Application of the Health Belief Model to Explain ADHD Service Under-Utilization in Asian Emerging Adults
Creators: name: Goh, Patrick
Publisher: name: OSF Registries
Year: 2024
Subjects: subject: Clinical Psychology
subject: Social and Behavioral Sciences
subject: Psychology
subject: FOS: Psychology

description: Although there appear to have been recent increases in diagnostic and treatment service utilization (Aluri et al., 2023), studies have suggested that fewer than 20% of emerging adults with ADHD receive these services. Underutilization of such services has been associated with lower grade point averages, greater academic and social impairment, and increased risk for substance use and suicide (Blasé et al., 2009; Eddy et al., 2020; Sedgwick, 2018; Fleming &amp; McMahon, 2012). Given such findings suggesting unmet needs in individuals with ADHD (Le et al., 2023), additional research is needed to identify and clarify the role of different factors impacting service utilization rates in those with ADHD symptoms, particularly in populations where such under-utilization of services has been particularly severe. 

Individuals with ADHD from racially and ethnically minoritized populations in the United States remain under-treated compared to their White peers (Slobodin &amp; Masalha, 2020), with one of the biggest disparities emerging for those who identify as Asian. Asians are the fastest-growing racial and ethnic group in the United States (Shimkhada &amp; Ponce, 2022), and currently represent almost 8% of the college population (U.S. Department of Education, 2021). Yet, studies in this area have also suggested that they are among the least likely of any racial or ethnic group to receive services for ADHD (Shi et al., 2021; Davis et al., 2021), with reasons for such disparities remaining understudied. The little work in this area has highlighted differences between Asians and non-Asians during “problem recognition” and the “decision to seek help” stages of general mental health service use (Eraldi et al., 2006; Cook et al., 2017; Hall et al., 2019). Findings have suggested several factors as contributing to lower service utilization in Asians, including stigma and elements of cultural identity (e.g., acculturation; adherence to Asian cultural values), treatment expectancies, mental health literacy, and structural barriers. Notably, although such barriers likely affect all racially/ethnically minoritized groups, the nature of these difficulties in Asians are unique in that they occur in the context of the Model Minority Stereotype, or the belief that Asians in the United States are successful, hard-working, intelligent, and experience fewer mental health problems than other groups. Such beliefs may lead one to believe that the disproportionately small number of Asians accessing mental health treatment is simply an effect of an overall lower incidence of mental illness.

Yet, low utilization of ADHD services is not necessarily a result of low need (Lin &amp; Cheung, 1999). This is echoed in the few research studies on Asians with ADHD: although they report the lower rates of treatment utilization, they also have been found to report higher levels of impairment and more severe comorbidity patterns compared to White students (Jhawar &amp; Antshel, 2024). Yet, as stated above, no research, to our knowledge, has sought to parse the specific factors that may help account for these findings. Hence, there is a need in the literature for a better understanding of factors related to treatment-utilization in Asians with ADHD, with college settings being an opportune context to conduct this examination given reduced structural barriers (e.g., accessibility, cost) to treatment services compared to community settings. 

One model that may help organize and clarify risk factors underlying service-use disparities between Asians and non-Asians is Rosenstock’s (1966) Health Belief Model (HBM). The HBM posits that key determinants of health behaviors include knowledge and awareness of a health condition and its treatments, as well as receiving cues to action. It has been useful for understanding health-related behaviors (Janz &amp; Becker, 2984), particularly as it relates to disease prevention and treatment adherence (Tanner-Smith &amp; Brown, 2010).

In particular, the HBM may also be an apt explanatory framework for service use disparities in Asians given the influences that cultural norms and beliefs assert on HBM mechanisms. Kim and Zane (2016) applied to HBM to understand differences in Asian-American versus White-American help-seeking intentions with respect to general psychological distress. They specifically focused on four primary factors within the HBM (perceived severity, susceptibility, benefits, and barriers), with findings suggesting that Asian-Americans reported fewer perceived benefits of treatment than White-Americans which, in turn, were associated with lower help-seeking intentions. Further, past research has suggested racial and ethnic differences in the psychological factors included in the HBM, with Asians reporting increased cultural pressure to minimize impairment with regard to mental health difficulties to “save face” (perceived severity; Augsberger, 2015), lower mental health literacy (perceived susceptibility; Jorm, 2012; Li &amp; Keshavan, 2010), negative help-seeking attitudes (perceived benefits; David, 2010; Soorkia et al., 2011), and increased levels of stigmatization (Goldberstein, Eisenberg, &amp; Gollust, 2008) compared to White populations. Most recently, Chung et al. (2024) applied the health belief model to understand parent-focused reasons functional improvement in children with ADHD, finding that Asian-American parents reported the lowest treatment expectations and treatment expectations were positively associated with parental engagement. Yet, such work was primarily aimed at parental factors of ADHD treatment engagement. 

Overall, past application of the HBM to Asian-Americans with ADHD has yielded important findings regarding potential reasons for treatment underutilization in this population. Yet, such work has yet to be conducted in emerging adults, despite its potential for informing important insights into disparities in service use during this highly sensitive period of development. The current study thus seeks to apply the HBM, as conceptualized by Kim and Zane (2016), as a framework the further understand disparities in ADHD service utilization in Asian versus non-Asian emerging adults. Specifically, using an indirect effects approach, we will examine the extent to which perceived severity, susceptibility, benefits, and barriers account for lower service utilization among Asians relative to non-Asians during emerging adulthood.