Asian and ethnic minority health research in Aotearoa New Zealand: a scoping review of grey literature (2011–2020)

Research on, about and by Aotearoa New Zealand’s rapidly growing “ethnic” (henceforth, Asian and ethnic minority [A/EM]) populations—namely groups identifying as having Asian, Latin American, Middle Eastern and African origins—is an emerging field in health research. As a population category, A/EM, who comprise nearly 17% of the population,¹ are known for their diverse ethno-cultural, linguistic, nationality, generational, migration and visa/residency status.¹

In 2021, three of the current authors co-published the findings of a 10-year scoping review of academic research publications on A/EM in the New Zealand Medical Journal.² The findings of our original review were based on—and, indeed, limited by its focus on—published research, overlooking the particular relevance of “grey literature” (GL). There is a thriving community and voluntary sector that produces evidence for reasons including visibility, policy impact and funding, which is likely to be published in non-traditional formats and in multiple languages. As New Zealand’s A/EM population grows generationally, there is also an increase in student research on ethnic health issues, which are often unpublished. This paper, a companion to the original, is a scoping review of GL on A/EM populations in New Zealand.

GL is gaining prominence as a reliable source of data for research and policy. The Cochrane Group defines GL as “literature that is not formally published in sources such as books or journal articles.”³ GL refers to “manifold document types”, both in print and electronic formats, produced by non-commercial publishers, distinguishing it from for-profit “white literature”. Understandably, there is vast diversity among GL and who produces it, which informs their credibility. Garousi et al.⁴ classify GL on the basis of credibility and outlet control into works of high (which includes books, theses, reports) medium (annual reports, news articles) and low (blogs, emails, tweets). Recognition of GL allows for representation of ideas in diverse formats and of authors, communities and publishers who may not meet conventional standards of mainstream publishers. In academic publishing spaces, which are known to be disadvantageous to minority scholarship, this recognition is especially validating.^5–7

Recognising the value of GL, we conducted a scoping review of GL on A/EM health in New Zealand covering a 10-year period (2011–2020) with the aim of determining the scope and coverage of this literature as well as broadly mapping its focus areas. A scoping review is typically the preferred strategy for appraising literature when the breadth of scholarship in a field is unclear and it is premature to pose specific questions, as in the case of a systematic review.⁸ Our scoping review aims to map and classify the body of GL in this field, identify prominent themes and potentially appraise its contributions to the body of A/EM health research in New Zealand. The paper discusses the implications of the findings for A/EM health research and practice and also evaluates GL as a source of evidence. The GL included in this review are student theses, research reports and reports from government and non-governmental organisations (NGOs).

Methods

GL search strategy

Given the dispersed and non-codified nature of GL, standard data searches (e.g., database keyword searches) are often insufficient to provide assurance that the key literatures have been identified. Furthermore, given that there are multiple categories of GL, each requires a different search strategy. Consequently, a multifaceted and iterative search approach was adopted.

This scoping review focusses on GL in four categories: a) student research, b) research reports, c) government reports, and d) NGO reports. As such, it adheres to the guidelines for “high credibility” sources.⁴ To be included in the review, the literature had to be published between 2011 and 2020 (both years inclusive), written in English and have a clear focus on any A/EM population group in New Zealand. Different search methods were undertaken for each of these categories, which are described below.

a) Student research: Theses and dissertations at the masters and doctoral levels were extracted from the online databases of eight universities in New Zealand (The University of Auckland, Auckland University of Technology, Massey University, University of Waikato, Victoria University of Wellington, Lincoln University, University of Canterbury and University of Otago), along with NZResearch.org, which houses a comprehensive selection of research from these universities as well as smaller polytechnics. The search strategy used to search these databases is provided in Appendix Table 1.

b) Research reports: Research reports are non-peer-reviewed publications that are outputs of university-based research projects. A three-pronged approach was undertaken to find research reports. First, relevant research centres housed at the eight New Zealand universities were identified and their websites were manually searched for reports that matched the inclusion criteria. Next, the search strategy listed in Appendix Table 1 was used to search NZResearch.org for research reports. Finally, a “filetype:pdf” Google search of the search terms in Appendix Table 1 was conducted in order to find all relevant PDF documents. The latter search strategy resulted in the inclusion of additional pieces of GL of all four categories.

c) Government reports: Reports from New Zealand government agencies such as the Ministry of Health or Ministry of Social Development were obtained through manual searches of the websites of each organisation listed on the New Zealand government website.

d) NGO reports: There is a thriving ethnic NGO sector in New Zealand, representing its diverse multicultural profile. Many are specific to ethnicities or nationalities (e.g, Indian NGOs or Latin American NGOs) although several are pan-ethnic in focus (such as the Migrant Resource Centre or The Asian Network Incorporated). For this scoping review, NGO reports were manually extracted from the websites of each NGO listed on the Ministry for Ethnic Communities’ Community Directory. ⁹

Study inclusion and exclusion

Papers were included if they a) fit into one of the four categories of GL, and b) included participants who identify with an A/EM group. Literature was excluded where the identification of ethnic group was non-specific; for example, where the only ethnic group referred to in a paper was the composite “Asian” which was not further disaggregated. Title and abstract screening for inclusion was done by AM in consultation with the team.

As shown in Figure 1, a total of 32,381 pieces of GL were initially identified. After the removal of 670 duplicates, 31,711 were selected for screening. Title and abstract screening excluded 31,452 pieces of literature. The most common reason for exclusion at this stage was not having an explicitly health-related focus, and therefore not addressing the aims of the review. The 259 remaining reports were then selected for full-text review. Appendix Figure 1 shows individual PRISMA flow diagrams for each of the four types of GL. A further 92 articles were excluded as they did not meet the inclusion criteria and did not address the aims of the review, resulting in a total of 167 pieces of GL included in this review.

Data extraction and thematic analysis

Each paper was reviewed to identify the ethnic group(s) and population group of interest, broad research area and field of study. Ethnic groups were coded exactly as they appeared in the literature. A coding sheet was collated using Microsoft Excel. The coded identifiers for the documents were analysed quantitatively to determine the overall profile of the body of GL.

This was followed by detailed qualitative thematic analysis based on the substantive content of the articles. The key themes and their descriptions are presented separately. Following established qualitative analyse practices of creating codes from which themes were collated, each GL item was read across three main fields: methodology, findings and recommendations, with individual authors focussing on at least one of these fields. Using an inductive approach, codes were determined based on frequency of word use (e.g., acculturation, cultural competency) or substantive content classification (e.g., methodological approach or participant types). Themes were then generated around these codes, drawing on similarities and differences among them. All codes and themes were cross-checked and verified across authors. The key themes and their descriptions are presented separately for each field below.

Author positionality

The research was undertaken by a transdisciplinary team comprising epidemiologists, public health researchers and social scientists. All authors on the paper are migrants to New Zealand and three are of A/EM ethnicity. While the quantitative segment followed objective protocols, the qualitative component was informed by the authors’ “insider” perspectives of the community and of their disciplinary backgrounds. This breadth was also helpful given that GL was found in diverse disciplinary fields. For instance, the focus on the underpinning methodological philosophy or construction of A/EM as a subject group in health would be of interest to social science frames of health, whereas appraising recommendations and actions would be a public health priority.

View Figure 1, Table 1–3.

Results

Profile of GL

Table 1 summarises the 167 studies that were selected for review. The majority (100/167) of the GL research is disseminated through theses, with 71 masters- and 29 doctorate-level theses captured by our inclusion criteria. Of the masters theses, 63% (45/71) adopted a qualitative methodology, 18% (20/71) utilised quantitative methods and 8% (6/71) were mixed-methods studies, compared with 52% (15/29), 10% (3/29) and 34% (11/29) of doctoral theses, respectively. There was a steady publication rate of A/EM-related government reports over the 10 years. The majority (29/37) of government reports were descriptive in nature, providing descriptive statistics about A/EM populations,^10–18 descriptive accounts of ethnic experiences or customs,^19–28 evaluation of existing policy or services^29–32 or review of existing literature on A/EM communities,^24,33–37 most of which included some recommendations for practice or future opportunities for more research. The remaining eight government reports were prescriptive, setting out future services plans,^38–41 guidelines^42,43 or training resources^44,45 for working with A/EM communities. NGO and research reports were published more sporadically, with gaps in publication in both types of literature between 2015 and 2017. NGO reports focussed on refugee health and services access,^46–48 sexual and family violence,^49–53 mental health^54–57 and experiences of the COVID-19 pandemic.^58,59 Research reports similarly focussed on the needs of refugee populations,^60–62 as well as sexual health of African communities^63–65 and Asian men who have sex with men,⁶⁶ and the wellbeing of youth.^67,68 Compared with the peer-reviewed literature on A/EM communities in New Zealand published in the last 10 years,² there was a greater diversity of A/EM ethnicities represented in theses and government reports. While the inclusion rate of Chinese populations was comparable between theses and peer-reviewed literature, this proportion decreased for Indian populations while increasing for African populations. The increased literature on African populations intersects with the relatively large body of GL on communities from refugee backgrounds and the intersections between African communities and sexual health research.

Interest in the study of women’s health experiences and outcomes is prominent among theses. Research focussed on women included topics such as appearance, weight and nutrition,^69–74 experiences of pregnancy and motherhood,^75–79 as well as intimate partner/family violence^80–82 and female genital mutilation^83,84 that was absent from the body of peer-reviewed literature in the last decade.

While the body of peer-reviewed articles published between 2010 and 2019 was largely focussed on chronic physical health conditions, this was not a dominant area of interest in student-led research. Mental health, particularly that of refugee,^85–89 youth,^88,90–92 Korean^93–95 and Chinese^92,96 populations, was prominent in the theses captured. Among other forms of GL, research focussed on deaths resulting from suicide and its prevention,^24,27,56 mental health needs^{33,37,48,55,57} and appropriateness of mental health services for A/EM communities.^23,61,97 In addition, there was interest in the experiences and wellbeing of the A/EM health workforce.^98–105

Results of thematic analysis

In addition to the profile findings of the GL research, substantive analyses identified the following dominant themes.

Conceptual framing

Compared with the peer-reviewed published outputs, GL (particularly theses) employed diverse theoretical frameworks to frame the concerns of the A/EM populations. While some studies drew on traditional public health frameworks (such as Health Belief Systems or Berry’s acculturation theory^106,107), a significant proportion of thesis research employed narrative, ethno-methodology, anthropological, participatory, critical, feminist and interpretive methodologies as these better represented the contradictions and tensions in the lived realities of these communities. A growing body of emerging researchers sought a fusion of cultural epistemologies within Western research models. Thus, creatively, student theses used Afri-centric philosophy,¹⁰⁸ Guanxi Confucianism,^96,109 Indian psychology,¹¹⁰ Burmese cultural concepts (such as apegan/social isolation, oaksukwede/internal fragmentation and thwesenyinyut/social solidarity),⁸⁵ Filipino folk philosophy¹¹¹ and Islamic value-frameworks,¹¹² among others, to define the health and wellbeing needs of their community.

Participant categories

As summarised in Appendix Table 2, the GL highlighted research on A/EM populations in three categories: first, by ethnicity or migrant status (e.g., migrants, refugees, Asian, Middle Eastern) highlighting discrepancies in cultural values and dislocation in healthcare access; second, there was a focus on A/EM as hospital or community programme service users (e.g., palliative care users, hospital patients, users of parenting programmes, resettlement programmes) evaluating current programme approaches and the incompatibility of existing models of care for migrant communities; finally, GL focussed on A/EM professional healthcare workers (e.g., A/EM healthcare practitioners, mental health professionals, international medical graduates, community therapists) to highlight problems with recruitment pathways, under-utilisation of skills and retention of A/EM healthcare providers.

Significantly, the GL reflected complex, intersectional representations of A/EM groups, typically within student research. For example, instead of a generalised category such as “ethnic or Asian women”, research specified women of Black African descent;¹¹³ older South Korean women;⁷⁴ Muslim women;^112,114 diasporic South Asian young women;⁸⁰ and pregnant Chinese women.⁷¹ Similarly, children and youth were studied in 11 different ways and the African population as 10 distinct identities. Finally, student theses were more likely to capture the marginalised among minority A/EM groups. For example, the research corpus focussed on gender-diverse youth⁹¹ or South Asian women experiencing period poverty.

Barriers to health and help-seeking

Barriers to healthcare services and help-seeking for A/EM communities were a dominant theme in the GL (Appendix Table 3). Across the four categories, studies highlighted structural barriers such as pre-migration trauma; poorly translated health messages;^{37,46,47,65,66,115–117} access to social determinants such as housing, employment, financial resources, social capital; values-based barriers such as stigma from mainstream society and feelings of being “othered” and a lack of trust in services;^{25,36–44,48–51,106,115,118} cultural beliefs and values, especially in relation to mental health services and women’s lives.^{24–27,48–50,80,90,95}

Of special note were barriers experienced especially by young people including acculturation and adaptation to New Zealand life, and consequent clash with cultural and parental expectations. The role of religion as influential in health and wellbeing was another emergent theme. Studies highlighted religious influences in (lack of) physical activity among Muslim women,¹¹² and in fostering conservative attitudes to sex education in Black African communities¹¹⁹ and in food preferences.¹²⁰ However, religion was also integral to resilience and coping,^86,121 and in the construction of positive ethnic identity.¹¹¹

Acculturation

Acculturation, the opportunities and challenges of “living in two worlds”¹²² and its implications for health and wellbeing, was a dominant and repeated theme, particularly within student research (Table 2). Although published research does reflect on acculturation to some degree,^2,122 within GL this aspect is particularly well developed. Acculturation, which shapes new pluralistic identities and value frames, is an expected part of the migration journey.^123–127 It also impacts changes in lifestyles, especially in diets^{71,99,128–130} and health-seeking behaviours.^35,76,131 Studies pointed to acculturation as distinct from assimilation and a reconciliation of two different cultures. Where acculturation was successful, it was associated with better physical and mental health,sense of belonging,^{92,93,112,124,125} improved sexual health knowledge,¹³¹ employment satisfaction^132,133 and ability to negotiate between pluralistic health knowledges.^{76,90,134,135}

Studies note, however, that acculturation is unevenly adopted by the A/EM community and therefore is also an underlying cause for stress and conflict^{95,118,136–138}and feelings of being “stuck”.^{76,77,90,112,113,119,122,123,125,139} Women and young people—namely, 1.5th- and 2nd-generation A/EM—were more likely to struggle with negotiating a “third space”. For women, there was a desire to be free of some of the burdensome expectations of their culture without being seen as “un-Asian” or “un-African”.^{22,24,25,49,75–77,112,113,139} For young people, differential acculturation could potentially result in intergenerational conflict and mental distress.^95,119,140

Analysing recommendations

We also analysed the recommendations emerging from all four strands of the GL with a strong theme across all categories being the need for cultural responsiveness (Table 3, Appendix Table 4).

To meet mental health needs, there were recommendations to establish cultural and linguistic mental health services,^89,93,140 improve culturally competent skills of health professionals^{76,90,125,141} and educate the community to improve access to mental health services.¹⁴¹ There were special recommendations for women who experience violence, including for culturally specialised and community-based services.^81–84

Recommendations also highlighted the importance of primary healthcare services creating partnerships with A/EM community groups,^107,118,142including for intersectional groups.^91,143 Whole-of-government approaches were proposed for refugee-specific health services,^88,144 including innovative art-based approaches to engage communities and facilitate social connections.^85,89 There were also recommendations for the provision of culturally appropriate food in hospitals.^120,130,145

Several studies made recommendations on prevention, such as prevention of tuberculosis,¹⁴⁶ period poverty¹⁴⁷ and domestic violence,⁸¹ and on enhancing quality of life of elderly migrants.¹⁴⁸ Prevention studies highlighted the importance of culturally tailored health messaging,¹³¹ culturally informed services for HIV prevention,^119,149 improving cultural awareness of health professionals in relation to screening^114,150 and ways to improve physical activity among South Asian migrant women.¹⁵¹

Theses/dissertations and reports recommended recruiting more A/EM professionals in mainstream healthcare services,¹⁴³ and improving employment conditions to minimise service disruptions reliant on A/EM professionals.^101,103Research and NGO reports had recommendations related to addressing racism and discrimination, both at a structural and interpersonal level, and highlighted the importance of community voice in decision making.

Recommendations for future research also featured in the GL. Future research suggestions included implications of Western dietary habits for children,¹²⁸ mental health risks and user-friendly services,^92,95,152 therapy needs to address oppression experienced by A/EM sexual and gender minority youth,⁹¹ sex education skills among A/EM parents¹¹⁹ and risk factors for increased blood pressure in primary school children.¹⁵³ In women’s health, improved intersectional understandings of family violence,⁸⁰ risk of pregnancy complications,⁶⁹ psychological services for women^75,77 and cervical screening uptake¹¹⁴ were recommended. Further research is also needed on elder care delivery,¹⁰¹ critical life events¹⁵⁴ and caregiving.¹⁵⁵

Discussion

The scoping review of the GL provided substantive and original knowledge on A/EM health in New Zealand. Some broad observations are noted here. First, studies in GL canvas a broader diversity of topics than is found among published A/EM health research. Rather than a disproportionate focus on “ethnic diseases”,² GL scholarship draws attention to issues not typically covered in such scholarship including body image, queer sexuality, parenting and sex education, among others. The GL scholarship, especially student research, showcased a particular focus on mental health and wellbeing issues; for new migrants, these centred around the challenges of settling into a new country, and for a younger generation, questions around identity and belonging were prominent.

A second observation is that the GL literature was more likely to focus on A/EM sub-groups often overlooked in published health research, allowing for more visibility of health issues for African, Middle Eastern and Latin American populations compared to published research in academic journals and books. GL research was also more likely to examine intersectional identities or complex identifications beyond merely being a homogenous “Asian” or migrant or refugee. A third observation relates to risk and protective factors. While GL confirmed what is already known in health equity research, highlighting the focus on structural determinants (such as employment, housing, etc.), institutional blindness (e.g., in health messaging) and structural discrimination (such as racism), it also showcases innovations in A/EM health through use of holistic, transdisciplinary, critical (highlighting imbalances in power) and non-Western frameworks (e.g., Afro-centric, Indian, Chinese epistemologies). The pervasiveness of acculturation in health outcomes was a prominent theme, reflecting both alignment and antagonisms between cultures, particularly impacting women and young people. These facets deserve attention within mainstream theories of A/EM health equity.

A final observation relates to recommendations for change. There is an overwhelming call across all strands of GL for cultural responsiveness in healthcare that includes, but is not limited to, designing culturally appropriate services, diagnostic tools and health messaging. Cultural responsiveness vis-à-vis recruitment and retention of diverse personnel is another key theme that was prominent in this research.

This GL analysis is limited in that the literature c overs the decade prior to COVID-19 and significant changes to migration policy and health sector reforms. At one level, the needs of the community are likely to be consistent despite these changes. However, there is also a possibility that the implications of the new landscape limit the findings of this analysis. That said, responses to these changes on migrant health are best captured in GL, reinforcing the value of this body of scholarship.

Conclusion

Our scoping review of GL is a companion to a previously published review of a 10-year analysis of published research on A/EM health in New Zealand. A detailed process for identifying and including “high credibility” GL was undertaken, culminating in a final corpus of 167 documents in four categories—namely, student research, NGO reports, research reports and government reports. GL tends to be considered as inferior to published health research but, contrary to this widely held view, our review affirms GL as a substantial repository of A/EM health research and knowledge. Indeed, GL research may offer opportunities for greater visibility of marginalised groups and opportunities to develop innovative frameworks for health and equity. Our review of GL also highlights the more prominent focus on recommendations and their application. Several recommendations, particularly around culturally competent healthcare, advance guidelines for practice and are foundations for evaluating existing practices (see Appendix Table 4). The GL also offers new areas to further research unique to ethnic communities; for example, there is scope to explore acculturation and intergenerational relationships as part of public health research. There is also the potential for ethnic methodologies to be the basis for practical screening and diagnostic tools.

In all, our main takeaways from this study are: a) GL literature offers practical recommendations not otherwise found in published research, b) GL student theses are a particular space for innovative and creative thinking during the period under consideration, but these are often unpublished—improving avenues for their work is a priority. Although all four categories were important knowledge bases for A/EM health, student research particularly offered creative, cutting-edge and “home-grown” conceptualisations that acknowledged hybridity of A/EM identities and lived realities. Yet student research is also the least likely to find its way into publication and recognition within mainstream health knowledges. This oversight needs to be corrected as it is within this sphere that innovations for future understanding of A/EM health are likely to emerge.

View Appendix.

Newsletter

Published by

ARTICLE

Vol. 138 No. 1615 | 23 May, 2025

DOI: 10.26635/6965.6854

Asian and ethnic minority health research in Aotearoa New Zealand: a scoping review of grey literature (2011–2020)

Methods

GL search strategy

Study inclusion and exclusion

Data extraction and thematic analysis

Author positionality

Results

Profile of GL

Results of thematic analysis

Conceptual framing

Participant categories

Barriers to health and help-seeking

Acculturation

Analysing recommendations

Discussion

Conclusion

See more related

Aim

Methods

Results

Conclusion

Authors

Correspondence

Correspondence email

Competing interests

Newsletter

Published by

ARTICLE

Vol. 138 No. 1615 | 23 May, 2025

DOI: 10.26635/6965.6854

Asian and ethnic minority health research in Aotearoa New Zealand: a scoping review of grey literature (2011–2020)

Methods

GL search strategy

Study inclusion and exclusion

Data extraction and thematic analysis

Author positionality

Results

Profile of GL

Results of thematic analysis

Conceptual framing

Participant categories

Barriers to health and help-seeking

Acculturation

Analysing recommendations

Discussion

Conclusion

See more related

Aim

Methods

Results

Conclusion

Authors

Correspondence

Correspondence email

Competing interests

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