OBJECTIVES/SPECIFIC AIMS: Stigma has been recognized as a majorimpediment to accessing mental health care among Vietnamese and Asian Americans(Leong and Lau, 2001; Sadavoy et al., 2004; Wynadenet al., 2005; Fong and Tsuang, 2007). The underutilizationof mental health care, and disparities in both access and outcomes have beenattributed to a large extent to stigma and cultural characteristics of thispopulation (Wynaden et al., 2005; Jang et al.,2009; Leung et al., 2010; Spencer et al.,2010; Jimenez et al., 2013; Augsberger et al.,2015). People with neurotic or behavioral disorders may be considered“bad” as many Vietnamese people believe it is aconsequence of one’s improper behavior in a previous life, for whichthe person is now being punished (Nguyen, 2003). Mental disorders can also beenseen as a sign of weakness, which contributes to ambivalence and avoidance ofhelp-seeking (Fong and Tsuang, 2007). Equally important is the need to protectfamily reputation; having emotional problems often implies that the person has“bad blood” or is being punished for the sins ofhis/her ancestors (Herrick and Brown, 1998; Leong and Lau, 2001),which disgraces the entire family (Wynaden et al., 2005). Inthese cases, public stigma (as opposed to internal stigma) is the primary reasonfor delays in seeking help (Leong and Lau, 2001). Other research has alsohighlighted the influences of culture on how a disorder may be labeled indifferent settings, although the presentation of symptoms might be identical(see Angel and Thoits, 1987). In Vietnamese culture, mental disorders are oftenlabeled điên (literally translated as“madness”). A điên person and his orher family are often severely disgraced; consequently the individuals and theirfamily become reluctant to disclose and seek help for mental health problems forfear of rejection (Sadavoy et al., 2004). Despite the criticalrole of stigma in accessing mental health care, there has been little work intrying to understand how stigmatizing attitudes towards mental illness amongVietnamese Americans manifest themselves and the influences of acculturation onthese attitudes. Some previous work indicated a significant level of mentalillness stigma among Vietnamese Americans, and experiences of living in theUnited States might interact with the way stigma manifests among this population(Do et al., 2014). Stigma is a complex construct that warrantsa deeper and more nuanced understanding (Castro et al., 2005).Much of the development of stigma-related concepts was based on the classic workby Goffman (1963); he defined stigma as a process by which an individualinternalizes stigmatizing characteristics and develops fears and anxiety aboutbeing treated differently from others. Public stigma (defined by Corrigan, 2004)includes the general public’s negative beliefs about specific groups,in this case individuals and families with mental illness concerns, thatcontribute to discrimination. Public stigma toward mental illness acts not onlyas a major barrier to care, but can also exacerbate anxiety, depression, andadherence to treatment (Link et al., 1999; Sirey etal., 2001; Britt et al., 2008; Keyes etal., 2010). Link and Phelan (2001) conceptualized public stigma throughfour major components. The first component, labeling, occurs when peopledistinguish and label human differences that are socially relevant, for example,skin color. In the second component, stereotyping, cultural beliefs link thelabeled persons to undesirable characteristics either in the mind or the body ofsuch persons, for example people who are mentally ill are violent. The thirdcomponent is separating “us” (the normal people) from“them” (the mentally ill) by the public. Finally, labeledpersons experience status loss and discrimination, where they are devalued,rejected and excluded. Link and Phelan (2001) emphasized that stigmatizationalso depends on access to social, economic, and political power that allowsthese components to unfold. This study aims to answer the following researchquestions: (1) how does public stigma related to mental illness manifest amongVietnamese Americans? and (2) in what ways does acculturation influence stigmaamong this population? We investigate how the 4 components of stigma accordingto Link and Phelan (2001) operationalized and how they depend on the level ofacculturation to the host society. Vietnamese Americans is the key ethnicminority group for this study for several reasons. Vietnamese immigration, whichdid not start in large numbers until the 1970s, has features that allow for anatural laboratory for comparisons of degree of acculturation. Previous researchhas shown significant intergenerational differences in the level ofacculturation and mental health outcomes (e.g., Shapiro et al.,1999; Chung et al., 2000; Ying and Han, 2007). In this study,we used age group as a proxy indicator of acculturation, assuming that those whowere born and raised in the United States (the 18–35 year olds) wouldbe more Americanized than those who were born in Vietnam but spent a significantpart of their younger years in the United States (the 36–55 yearolds), and those who were born and grew up in Vietnam (the 56–75 yearolds) would be most traditional Vietnamese. The language used in focus groupdiscussions (FGDs) reflected some of the acculturation, where all FGDs with theyoungest groups were done in English, and all FGDs with the oldest groups weredone in Vietnamese. METHODS/STUDY POPULATION: Data were collectedthrough a set of FGDs and key informant interviews (KIIs) with experts toexplore the conceptualization and manifestation of mental illness public stigmaamong Vietnamese Americans in New Orleans. Six FGDs with a total of 51participants were conducted. Participants were Vietnamese American men and womenages 18–75. Stratification was used to ensure representation in thefollowing age/immigration pattern categories: (1) individuals age56–75 who were born and grew up in Vietnam and immigrated to theUnited States after age 35; (2) individuals age 36–55 who were bornin Vietnam but spent a significant part of their youth in the United States; and(3) individuals age 18–35 who were born and grew up in the UnitedStates. These groups likely represent different levels of acculturation,assuming that people who migrate at a younger age are more likely to assimilateto the host society than those who do at a later age. Separate FGDs wereconducted with men and women. Eleven KIIS were conducted with 6 serviceproviders and 5 community and religious leaders. In this analysis, we focused onmental illness public stigma from the FGD participants’ perspectives.FGDs were conducted in either English or Vietnamese, whichever participants feltmore comfortable with, using semistructured interview guides. All interviewswere audio recorded, transcribed and translated into English if conducted inVietnamese. Data coding and analysis was done using NVivo version 11 (QSRInternational, 2015). The analysis process utilized a Consensual QualitativeResearch (CQR) approach, a validated and well-established approach to collectingand analyzing qualitative data. CQR involves gathering textual data throughsemistructured interviews or focus groups, utilizing a data analysis processthat fosters multiple perspectives, a consensus process to arrive at judgmentsabout the meaning of data, an auditor to check the work of the research team,and the development of domains, core-ideas, and cross-analysis (Hill etal., 2005). The study was reviewed and approved by TulaneUniversity’s Internal Review Board. RESULTS/ANTICIPATEDRESULTS: Components of public stigma related to mental illness. The 4 componentsof public stigma manifest to different extents within the Vietnamese Americansin New Orleans. Labeling was among the strongest stigma components, while theevidence of the other components was mixed. Across groups of participants,Vietnamese Americans agreed that it was a common belief that people with mentaldisorders were “crazy,” “actingcrazy,” or “madness.” “Notnormal,” “sad,” and“depressed” were among other words used to describe thementally ill. However, there were clear differences between younger and olderVietnamese on how they viewed these conditions. The youngest groups ofparticipants tended to recognize the “craziness” and“madness” as a health condition that one would need toseek help for, whereas the oldest groups often stated that these conditions wereshort term and likely caused by family or economic problems, such as a divorce,or a bankruptcy. The middle-aged groups were somewhere in between. The evidencesupporting the second component, stereotyping, was not strong among VietnameseAmericans. Most FGD participants agreed that although those with mentaldisorders may act differently, they were not distinguishable. In a few extremecases, mentally ill individuals were described as petty thefts or being violenttowards their family members. Similarly to the lack of strong evidence ofstereotyping, there was also no evidence of the public separating the mentallyill (“them”) from “us”. It wasnearly uniformly reported that they felt sympathetic to those with mentaldisorders and their family, and that they all recognized that they needed help,although the type of help was perceived differently across groups. The olderparticipants often saw that emotional and financial support was needed to helpindividuals and families to pass through a temporary phase, whereas youngerparticipants often reported that professional help was necessary. The lastcomponent, status loss and discrimination, had mixed evidence. While nearly noparticipants reported any explicit discriminatory behaviors observed andpracticed towards individuals with mental disorders and their families, wordslike “discrimination” and “stigma”were used in all FGDs to describe direct social consequences of having a mentaldisorder. Social exclusion was common. Our older participants said:“They see less of you, when they see a flaw in you theydon’t talk to you or care about you. That’s one thing theVietnamese people are bad at, spreading false rumors anddiscrimination” (Older women FGD). One’s loss of statusseemed certain if their or their loved one’s mental health status wasdisclosed. Shame, embarrassment, and being “frowned upon”were direct consequences of one’s mental health status disclosure andsubsequently gossiped about. Anyone with mental disorders was certain toexperience this, and virtually everyone in the community would reportedly dothis to such a family. “You get frowned upon. In the Vietnameseculture, that’s [a family identified as one with mentalhealth problems] the big no-no right there. When everybody frownsupon your family and your family name, that’s when it becomes aproblem” (Young men FGD). This is tied directly to what ourparticipants described as Vietnamese culture, where pride and family reputationwere such a high priority that those with mental disorders needed to go to agreat extent to protect—“We all know what saving facemeans” as reported by our young participants. Even among youngparticipants, despite their awareness of mental illness and the need forprofessional help, the desire to avoid embarrassment and save face was so strongthat one would think twice about seeking help. “No, you justdon’t want to get embarrassed. I don’t want to go to thedamn doctor and be like ‘Oh yeah, my brother got an issue. You canhelp him?’ Why would I do that? That’s embarrassing tomyself…” (Young men FGD). Our middle-aged participantsalso reported: “If I go to that clinic [mental health orcounseling clinic], I am hoping and praying that I won’tbump into somebody that I know from the community” (Middle-aged womenFGD). Vietnamese people were also described as being very competitive amongthemselves, which led to the fact that if a family was known for having anyproblem, gossips would start and spread quickly wherever they go, and prettysoon, the family would be looked down by the entire community. “Ithink for Vietnamese people, they don’t help those that are in need.They know of your situation and laugh about it, see less of you, and distantthemselves from you” (Older women FGD). Culture and mental illnessstigma, much of the described stigma and discrimination expressed, andconsequently the reluctance to seek help, was attributed to the lack ofawareness of mental health and of mental health disorders. Many studyparticipants across groups also emphasized a belief that Vietnamese Americanswere often known for their perseverance and resilience, overcoming wars andnatural disasters on their own. Mental disorders were reportedly seen asconditions that individuals and families needed to overcome on their own, ratherthan asking for help from outsiders. This aspect of Vietnamese culture isintertwined with the need to protect one’s family’sreputation, being passed on from one generation to the next, reinforcing thebeliefs that help for mental disorders should come from within oneself andone’s family only. Consequently persons with mental health problemswould be “Keeping it to themselves. Holding it in and believing inthe power of their friends” (Middle-aged FGD) instead of seekinghelp. Another dimension of culture that was apparent from FGDs (as well as KIIs)was the mistrust in Western medicine. Not understanding how counseling ormedicines work made one worry about approaching service providers or staying intreatment. The habit of Vietnamese people to only go see a doctor if they aresick with physical symptoms was also a hindrance to acknowledging mental illnessand seeking care for it. Challenges, including the lack of vocabulary to expressmental illness and symptoms, in the Vietnamese language, exaggerated theproblem, even among those who had some understanding of mental disorders. It wassaid in the young men FGD that: “when you classify depression as anillness, no one wants to be sick,… if you call it an illness, no onewants to have that sort of illness, and it’s not an illness that youcan physically see…” (Young men FGD). Another young mansummarized so well the influence of culture on mental illness stigma:“Us Southeast Asian, like, from my parents specifically has VietnamWar refugees. I think the reason why they don’t talk about it isbecause it’s a barrier that they have to overcome themselves, right?As refugees, as people who have been through the war…[omitted]They don’t want to believe that theyneed help, and so the trauma that they carry when they give birth to us iscarried on us as well. But due to the language barrier and also the, like, theysay with the whole health care, in Vietnam I know that they don’treally believe in Western and Eurocentric medicine. So, from their understandingof how, like from their experience with colonization or French people, and howmedicine works, they don’t believe in it” (Young men FGD).One characteristic of the Vietnamese culture that was also often mentioned byour FGD participants (as well as KIIs) was the lack of sharing and opennessbetween generations, even within a family. Grandparents, parents, and childrendo not usually share and discuss each other’s problems. Parents andgrandparents do not talk about problems because they need to appear strong andgood in front of their children; children do not talk about problems becausethey are supposed to do well in all aspects, particularly in school. Thecompetitiveness of Vietnamese and high expectations of younger generations againcome into play here and create a vicious cycle. Young people are expected to dowell in school, which put pressure on them and may result in mental healthproblems, yet, they cannot talk about it with their parents because they are notsupposed to feel bad about school, and sharing is not encouraged. The Asianmodel minority myth and the expectations of parents that their children would dowell in school and become doctors and lawyers were cited by many as a cause ofmental health problems among young people. “Our parents are refugees,they had nothing and our parents want us to achieve this AmericanDream…. [omitted] It set expectations andimages for us…. It was expected for all the Asians to be in the top10, and for, like a little quick minute I thought I wasn’t going tomake it, I was crying” (Yong men FGD). As a result, the mental healthproblems get worse. “If you’re feeling bad aboutsomething, you don’t feel like you can talk about it with anyoneelse, especially your family, because it is not something that is encouraged tobe talked about anyway, so if you are feeling poorly and you don’tfeel like you could talk to anybody, I think that just perpetuates the badfeelings” (Middle-aged women FGD). Acculturation and mental illnessstigma Acculturation, the degree of assimilation to the host society, haschanged some of the understanding of mental illness and stigmatizing attitudes.Differences across generations expressed in different FGDs indicated differencesin perceptions towards mental illness that could be attributed to acculturation.For example, the young generation understood that mental illness was a healthproblem that was prevalent but less recognized in the Vietnamese community,whereas a prominent theme among the older participants was that mental illnesswas a temporary condition due to psychological stress, that it was a conditionthat only Caucasians had. Some of the components of public stigma related tomental illness seemed to vary between generations, for example the youngestparticipants were less likely to put a label on a person with mental healthproblems, or to stereotype them, compared to the oldest and middle-agedparticipants. This was attributed to their education, exposure to the media andinformation, and to them “being more Americanized.”However, there was no evidence that acculturation played an important role inchanging the other components of public stigma, including stereotyping,separating, and status loss and discrimination. For example, the need to protectthe family reputation was so important that our young participants shared:“If you damage their image, they will disown you before you damagethat image” (Young men FGD). Young people, more likely to recognizemental health problems, were also more likely to share within the family and toseek help, but no more likely than their older counterparts to share outside ofthe family—“maybe you would go to counseling or go totherapy, but you wouldn’t tell people you’re doingthat” (Young women FGD). The youngest participants in our study werefacing a dilemma, in which they recognized mental health problems and the needfor care, yet were still reluctant to seek care or talk about it publiclybecause of fears of damaging the family reputation and not living up to theparents’ expectations. Many young participants reported that itactually made it very difficult for them to navigate mental health issuesbetween the 2 cultures, despite the awareness of the resources available.“I think it actually makes it harder. Only because you know to yourparents and the culture, and your own people, it’s taboo, andit’s something that you don’t talk about. Just knowingthat you have the resources to go seek it… You want advice from yourfamily also, but you can’t connect the appointment to your familybecause you’re afraid to express that to your parents, you know? So Ithink that plays a big part, and knowing that you are up and coming, but youdon’t want to do something to disappoint your family because they areso traditional” (Young men FGD). Some participants felt morecomfortable talking about mental health problems, like depression, if it wastheir friend who experienced it and confided in them, but they would notnecessarily felt open if it was their problem. Subtle cultural differences likethis are likely overlooked by Western service providers. One older participantsummarized it well “They [the young generation]are more Americanized. They are more open to other things[but] I think that mental health is still abarrier.” DISCUSSION/SIGNIFICANCE OF IMPACT: This studyinvestigated how different components of public stigma related to mental illnessmanifest among Vietnamese Americans, a major ethnic group in the United States,and how acculturation may influence such stigma. The findings highlightedimportant components of public stigma, including labeling and status loss, butdid not provide strong evidence of the other components within our studypopulation. Strong cultural beliefs underlined the understanding of mentalhealth and mental illness in general, and how people viewed people with mentalillness. Several findings have been highlighted in previous studies with Asianimmigrants elsewhere; for example, a study from the perspectives of health careproviders in Canada found that the unfamiliarity with Western biomedicine andspiritual beliefs and practices of immigrant women interacted with social stigmain preventing immigrants from accessing care (O’Mahony and Donnelly,2007). Fancher et al. (2010) reported similar findingsregarding stigma, traditional beliefs about medicine, and culture amongVietnamese Americans. Acculturation played a role in changing stigmatizingattitudes as evidenced in intergenerational differences. However, being moreAmericanized did not equate to being more open, having less stigmatizingattitudes, or being more willing to seek care for mental health issues.Consistent with previous studies (Pedersen and Paves, 2014), we still found somelevel of stigma among young people aged 18–35, although somecomponents were lessened with an increased level of acculturation. There wasalso a conflict among the younger generation, in which the need for mentalhealth care was recognized but accessing care was no easier for them than fortheir parent and grandparent generations. The study’s findings areuseful to adapt existing instruments to measure stigma to this population. Thefindings also have important program implications. One, they can be directlytranslated into basic supports for local primary and behavioral health careproviders. Two, they can also be used to guide and inform the development andevaluation of an intervention and an additional study to validate the findingsin other immigrant ethnic groups in the United States. Finally, based on resultsof the study, we can develop a conceptual framework that describes pathwaysthrough which social, cultural, and ecological factors can influence stigma andthe ways in which stigma acts as a barrier to accessing mental health care amongVietnamese Americans. The guiding framework then can be validated and applied infuture programs aimed to improve mental health care utilization among ethnicminorities.
