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Overlooked No More: Shining a Light on Asian American Pacific Islander Youth During the COVID-19 Pandemic and the Need for Visibility

      See Related Article on p.500
      These last 2 years of the COVID-19 pandemic have drawn increased attention to Asian populations living in the United States and Canada []. Frontline and essential workers are comprised of higher numbers of Asian American Pacific Islanders (AAPI), and they have higher risk of being exposed to COVID-19 than the general population [
      New American Economy. Asian Americans Pac Isl Americans Frontlines.
      ]. The AAPI community, already feeling vulnerable to xenophobia as a minority in North America, has experienced increasingly horrific anti-Asian acts of violence []. The targeted racially motivated mass shooting of Asian individuals in a spa in Atlanta in May 2021 as well as the countless unprovoked random attacks, particularly of elderly Asian individuals, in New York City, San Francisco and throughout the United States, have left the AAPI community reeling [,
      • Kim O.
      Addressing the mental health needs of the AAPI community”.
      ]. Furthermore, the previous US administration’s persistent use of the terms “Wuhan Virus” and “China Virus” further inflamed growing hostility in the United States toward Asian populations [
      • Hswen Y.
      • Xu X.
      • Hing A.
      • et al.
      Association of #covid19” versus “#chinesevirus” with anti-Asian Sentiments on Twitter: March 9-23, 2020.
      ]. In the setting of strain of the COVID-19 pandemic and increased focus of anti-Asian racist attacks and discrimination, it is long overdue that we examine the well-being of Asian youth during this time.
      There is, however, a relative dearth of medical research about AAPIs compared to other populations [
      • Yee A.
      Research on Asian Americans and Pacific Islanders is being Stifled.
      ,
      • Liu Y.
      • Elliott A.
      • Strelnick H.
      • et al.
      Asian Americans are less willing than other racial groups to participate in health research.
      ]. From 1966 to 2000, only 0.01% of articles in MEDLINE’s database mentioned AAPIs [
      • Ghosh C.
      Healthy people 2010 and Asian Americans/Pacific Islanders: Defining a baseline of information.
      ]. Meanwhile, between 1992 and 2018, only 0.17% of NIH research funding went toward studies focusing on AAPI populations [
      • Đoàn L.N.
      • Takata Y.
      • Sakuma K.K.
      • Irvin V.L.
      Trends in Clinical research including Asian American, Native Hawaiian, and Pacific Islander participants funded by the US national Institutes of health, 1992 to 2018.
      ]. The studies that we do have about the mental health of AAPI youth before the COVID-19 pandemic are alarming [
      Centers for Disease Control and Prevention (CDC)
      Youth risk Behavior Surveillance System (2021). 1991-2019 High School Youth Risk Behavior Survey Data [Data file].
      ,
      Substance Abuse and Mental Health Services Administration
      A Snapshot of Behavioral health issues for Asian American/Native Hawaiian/Pacific Islander Boys and men: Jumpstarting an overdue Conversation. HHS Publication No. (SMA) 16-4959.
      ,
      • Kam K.
      Cultural Stigma Hurts Asian American Teens with depression. New America Media.
      ,
      • Zou P.
      • Siu A.
      • Wang X.
      • et al.
      Influencing factors of depression among adolescent Asians in North America: A systematic review.
      ,
      • Gee K.A.
      • Cooc N.
      Will I be victimized at school today? How schools influence the victimization experiences of Asian American teenagers.
      ,
      • Nadal K.L.
      • Wong Y.
      • Sriken J.
      • et al.
      Racial Microaggressions and Asian Americans: An Exploratory study on within-group differences and mental health.
      ,
      • Nadal K.L.
      • Kuramoto F.
      • Lin P.
      Advancing best Practices in Behavioral health for Asian American, Native Hawaiian, and Pacific Islander Boys and men SAMHSA.
      ]. AAPI youth were more likely to exhibit depressive symptoms and attempt suicide compared to their peers [
      • Wyatt L.C.
      • Ung T.
      • Park R.
      • et al.
      Risk factors of suicide and depression among Asian American, Native Hawaiian, and Pacific Islander youth: A systematic literature review.
      ]. Asian youth were also less likely to seek mental health help [
      • Chu J.P.
      • Sue S.
      Asian American mental health: What We Know and what We Don’t Know.
      ,
      • Spencer M.S.
      • Chen J.
      • Gee G.C.
      • et al.
      Discrimination and mental health-related service use in a national study of Asian Americans.
      ].
      In this issue of Journal of Adolescent Health, Exner-Cortens et al. [
      • Exner-Cortens D.
      • Schwartz K.D.
      • McMorris C.
      • et al.
      Stress among Asian youth during COVID-19: Moderation by educational, spiritual and cultural Sources of belonging.
      ] report on stress among Asian youth living in Canada during the COVID-19 pandemic. They conducted a longitudinal study with a subsample of 974 individuals ages 12–18 years; 202 participants identified as Asian (including those of East Asian, South Asian, West Asian, and Southeast Asian descent) while 772 identified as White. Data points were collected during three distinct timepoints: September 2020, November 2020, and March 2021. Exner-Cortens et al. examined COVID-19 related stress among Asian youth compared to White youth using an 11-item questionnaire which asked about aspects of the impact of COVID-19 on people’s health and family confinement. The predictors assessed were contextual aspects of resilience which were measured using a 10-item subset of questions of the Child and Youth Resilience Measure-28 (CYRM-28), which measures sense of belonging in spiritual, educational, and cultural realms [
      • Ungar M.
      • Liebenberg L.
      Assessing resilience across Cultures using Mixed methods: Construction of the Child and youth resilience measure.
      ]. A higher CYRM score was hypothesized to be protective for adolescents. The authors also accounted for family loss of job or reduced work, if a family member had been tested for COVID-19, as well as other demographic information.
      Perhaps not surprisingly, the results of the multivariate logistic regression model show that Asian youth reported significantly higher amounts of COVID-19 related stress compared to White youth. What was unexpected about their findings was that Asian youth who at the beginning of the survey reported a higher CYRM—that is, a greater sense of belonging—also reported significantly higher COVID-19 stress by the end of the study. The sense of belonging was presumed to be a protective factor [
      • Ungar M.
      • Liebenberg L.
      Assessing resilience across Cultures using Mixed methods: Construction of the Child and youth resilience measure.
      ,
      • Anderson K.
      • Priebe S.
      Concepts of resilience in adolescent mental health research.
      ], but instead the opposite was found to be true in this study.
      There are some limitations to this study which the authors note. Despite this being a longitudinal assessment, the first survey was collected approximately 6 months into the COVID-19 pandemic. There were no baseline data prior to the pandemic regarding the participants’ level of stress or other markers of their mental well-being. Immigration and language proficiency data were also not available, and these may be important confounders in Asian families.
      Exner-Cortens et al. also acknowledge that subgroups of East Asian, South Asian, Southeast Asian, and West Asian descent were aggregated together to be termed “Asian.” This all-encompassing umbrella category of “Asian’ fails to allow analysis of the diversity within Asian populations, as AAPI communities consist of approximately 50 ethnic groups that speak over 100 languages. There are distinct physical and cultural differences of people from different regions of Asia, and there should be no presumption that their experiences and backgrounds are the same, though in North America they share the experience of being minority populations.
      Exner-Cortens et al. are to be congratulated on adding to the AAPI youth literature, and particularly within the context of the ongoing COVID-19 pandemic which is having major impacts on the health and emotional well-being of the Asian community. Further research will be needed to better understand their unexpected and striking finding. It is important to increase awareness that AAPI youth are disproportionately impacted compared to White youth and to better understand and support all young people as the pandemic evolves.
      This study also provides an opportunity to highlight a broader context. The experiences of Asian communities are understudied, and there is a need for more AAPI representation in leadership positions. Furthermore, studies that have differentiated between people of South Asian and East Asian descent in the United States have revealed important nuances. For example, Lu et al. [
      • Lu J.G.
      • Nisbett R.E.
      • Morris M.W.
      Why East Asians but not South Asians are underrepresented in leadership positions in the United States.
      ] have reported that in the S&P 500, South Asians are well represented in business leadership roles, but those of East Asian descent fell far behind Whites and South Asians. They report that the South Asian leaders had more qualities of assertiveness, whereas East Asians were less likely to be chosen for senior leadership positions because they did not show signs of assertiveness. East Asians—particularly women—in Western countries grow up with the societal expectation to be docile, obedient, submissive, and sexually exotic [
      • Mukkamala S.
      • Suyemoto K.L.
      Racialized sexism/sexualized racism: A multimethod study of intersectional experiences of discrimination for Asian American women.
      ]. However, leaders in Western society are expected to be assertive, not submissive [
      • Lu J.G.
      • Nisbett R.E.
      • Morris M.W.
      Why East Asians but not South Asians are underrepresented in leadership positions in the United States.
      ]. Lu et al. reason that the lack of assertiveness accounts for under-representation of East Asians in leadership roles in US businesses.
      On evaluating the academic medical community, there is a drop-off in promotion and selection of AAPI to leadership positions. AAPIs make up about a fifth of enrollment in US Medical Schools and GME programs as well as faculty positions at academic institutions. However, only 10% of academic department chairs are AAPI [
      • Choi A.M.K.
      • Rustgi A.K.
      Diversity in leadership at academic medical Centers: Addressing underrepresentation among Asian American faculty.
      ]. In 2021, out of 155 Deans, only 6 are Asian. In fact, in 1998, 2003, and 2008, there were no Asian Deans [
      • Yu P.T.
      • Parsa P.V.
      • Hassanein O.
      • et al.
      Minorities struggle to advance in academic medicine: A 12-y review of diversity at the highest levels of America's teaching institutions.
      ]. As we look within Adolescent Medicine, it is noticeable that there is underrepresentation of Asians in leadership roles as well. If we extrapolate the findings of Lu et al. from the business world to academic medicine, we can surmise that lack of assertiveness, or perceived lack of assertiveness, may also be an obstacle to promotion and leadership for those of East Asian descent.
      Figure thumbnail fx1
      The author with Congressmember Andy Kim, who represents New Jersey's 3rd congressional district.

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