widely acknowledged.^25–27 It is intriguing that concerns relating to sexual health were not specifically commented on in the youth study,²¹ which may reflect their discomfort discussing this sensitive topic in one-off focus group meetings, each including boys and girls. Although not raised in this study, the lower rates of sexual health checks and HIV screening among same-sex attracted, bi-sexual or transgender young Asians in New Zealand highlights the need for social and health care environments that are safe for people of all ethnic groups, including Asian, to discuss their sexual behaviour and health and receive the necessary care without fears of discrimination.^28,29

The stakeholders in this study discussed the importance of engaging young people in the research process over a period of time, enabling them to become familiar with the people with whom they share their views, a sentiment voiced by the young participants as well.²¹ This is consistent with a growing body of knowledge supporting the benefits of hearing young people’s voice in identifying their health issues and in developing appropriate solutions.^30–32

Although different methodologies are used in research with young people, participatory methodologies are increasingly employed. However, the need for more meaningful intergenerational research that is collaborative, inclusive and empowering is advocated.³¹ The feedback from stakeholders reinforces views of youth on how intergenerational issues can be explored with appropriate sensitivity, safety and respect for all involved, including parents.²¹

Although racism and racial discrimination were felt strongly by the youth participants in the parallel study²¹ and have been previously reported to be significant factor influencing the wellbeing of young Asians in New Zealand,³³ it was not a significant finding in this study. Racism and discrimination are not new ideas, but the significance of their influence on the health and wellbeing of ethnic minority youth in New Zealand has received attention only relatively recently.^9,34 Despite racism being increasingly implicated in known disparities in health and healthcare among ethnic minority groups, and its being raised as an ethical issue in health care,³⁵ denial of racism by healthcare providers is common.^36,37 Unless there is acknowledgment and investment in efforts to deal with racism and racial discrimination, the disparities in health and healthcare will remain difficult to prevent or address.^9,38

This was a study of six stakeholders who were opinion leaders and key decision makers on Asian youth health from the academic field, in health service planning and community organisations. The small number of participants in this study may have contributed to the lack of reference to racism and racial discrimination by the stakeholders. It is not clear if the findings are pertinent to both first and second generation Asian immigrants as this was not clarified in the interviews and therefore care is required when interpreting findings. Compared to their non-immigrant counterparts, first generation immigrants in secondary schools in New Zealand reported lower risks of alcohol consumption and marijuana use, although second generation immigrants had similar risks.³⁹ While it is uncertain if data saturation was achieved, the key themes reported were common to all interviews. This together with the parallel study conducted with Asian youth provide a rich dataset on the factors influencing the wellbeing of young Asian New Zealanders, and their perceptions on engaging in health research.

Although New Zealand youth use a variety of services including school health clinics, family planning and youth-specific health services, most use general practitioners as their first point of contact.⁴⁰ While recent reviews have highlighted examples of initiatives to improve primary care for young people in New Zealand, the need to address inequitable access is highlighted.^41,42 At the core of this effort should be a concerted effort to actively engage young Asians, their families, and primary care health professionals to collaborate on research and co-design responsive health services.