JMIR FORMATIVE RESEARCH

Shi et al

Original Paper

Characterizing Mental Health Status and Service Utilization in
Chinese Americans With Type 2 Diabetes in New York City:
Cross-Sectional Study
Yun Shi1,2, PhD; Bei Wu3, PhD; Nadia Islam1, PhD; Mary Ann Sevick1,4, SCD; Amanda J Shallcross5, MPH, ND;
Natalie Levy1, MD; Kosuke Tamura6, PhD; Han Bao7, MD; Ricki Lieu1,2,8, BA; Xinyi Xu1,2, BS; Yulin Jiang1,2, BS;Lu Hu1,2, PhD
1

Department of Population Health, New York University Grossman School of Medicine, New York University Langone Health, New York, NY, UnitedStates2

Center for Healthful Behavior Change, New York University Grossman School of Medicine, New York University Langone Health, New York, NY,
United States
3

New York University Rory Meyers College of Nursing, New York, NY, United States

4

Department of Medicine, New York University Grossman School of Medicine, New York University Langone Health, New York, NY, United States

5

Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, United States

6

Socio-Spatial Determinants of Health Laboratory, Population and Community Health Sciences Branch, Division of Intramural Research, National
Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, United States
7

Jacobi Medical Center, Bronx, NY, United States

8

Creighton University School of Medicine, Omaha, NE, United States

Corresponding Author:
Lu Hu, PhD
Center for Healthful Behavior Change
New York University Grossman School of Medicine
New York University Langone Health180 Madison Ave
7th floor
New York, NY, 10016
United States
Phone: 1 6465013438
Email: lu.hu@nyulangone.org

Abstract
Background: Emerging evidence indicates that individuals with type 2 diabetes (T2D) are more prone to mental health issues
than the general population; however, there is a significant lack of data concerning the mental health burden in Chinese Americans
with T2D.
Objective: The aim of this study was to explore the comorbid mental health status, health-seeking behaviors, and mental service
utilization among Chinese Americans with T2D.
Methods: A cross-sectional telephone survey was performed among 74 Chinese Americans with T2D in New York City. We
used standardized questionnaires to assess mental health status and to gather data on mental health–seeking behaviors and service
utilization. Descriptive statistics were applied for data analysis.
Results: A total of 74 Chinese Americans with T2D completed the survey. Most participants (mean age 56, SD 10 years)
identified as female (42/74, 57%), were born outside the United States (73/74, 99%), and had limited English proficiency (71/74,96%). Despite nearly half of the participants (34/74, 46%) reporting at least one mental health concern (elevated stress, depressive
symptoms, and/or anxiety), only 3% (2/74) were currently using mental health services. Common reasons for not seeking careincluded no perceived need, lack of information about Chinese-speaking providers, cost, and time constraints. The cultural andlanguage competence of the provider was ranked as the top factor related to seeking mental health care.

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Shi et alConclusions: Chinese Americans with T2D experience relatively high comorbid mental health concerns yet have low service
utilization. Clinicians may consider team-based care to incorporate mental health screening and identify strategies to provide
culturally and linguistically concordant mental health services to engage Chinese Americans with T2D.
(JMIR Form Res 2024;8:e59121) doi: 10.2196/59121
KEYWORDS
mental health; diabetes distress; depression; anxiety; service utilization; psychological distress; type 2 diabetes; diabetes; UnitedStates; mental health burden; Chinese American; cross-sectional; telephone survey; stress; depressive symptoms; mental healthcare; mental health screening

Introduction
Type 2 diabetes (T2D) is a growing public health concern within
the Chinese American community [1]. Recent epidemiological
data have brought to light the startling prevalence of T2D among
Chinese Americans, with 13.3% of this population diagnosed
with T2D and an additional 33.8% classified as having
prediabetes [2]. These statistics are especially worrisomeconsidering that Chinese Americans constitute one of thefastest-growing immigrant populations in the United States,making up the largest Asian demographic with a population
exceeding 5 million [3,4]. In comparison to their non-Hispanic
White counterparts, Chinese Americans face distinct challenges
with managing diabetes, including higher rates of poverty,
limited English proficiency, and limited access to health careservices [5,6]. This underscores the pressing need for research
efforts to mitigate these disparities and improve diabetes
management within the Chinese American community.
Accumulating evidence suggests that individuals with T2D havea higher likelihood of experiencing mental health issues suchas depression, anxiety, and distress compared to those without
T2D [7]. Among patients with T2D, those experiencing mental
health issues are more likely to exhibit suboptimal adherence
to diabetes self-care behaviors and poorer glycemic control
compared to their counterparts without such issues [8,9].
Therefore, there are increasing calls from national organizations
such as the American Diabetes Association and the Associationof Diabetes Care and Education Specialists to screen for mental
health issues and integrate mental health into diabetes care
[10,11].

both past and current health-seeking behaviors of these
individuals, identified barriers to accessing mental healthservices, and evaluated preferences for mental health care. This
report serves as an important first step to provide criticalformative data to understand the mental health challenges facedby Chinese Americans with T2D and to inform the developmentof more effective, culturally sensitive interventions to address
comorbid mental health and T2D burden in underserved
communities.

Methods
Study Design
This cross-sectional survey was conducted as an ancillary study
to a pilot randomized controlled trial testing the potential
efficacy of a culturally tailored text messaging–based diabetes
intervention to improve glycemic control in Chinese Americans
with T2D [13]. The survey data were collected in New York
City between October 2022 and January 2023. Standardized
questionnaires were used to collect data on participants’ mental
health status, mental health–seeking behaviors, and demographic
information. Study materials were available in both English andMandarin Chinese. A bilingual community health worker
administered the surveys over the phone in the participant’s
preferred language. To minimize participant burden, we opted
for a phone-based survey over in-person interviews or online
surveys. This approach is particularly well-suited for our target
population of low-income, aging Chinese Americans withlimited education and digital literacy, as phone surveys offer
greater accessibility and inclusivity compared to the other two
methods.

Cultural context significantly influences mental health–seeking
behaviors and service utilization. For instance, in Chinese
culture, mental health conditions are often stigmatized, leading
to reluctance to discuss these issues or seek professional help
[12]. This cultural barrier contributes to a significant gap in
understanding the mental health burden among Chinese
Americans with T2D, including their mental health status andhealth-seeking behaviors. The lack of data on these aspects
hampers efforts to highlight the critical need for tailored mental
health services in this underserved community, making it
imperative to address these informational gaps to improvediabetes care outcomes.

Ethical Considerations

Therefore, the aim of this study was to bridge critical knowledge
gaps by assessing the comorbid mental health burden of Chinese
Americans with T2D, including levels of depression, anxiety,general stress, and diabetes-specific stress. We also investigatedParticipants were recruited from a registry comprising Chinese
Americans with T2D who had previously taken part in diabetesstudies led by the same study team. These earlier studies usedcommunity-based participatory research methods and partneredhttps://formative.jmir.org/2024/1/e59121

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The study protocols were approved by the Institutional Review
Board (IRB) of the New York University Grossman School of
Medicine (s18-00609). Informed consent was obtained from allparticipants prior to their involvement in the study. During thecall, a community health worker read the IRB-approved
telephone consent script and obtained verbal consent. The entire
process was recorded. The data were deidentified for analysis.
Participants received a US $20 gift card after completing thesurvey.

Participants

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with several community-based organizations to evaluate mobile
health interventions that were culturally and linguisticallytailored to enhance glycemic control in low-income Chinese
Americans with T2D [13-15]. The general inclusion criteria
were as follows: (1) self-identified as Chinese American, (2)aged 18 years or older, (3) ability to speak and understandMandarin or English, (4) self-reported or medical diagnosis of
T2D, and (5) currently living in their homes and self-managing
T2D at home. Exclusion criteria were individuals who wereunable or unwilling to provide informed consent and those who
had gestational diabetes. Further details regarding the inclusionand exclusion criteria for the study have been reported elsewhere[13,14].

Measures
Mental Health Status
We used four standardized questionnaires to measureparticipants’ mental health status. The 9-item Patient Health
Questionnaire (PHQ-9) [16], Hospital Anxiety and Depression
Scale Anxiety Subscale (HADS-A) [17], Perceived Stress Scale(PSS) [18], and Diabetes Distress Scale (DDS) [19] were used
to measure depressive symptoms, anxiety, general stress, anddiabetes-specific distress, respectively. All these questionnaires
are available in Chinese and have been validated among the
Chinese population [20-23]. The PHQ-9 has a score range of 0
to 27, with higher scores indicating more severe depressive
symptoms. A PHQ-9 score of 0-4, 5-9, 10-14, 15-19, or ≥20
indicates no, mild, moderate, moderately severe, or severe
depression, respectively [24]. A score ≥10 indicates a significant
risk for major depression [24]. The HADS-A has a score rangeof 0 to 21, with higher scores indicating more severe anxiety
symptoms. A score of 0-7, 8-10, or ≥11 on the HADS-A scale
indicates normal, borderline abnormal, or abnormal anxiety,respectively [17]. The PSS has a score range of 0 to 40, withhigher scores indicating higher perceived stress. A score of
0-13, 14-26, or ≥27 indicates low, moderate, or high stresslevels, respectively [25]. The DDS has a score range of 1 to 6,

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Shi et alwith higher scores indicating higher diabetes-specific distress.
A total score ≥2 indicates a moderate or higher distress level
and is considered clinically important [26].

Mental Health–Seeking Behavior
We used an investigator-developed questionnaire to collectinformation regarding participants’ mental health service use
and health-seeking behavior, including whether they had amental health–related diagnosis, whether they had seen a mental
health provider in the past 12 months, whether they werecurrently seeking mental health services, reasons for not seeing
a provider, coping strategies for stress, preferences for mental
health services, and factors to consider when seeking mental
health services.

Statistical Analysis
We performed descriptive analyses for all variables, reporting
frequencies and percentages for categorical variables and means
with SDs for continuous variables. To evaluate the internalconsistency of the standardized questionnaires, we computed
Cronbach α coefficients. We used R version 4.2.1 [27] for data
analysis.

Results
Demographic Characteristics of Participants
Data from 74 Chinese Americans with T2D were analyzed inthis study. As shown in Table 1, most participants (mean age
56, SD 10 years) identified as female (42/74, 57%), were born
outside the United States (73/74, 99%), were currently married(57/74, 77%), had a high school education or less (56/74, 76%),and had a household annual income <US $25,000 (49/74, 66%).
Approximately 18% (13/74) of the participants were
unemployed and 58% (43/74) had Medicaid health coverage.
On average, participants have been residing in the United Statesfor 18 (SD 11) years, although 96% (71/74) of them had limited
English proficiency.

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Shi et al

Table 1. Demographic characteristics of participants (N=74).
Characteristics

Value

Age (years), mean (SD)a56 (10)Female sex, n (%)

42 (57)

Currently married or cohabitating, n (%)

57 (77)

Education level, n (%)
Less than high school

29 (39)High school graduate

27 (37)More than high school

18 (24)

Annual income (US $), n (%)<25,00049 (66)≥25,000

23 (31)

Declined to answer or don’t know

2 (3)Employment status, n (%)
Employed

45 (61)

Not employed, not working

13 (17)Retired16 (22)

Insurance type, n (%)

ab

Private insurance

7 (9)Medicaid

43 (58)

Medicare16 (22)Other types of public/government insurance

15 (20)No insurance

6 (8)Born outside United States, n (%)

73 (99)Limited English proficiency, n (%)

71 (96)

Duration of US residency (years), mean (SD)c

18 (11)

Owing to missing values, the sample size is 73.

bParticipants were asked to select all insurance types they possessed (ie, “check all that apply”).

cOwing to missing values, the sample size is 72.

Mental Health Status
Table 2 displays the mental health status of the participants.
Among the 74 participants in the study, 46% (34/74) had atleast one mental health concern, which included 9% (7/74) witha diagnosis of either major depression or anxiety disorders

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before study entry and an additional 36% (27/74) with either
elevated stress, depressive symptoms, or anxiety. Specifically,
27% (20/74) had moderate or higher levels of general stress,
26% (15/57) had moderate or higher levels of diabetes-specificdistress, 9% (7/74) reported mild or higher levels of depressive
symptoms, and 7% (5/74) had borderline or abnormal anxiety.

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Shi et al

Table 2. Mental health status of the participants (N=74).
Mental health status

Participants, n (%)

Self-reported mental health-related diagnosis, n (%)

Cronbach α

—a

—

No

67 (91)—

Yes (depression or anxiety)

7 (9)

—

Major depression

4 (5)

—

Anxiety disorders

3 (4)

—

Depressive symptoms (PHQ-9b level), n (%)

0-27

No

67 (91)

0-4

Mild

4 (5)

5-9

Moderate

2 (3)

10-14

Moderate-severe

1 (1)

15-19

Severe

0 (0)

20-27

Anxiety (HADS-Ac level), n (%)

0-21

Normal69 (93)0-7

Borderline abnormal

3 (4)

8-10

Abnormal

2 (3)

11-21

Perceived stress (PSSd level), n (%)

0-40

Low

54 (73)0-13Moderate

19 (26)

14-26

High

1 (1)

27-40

Diabetes distress (DDSe level), n (%)faPotential score range

1-6

Moderate to higher distress

15 (26)2-6

Low distress

42 (74)

1

0.82

0.79

0.56

0.92

Not applicable.

b

PHQ-9: 9-item Patient Health Questionnaire.

c

HADS-A: Hospital Anxiety and Depression Scale Anxiety Subscale.

d

PSS: Perceived Stress Scale.

e

DDS: Diabetes Distress Scale.

f

The sample size for diabetes distress is 57.

Mental Health–Seeking Behaviors
As shown in Table 3, only 7% (5/74) of the participants reported
ever having seen a mental health professional and 3% (2/74)
were currently seeking mental health services. Not seeking
mental health services was attributed to no perceived need
(69/74, 93%), lack of information about Chinese-speaking
providers (3/74, 4%), cost (1/74, 1%), and time constraints(1/74, 1%). Participants managed stress through various means

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such as listening to music/watching TV (52/74, 70%), engaging
in physical activities (20/74, 27%), or talking to family andfriends (26/74, 35%). Concerning preferences for the format ofmental health services, most participants favored individual
sessions (28/74, 38%) and in-person consultations (32/74, 43%).
The three primary factors participants considered when seeking
mental health services were the cultural and language
competence of the provider (26/74, 35%), confidentiality (16/74,22%), and cost (13/74, 18%).

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Table 3. Health-seeking behaviors (N=74).
Health-seeking behaviors

Participants, n (%)

Have seen a provider in the past 12 months

5 (7)Currently seeking mental health services

2 (3)Talk to a therapist

1 (1)See a psychiatrist

1 (1)Taking medication

1 (1)Reasons for not seeking mental health services
No need69 (93)Lack of information about Chinese-speaking providers

3 (4)

Cost

1 (1)

Don’t have time

1 (1)Stigma0 (0)Transportation barriers

0 (0)Strategies to cope with stress
Listen to music/watch TV/entertainment

52 (70)

Talk to family/friends

26 (35)

Physical activity/exercise

20 (27)

No stress

5 (7)Drinking

2 (3)Seek help from mental health providers

1 (1)Meditation

1 (1)Smoking

1 (1)Binge eating

1 (1)Keep silence

1 (1)

Sleep

1 (1)

Mental health services preference
Individual

28 (38)Group

9 (12)Neither. I don’t want to use mental health services

25 (34)Either12 (16)

Mental health services format preference
In-person

32 (43)Don’t want to use mental health services

20 (27)Phone

12 (16)

Any format

8 (11)

Video-based

2 (3)Factors to consider when seeking mental health services
A provider that understands my language/culture

26 (35)

Confidentiality

16 (22)Cost

13 (18)

Access7 (9)Close to home

5 (7)Flexibility

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Health-seeking behaviors

10 (14)

No need8 (11)

Qualified doctor

1 (1)No idea

1 (1)Principal Findings
To the best of our knowledge, this is the first study to examine
the comorbid mental health status and health-seeking behaviors
among Chinese Americans with T2D. Nearly half (34/74, 46%)of the participants had mental health concerns. However, only
7% (5/74) have previously sought help from a mental healthprofessional, while 3% (2/74) were using mental health services.
The major reasons for not seeking mental health services wereno perceived need (69/74, 93%), lack of information about
Chinese-speaking providers (3/74, 4%), cost (1/74, 1%), andtime constraints (1/74, 1%).
Our results indicate a high prevalence of mental health issues
among Chinese Americans with T2D. This prevalence rate ishigher than the rates reported in another study; according to asecondary data analysis using information from the 2019 US
Medical Expenditure Panel Survey, the rates of mental healthburden were 25.7% in White participants, 14.9% in Blackparticipants, 12.8% in Hispanic participants, and 10.2% in
Asian/Native Hawaiian participants [28]. Our higher percentage
may be due to the fact that the study based on national data
focused only on self-report diagnoses of mental health issues,
whereas our study included self-reported diagnoses plus thescreening results of elevated levels of depressive symptoms,
anxiety, general stress, and diabetes-specific stress. Notably,
our findings based on self-reported mental health–related
diagnoses (7/74, 9%) align closely with the findings fromnational data (10.2%).
Despite a relatively high mental health burden, our participants
reported a low use rate and perceived no need to seek mental
health services. These findings align with previous studies
reporting that Chinese Americans may view mental healthsymptoms as negative emotions rather than a disorder and arethus less likely to seek professional help [29]. This could be
attributed to traditional Chinese values of viewing negative
emotions as “part of life,” accepting destiny, and withstanding
hardship [30]. These cultural influences can contribute to theunderrecognition of mental health issues and further prevent
health-seeking behaviors.
Other studies have previously identified stigma as a significant
contributor to the underutilization of mental health services
among Chinese adults [12]. Surprisingly, none of ourparticipants reported stigma as a barrier to mental
health–seeking. This finding could be related to social
desirability bias, where participants might deny their stigmatized
perceptions of mental health services to conform to societal
expectations. In subsequent focus group discussions, participantsbrought up the stigma surrounding mental health within Chinese
communities. Another piece of evidence that supports why our
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Participants, n (%)

OthersDiscussion

XSL• FOShi et alpatients did not report stigma as a barrier is our finding thatparticipants ranked confidentiality, a factor often associatedwith stigma, as the second most important consideration inseeking mental health services. This emphasis on confidentiality
suggests an underlying concern, indicating that althoughparticipants may not have reported stigma, their fear of mental
health service usage disclosure may serve as a significant
stigma-related barrier to mental health service access.
Additionally, our participants indicated a key barrier to seeking
mental health services: the lack of information about providers
proficient in their language and cultural context. This findingis largely because Chinese Americans do not feel comfortablespeaking to a mental health professional who does not share thesame cultural background or speak the same language [31]. Thishighlights a gap in the system where the dearth of culturallycompetent providers leads to a reluctance to seek necessary
mental health services. Indeed, our findings reveal that thepresence of a culturally and linguistically competent provider
is the most frequently attributed factor Chinese Americans with
T2D consider when seeking mental health services.
Consequently, these findings emphasize the urgent need toembrace cultural competency and intervention adaptation tomeet the unique needs of diverse populations.

Strengths and Limitations
To our knowledge, this study is the first to describe the comorbid
mental health burden and health-seeking behaviors in Chinese
Americans with T2D. By addressing this significant gap, ourstudy lays the foundation for future investigations andinterventions that target the mental health and diabetes
management needs of this particular minoritized group. In
addition, we used a community-based participatory research
design and included many low-income Chinese Americans withlimited English proficiency, who are often understudied andnot included in large national data sets due to language barriers.
This study thus provides critical preliminary data on thisunderserved population.
There were several limitations of our study. First, the sample
size was relatively small with all participants recruited fromNew York City, which may limit the generalizability of ourfindings to the broader Chinese American community. Factors
such as access to Chinese-speaking health care providers andcommunity support may vary significantly across different
regions of the United States. Furthermore, the participants ofthis study had previously taken part in our prior research studies,potentially biasing our sample toward individuals more inclined
to seek care. This suggests that the mental health status andunderutilization of mental health services could be even more
pronounced in the broader population. While two of our recent
studies used electronic medical records to confirm the T2D
diagnosis [14,15], one of our earlier studies relied on a
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self-reported diagnosis of T2D [13]. In addition, our study reliedon self-report measures and there may be inherent biases andlimitations associated with self-reported data, such as social
desirability bias or recall bias. For example, participants may
conceal their previous diagnosis or mental health service use
due to stigma and/or feelings of shame. Future studies could
incorporate electronic medical records or use multiple sourcesof data to overcome these limitations to provide a morecomprehensive understanding of the mental health status andhealth-seeking behaviors among Chinese Americans with T2D.

Shi et alConclusions
Mental health issues among Chinese Americans with T2D are
prevalent, yet their utilization of mental health services remains
strikingly low. This discrepancy can be attributed to several
factors, including the low perceived need for mental healthsupport and the lack of knowledge of culturally and linguisticallycompetent providers. To address this issue, it is imperative toincorporate mental health screening into comprehensive T2D
care and raise awareness of mental health issues within thispopulation. Moreover, the development and implementation ofculturally tailored interventions are crucial to effectively reachand engage Chinese Americans in mental health treatment.

Acknowledgments
LH received support from the National Institutes of Health (NIH) (grants R01MD017579-01A1, K99MD012811, and
R00MD012811), Agency for Healthcare Research and Quality (grant R18HS029813), American Diabetes Association(7-22-ICTSN-08), and NIH pilot awards (P50MD017356, U54MD000538-15, and P30DK111022). Funding for the Socio-Spatial
Determinants of Health (SSDH) Laboratory is provided through the Division of Intramural Research at the National Institute on
Minority Health and Health Disparities (NIMHD), the NIH, and the NIH Distinguished Scholars Programs. The views of thisstudy are those of the authors listed and do not necessarily represent the views of the National Institute on Minority Health and
Health Disparities, NIH, or the US Department of Health and Human Services. We used ChatGPT to enhance the English language
and clarity of this manuscript. However, it was not used for study design, content generation, or any other aspects of the research.

Data Availability
The data presented in this study are available on request from the corresponding author.

Authors' Contributions
YS was responsible for data curation, formal analysis, and writing the original draft of the manuscript. BW, NI, MAS, and AJS
contributed to study conceptualization, investigation, methodology, and supervision. RL and XX contributed to data curation.
YJ participated in data curation and project administration. LH was responsible for study conceptualization, data curation, funding
acquisition, investigation, methodology, project administration, supervision, and writing the original draft of the manuscript. All
authors contributed to review and editing of the manuscript.

Conflicts of Interest
None declared.

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Abbreviations
DDS: Diabetes Distress Scale
HADS-A: Hospital Anxiety and Depression Scale Anxiety Subscale
IRB: Institutional Review Board
PHQ: Patient Health Questionnaire
PSS: Perceived Stress Scale
T2D: type 2 diabetes

Edited by A Mavragani; submitted 03.04.24; peer-reviewed by J Ruan, Q Wang; comments to author 24.04.24; revised version received
14.05.24; accepted 05.06.24; published 02.07.24
Please cite as:
Shi Y, Wu B, Islam N, Sevick MA, Shallcross AJ, Levy N, Tamura K, Bao H, Lieu R, Xu X, Jiang Y, Hu L
Characterizing Mental Health Status and Service Utilization in Chinese Americans With Type 2 Diabetes in New York City:
Cross-Sectional StudyJMIR Form Res 2024;8:e59121
URL: https://formative.jmir.org/2024/1/e59121
doi: 10.2196/59121
PMID:©Yun Shi, Bei Wu, Nadia Islam, Mary Ann Sevick, Amanda J Shallcross, Natalie Levy, Kosuke Tamura, Han Bao, Ricki Lieu,
Xinyi Xu, Yulin Jiang, Lu Hu. Originally published in JMIR Formative Research (https://formative.jmir.org), 02.07.2024. Thisis an open-access article distributed under the terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information,a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

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