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Abstract
Background: Ethnic disparities in mental health service utilization persist, particularly for immigrants with Limited English Proficiency (LEP) who face compounded barriers due to language, cultural factors, and provider shortages. This dissertation investigates the spatial and virtual accessibility of mental health services for these populations, examining the influence of structural factors, policy environments, and digital technologies, guided by the Public Health Critical Race Praxis (PHCRP) and Network Episode Model (NEM) frameworks.
Research Aims: The research aims correspond to the three studies comprising this dissertation.
Research Aim 1 (Study 1) was to assess the multidimensional (spatial, virtual, financial) accessibility of language-concordant mental health services for five major LEP populations (Spanish, Chinese, Vietnamese, Korean, Tagalog) across public and private sectors in all 50 U.S. states, identifying disparities and language access deserts.
Research Aim 2 (Study 2) was to examine how state-level anti-immigrant policy climates and political factors (e.g., partisan lean, non-white congressional representation) impact the availability of these language-concordant services.
Research Aim 3 (Study 3) was to explore the telemental health (TMH) help-seeking experiences of LEP immigrants (Korean and Mandarin speakers) to develop an adapted Network Episode Model for Immigrants (NEM-IM) that incorporates migration, acculturation, and digital mobilities.
Design and Analyses: For Aims 1 and 2, quantitative analyses were conducted using national datasets including SAMHSA's National Directory of Mental Health Treatment Facilities, PsychologyToday.com therapist listings, the American Community Survey, and the Immigration Policy Climate (IPC) index. Methods included the Two-Step Floating Catchment Area (2SFCA) for spatial access, descriptive statistics, correlational analyses, negative binomial regressions, and multilevel logistic regressions. For Aim 3, semi-structured interviews were conducted with 30 LEP immigrants (15 Korean, 15 Mandarin speakers). A general inductive approach was used for qualitative data analysis to adapt and refine the Network Episode Model.
Results: Analyses for Aim 1 revealed substantial language access deserts, especially for Asian language groups (e.g., 49.2% of census tracts with Tagalog LEP populations lacked public sector concordant services). Private sector coverage was generally better but remained inadequate, and financial access disparities were evident, with low public insurance acceptance by private practitioners (e.g., only 4.3% of Korean-speaking private practitioners accepted Medicaid).
Analyses for Aim 2 found that more supportive political climates (higher Democratic vote margins, greater non-white congressional representation) were generally associated with increased availability of language-concordant services. Conversely, more restrictive anti-immigrant climates correlated with significantly fewer private practitioners offering services in Chinese and Vietnamese.
Analyses for Aim 3 yielded the NEM-IM, which reconceptualizes immigrant help-seeking through five interconnected domains: Social Content or Episode Base (integrating immigration background, digital access, pre-migration experiences), Informal Network System (spanning offline, online, and transnational ties influencing provider selection), the Individual’s Evolving Acculturation and Wellbeing/Mental Health Careers, and the Treatment System (demonstrating strategic TMH decision-making based on cultural understanding, language concordance, cost, insurance, and scheduling flexibility across geographic boundaries).
Conclusions: Findings from this dissertation demonstrate significant and multidimensionally determined inequities in mental health service access for LEP immigrants, which are shaped by state-level sociopolitical contexts and structural xenophobia. While digital technologies like TMH offer potential to bridge geographic gaps, their benefits are unevenly distributed and influenced by digital literacy and acculturation. The NEM-IM provides a framework for understanding immigrant help-seeking in the digital age. These findings underscore the need for targeted policy interventions, including investment in a diverse multilingual workforce, advocacy for inclusive state policies that actively counter structural xenophobia, improved insurance coverage for culturally and linguistically appropriate care (including TMH), and strategies to enhance digital equity and literacy among immigrant communities.
