OBJECTIVES/SPECIFIC AIMS: Stigma has been recognized as a major
impediment to accessing mental health care among Vietnamese and Asian Americans
(Leong and Lau, 2001; Sadavoy et al., 2004; Wynaden
et al., 2005; Fong and Tsuang, 2007). The underutilization
of mental health care, and disparities in both access and outcomes have been
attributed to a large extent to stigma and cultural characteristics of this
population (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 a
consequence of one’s improper behavior in a previous life, for which
the person is now being punished (Nguyen, 2003). Mental disorders can also been
seen as a sign of weakness, which contributes to ambivalence and avoidance of
help-seeking (Fong and Tsuang, 2007). Equally important is the need to protect
family reputation; having emotional problems often implies that the person has
“bad blood” or is being punished for the sins of
his/her ancestors (Herrick and Brown, 1998; Leong and Lau, 2001),
which disgraces the entire family (Wynaden et al., 2005). In
these cases, public stigma (as opposed to internal stigma) is the primary reason
for delays in seeking help (Leong and Lau, 2001). Other research has also
highlighted the influences of culture on how a disorder may be labeled in
different settings, although the presentation of symptoms might be identical
(see Angel and Thoits, 1987). In Vietnamese culture, mental disorders are often
labeled điên (literally translated as
“madness”). A điên person and his or
her family are often severely disgraced; consequently the individuals and their
family become reluctant to disclose and seek help for mental health problems for
fear of rejection (Sadavoy et al., 2004). Despite the critical
role of stigma in accessing mental health care, there has been little work in
trying to understand how stigmatizing attitudes towards mental illness among
Vietnamese Americans manifest themselves and the influences of acculturation on
these attitudes. Some previous work indicated a significant level of mental
illness stigma among Vietnamese Americans, and experiences of living in the
United States might interact with the way stigma manifests among this population
(Do et al., 2014). Stigma is a complex construct that warrants
a deeper and more nuanced understanding (Castro et al., 2005).
Much of the development of stigma-related concepts was based on the classic work
by Goffman (1963); he defined stigma as a process by which an individual
internalizes stigmatizing characteristics and develops fears and anxiety about
being 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, that
contribute to discrimination. Public stigma toward mental illness acts not only
as a major barrier to care, but can also exacerbate anxiety, depression, and
adherence to treatment (Link et al., 1999; Sirey et
al., 2001; Britt et al., 2008; Keyes et
al., 2010). Link and Phelan (2001) conceptualized public stigma through
four major components. The first component, labeling, occurs when people
distinguish and label human differences that are socially relevant, for example,
skin color. In the second component, stereotyping, cultural beliefs link the
labeled persons to undesirable characteristics either in the mind or the body of
such persons, for example people who are mentally ill are violent. The third
component is separating “us” (the normal people) from
“them” (the mentally ill) by the public. Finally, labeled
persons experience status loss and discrimination, where they are devalued,
rejected and excluded. Link and Phelan (2001) emphasized that stigmatization
also depends on access to social, economic, and political power that allows
these components to unfold. This study aims to answer the following research
questions: (1) how does public stigma related to mental illness manifest among
Vietnamese Americans? and (2) in what ways does acculturation influence stigma
among this population? We investigate how the 4 components of stigma according
to Link and Phelan (2001) operationalized and how they depend on the level of
acculturation to the host society. Vietnamese Americans is the key ethnic
minority group for this study for several reasons. Vietnamese immigration, which
did not start in large numbers until the 1970s, has features that allow for a
natural laboratory for comparisons of degree of acculturation. Previous research
has shown significant intergenerational differences in the level of
acculturation 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 who
were born and raised in the United States (the 18–35 year olds) would
be more Americanized than those who were born in Vietnam but spent a significant
part of their younger years in the United States (the 36–55 year
olds), and those who were born and grew up in Vietnam (the 56–75 year
olds) would be most traditional Vietnamese. The language used in focus group
discussions (FGDs) reflected some of the acculturation, where all FGDs with the
youngest groups were done in English, and all FGDs with the oldest groups were
done in Vietnamese. METHODS/STUDY POPULATION: Data were collected
through a set of FGDs and key informant interviews (KIIs) with experts to
explore the conceptualization and manifestation of mental illness public stigma
among Vietnamese Americans in New Orleans. Six FGDs with a total of 51
participants were conducted. Participants were Vietnamese American men and women
ages 18–75. Stratification was used to ensure representation in the
following age/immigration pattern categories: (1) individuals age
56–75 who were born and grew up in Vietnam and immigrated to the
United States after age 35; (2) individuals age 36–55 who were born
in 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 United
States. These groups likely represent different levels of acculturation,
assuming that people who migrate at a younger age are more likely to assimilate
to the host society than those who do at a later age. Separate FGDs were
conducted with men and women. Eleven KIIS were conducted with 6 service
providers and 5 community and religious leaders. In this analysis, we focused on
mental illness public stigma from the FGD participants’ perspectives.
FGDs were conducted in either English or Vietnamese, whichever participants felt
more comfortable with, using semistructured interview guides. All interviews
were audio recorded, transcribed and translated into English if conducted in
Vietnamese. Data coding and analysis was done using NVivo version 11 (QSR
International, 2015). The analysis process utilized a Consensual Qualitative
Research (CQR) approach, a validated and well-established approach to collecting
and analyzing qualitative data. CQR involves gathering textual data through
semistructured interviews or focus groups, utilizing a data analysis process
that fosters multiple perspectives, a consensus process to arrive at judgments
about 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 et
al., 2005). The study was reviewed and approved by Tulane
University’s Internal Review Board. RESULTS/ANTICIPATED
RESULTS: Components of public stigma related to mental illness. The 4 components
of public stigma manifest to different extents within the Vietnamese Americans
in New Orleans. Labeling was among the strongest stigma components, while the
evidence of the other components was mixed. Across groups of participants,
Vietnamese Americans agreed that it was a common belief that people with mental
disorders were “crazy,” “acting
crazy,” or “madness.” “Not
normal,” “sad,” and
“depressed” were among other words used to describe the
mentally ill. However, there were clear differences between younger and older
Vietnamese on how they viewed these conditions. The youngest groups of
participants tended to recognize the “craziness” and
“madness” as a health condition that one would need to
seek help for, whereas the oldest groups often stated that these conditions were
short 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 evidence
supporting the second component, stereotyping, was not strong among Vietnamese
Americans. Most FGD participants agreed that although those with mental
disorders may act differently, they were not distinguishable. In a few extreme
cases, mentally ill individuals were described as petty thefts or being violent
towards their family members. Similarly to the lack of strong evidence of
stereotyping, there was also no evidence of the public separating the mentally
ill (“them”) from “us”. It was
nearly uniformly reported that they felt sympathetic to those with mental
disorders and their family, and that they all recognized that they needed help,
although the type of help was perceived differently across groups. The older
participants often saw that emotional and financial support was needed to help
individuals and families to pass through a temporary phase, whereas younger
participants often reported that professional help was necessary. The last
component, status loss and discrimination, had mixed evidence. While nearly no
participants reported any explicit discriminatory behaviors observed and
practiced towards individuals with mental disorders and their families, words
like “discrimination” and “stigma”
were used in all FGDs to describe direct social consequences of having a mental
disorder. Social exclusion was common. Our older participants said:
“They see less of you, when they see a flaw in you they
don’t talk to you or care about you. That’s one thing the
Vietnamese people are bad at, spreading false rumors and
discrimination” (Older women FGD). One’s loss of status
seemed certain if their or their loved one’s mental health status was
disclosed. Shame, embarrassment, and being “frowned upon”
were direct consequences of one’s mental health status disclosure and
subsequently gossiped about. Anyone with mental disorders was certain to
experience this, and virtually everyone in the community would reportedly do
this to such a family. “You get frowned upon. In the Vietnamese
culture, that’s [a family identified as one with mental
health problems] the big no-no right there. When everybody frowns
upon your family and your family name, that’s when it becomes a
problem” (Young men FGD). This is tied directly to what our
participants described as Vietnamese culture, where pride and family reputation
were such a high priority that those with mental disorders needed to go to a
great extent to protect—“We all know what saving face
means” as reported by our young participants. Even among young
participants, despite their awareness of mental illness and the need for
professional help, the desire to avoid embarrassment and save face was so strong
that one would think twice about seeking help. “No, you just
don’t want to get embarrassed. I don’t want to go to the
damn doctor and be like ‘Oh yeah, my brother got an issue. You can
help him?’ Why would I do that? That’s embarrassing to
myself…” (Young men FGD). Our middle-aged participants
also reported: “If I go to that clinic [mental health or
counseling clinic], I am hoping and praying that I won’t
bump into somebody that I know from the community” (Middle-aged women
FGD). Vietnamese people were also described as being very competitive among
themselves, which led to the fact that if a family was known for having any
problem, gossips would start and spread quickly wherever they go, and pretty
soon, the family would be looked down by the entire community. “I
think 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 distant
themselves from you” (Older women FGD). Culture and mental illness
stigma, much of the described stigma and discrimination expressed, and
consequently the reluctance to seek help, was attributed to the lack of
awareness of mental health and of mental health disorders. Many study
participants across groups also emphasized a belief that Vietnamese Americans
were often known for their perseverance and resilience, overcoming wars and
natural disasters on their own. Mental disorders were reportedly seen as
conditions that individuals and families needed to overcome on their own, rather
than asking for help from outsiders. This aspect of Vietnamese culture is
intertwined with the need to protect one’s family’s
reputation, being passed on from one generation to the next, reinforcing the
beliefs that help for mental disorders should come from within oneself and
one’s family only. Consequently persons with mental health problems
would be “Keeping it to themselves. Holding it in and believing in
the power of their friends” (Middle-aged FGD) instead of seeking
help. Another dimension of culture that was apparent from FGDs (as well as KIIs)
was the mistrust in Western medicine. Not understanding how counseling or
medicines work made one worry about approaching service providers or staying in
treatment. The habit of Vietnamese people to only go see a doctor if they are
sick with physical symptoms was also a hindrance to acknowledging mental illness
and seeking care for it. Challenges, including the lack of vocabulary to express
mental illness and symptoms, in the Vietnamese language, exaggerated the
problem, even among those who had some understanding of mental disorders. It was
said in the young men FGD that: “when you classify depression as an
illness, no one wants to be sick,… if you call it an illness, no one
wants to have that sort of illness, and it’s not an illness that you
can physically see…” (Young men FGD). Another young man
summarized so well the influence of culture on mental illness stigma:
“Us Southeast Asian, like, from my parents specifically has Vietnam
War refugees. I think the reason why they don’t talk about it is
because 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 they
need help, and so the trauma that they carry when they give birth to us is
carried on us as well. But due to the language barrier and also the, like, they
say with the whole health care, in Vietnam I know that they don’t
really believe in Western and Eurocentric medicine. So, from their understanding
of how, like from their experience with colonization or French people, and how
medicine works, they don’t believe in it” (Young men FGD).
One characteristic of the Vietnamese culture that was also often mentioned by
our FGD participants (as well as KIIs) was the lack of sharing and openness
between generations, even within a family. Grandparents, parents, and children
do not usually share and discuss each other’s problems. Parents and
grandparents do not talk about problems because they need to appear strong and
good in front of their children; children do not talk about problems because
they are supposed to do well in all aspects, particularly in school. The
competitiveness of Vietnamese and high expectations of younger generations again
come into play here and create a vicious cycle. Young people are expected to do
well in school, which put pressure on them and may result in mental health
problems, yet, they cannot talk about it with their parents because they are not
supposed to feel bad about school, and sharing is not encouraged. The Asian
model minority myth and the expectations of parents that their children would do
well in school and become doctors and lawyers were cited by many as a cause of
mental health problems among young people. “Our parents are refugees,
they had nothing and our parents want us to achieve this American
Dream…. [omitted] It set expectations and
images for us…. It was expected for all the Asians to be in the top
10, and for, like a little quick minute I thought I wasn’t going to
make it, I was crying” (Yong men FGD). As a result, the mental health
problems get worse. “If you’re feeling bad about
something, you don’t feel like you can talk about it with anyone
else, especially your family, because it is not something that is encouraged to
be talked about anyway, so if you are feeling poorly and you don’t
feel like you could talk to anybody, I think that just perpetuates the bad
feelings” (Middle-aged women FGD). Acculturation and mental illness
stigma Acculturation, the degree of assimilation to the host society, has
changed some of the understanding of mental illness and stigmatizing attitudes.
Differences across generations expressed in different FGDs indicated differences
in perceptions towards mental illness that could be attributed to acculturation.
For example, the young generation understood that mental illness was a health
problem that was prevalent but less recognized in the Vietnamese community,
whereas a prominent theme among the older participants was that mental illness
was a temporary condition due to psychological stress, that it was a condition
that only Caucasians had. Some of the components of public stigma related to
mental illness seemed to vary between generations, for example the youngest
participants were less likely to put a label on a person with mental health
problems, or to stereotype them, compared to the oldest and middle-aged
participants. This was attributed to their education, exposure to the media and
information, and to them “being more Americanized.”
However, there was no evidence that acculturation played an important role in
changing the other components of public stigma, including stereotyping,
separating, and status loss and discrimination. For example, the need to protect
the family reputation was so important that our young participants shared:
“If you damage their image, they will disown you before you damage
that image” (Young men FGD). Young people, more likely to recognize
mental health problems, were also more likely to share within the family and to
seek help, but no more likely than their older counterparts to share outside of
the family—“maybe you would go to counseling or go to
therapy, but you wouldn’t tell people you’re doing
that” (Young women FGD). The youngest participants in our study were
facing a dilemma, in which they recognized mental health problems and the need
for care, yet were still reluctant to seek care or talk about it publicly
because of fears of damaging the family reputation and not living up to the
parents’ expectations. Many young participants reported that it
actually made it very difficult for them to navigate mental health issues
between the 2 cultures, despite the awareness of the resources available.
“I think it actually makes it harder. Only because you know to your
parents and the culture, and your own people, it’s taboo, and
it’s something that you don’t talk about. Just knowing
that you have the resources to go seek it… You want advice from your
family also, but you can’t connect the appointment to your family
because you’re afraid to express that to your parents, you know? So I
think that plays a big part, and knowing that you are up and coming, but you
don’t want to do something to disappoint your family because they are
so traditional” (Young men FGD). Some participants felt more
comfortable talking about mental health problems, like depression, if it was
their friend who experienced it and confided in them, but they would not
necessarily felt open if it was their problem. Subtle cultural differences like
this are likely overlooked by Western service providers. One older participant
summarized it well “They [the young generation]
are more Americanized. They are more open to other things
[but] I think that mental health is still a
barrier.” DISCUSSION/SIGNIFICANCE OF IMPACT: This study
investigated how different components of public stigma related to mental illness
manifest among Vietnamese Americans, a major ethnic group in the United States,
and how acculturation may influence such stigma. The findings highlighted
important components of public stigma, including labeling and status loss, but
did not provide strong evidence of the other components within our study
population. Strong cultural beliefs underlined the understanding of mental
health and mental illness in general, and how people viewed people with mental
illness. Several findings have been highlighted in previous studies with Asian
immigrants elsewhere; for example, a study from the perspectives of health care
providers in Canada found that the unfamiliarity with Western biomedicine and
spiritual beliefs and practices of immigrant women interacted with social stigma
in preventing immigrants from accessing care (O’Mahony and Donnelly,
2007). Fancher et al. (2010) reported similar findings
regarding stigma, traditional beliefs about medicine, and culture among
Vietnamese Americans. Acculturation played a role in changing stigmatizing
attitudes as evidenced in intergenerational differences. However, being more
Americanized did not equate to being more open, having less stigmatizing
attitudes, or being more willing to seek care for mental health issues.
Consistent with previous studies (Pedersen and Paves, 2014), we still found some
level of stigma among young people aged 18–35, although some
components were lessened with an increased level of acculturation. There was
also a conflict among the younger generation, in which the need for mental
health care was recognized but accessing care was no easier for them than for
their parent and grandparent generations. The study’s findings are
useful to adapt existing instruments to measure stigma to this population. The
findings also have important program implications. One, they can be directly
translated into basic supports for local primary and behavioral health care
providers. Two, they can also be used to guide and inform the development and
evaluation of an intervention and an additional study to validate the findings
in other immigrant ethnic groups in the United States. Finally, based on results
of the study, we can develop a conceptual framework that describes pathways
through which social, cultural, and ecological factors can influence stigma and
the ways in which stigma acts as a barrier to accessing mental health care among
Vietnamese Americans. The guiding framework then can be validated and applied in
future programs aimed to improve mental health care utilization among ethnic
minorities.
