- Email: [email protected]
Perceptions of mental health and mental health services among college students in Vietnam and the United States
Accepted Manuscript Title: Perceptions of mental health and mental health services among college students in Vietnam and the United States Authors: Akiko Kamimura, Ha N. Trinh, Mitch Johansen, Jazmine Hurley, Mu Pye, Kai Sin, Hanh Nguyen PII: DOI: Reference:
S1876-2018(18)30537-9 https://doi.org/10.1016/j.ajp.2018.07.012 AJP 1495
To appear in: Received date: Revised date: Accepted date:
6-6-2018 23-7-2018 23-7-2018
Please cite this article as: Kamimura A, Trinh HN, Johansen M, Hurley J, Pye M, Sin K, Nguyen H, Perceptions of mental health and mental health services among college students in Vietnam and the United States, Asian Journal of Psychiatry (2018), https://doi.org/10.1016/j.ajp.2018.07.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Original Article Perceptions of mental health and mental health services among college students in Vietnam and the United States
SC RI PT
Akiko Kamimuraa,*, Ha N. Trinhb, Mitch Johansena, Jazmine Hurleya, Mu Pyea, Kai Sina, Hanh Nguyenc a
University of Utah, Salt Lake City, Utah, USA University of Kansas Medical Center, Kansas City, Kansas, USA C Vietnam National University, Ho Chi Minh City, Vietnam b
*
N
U
Corresponding author at: Department of Sociology, University of Utah, 380 S 1530 E, Salt Lake City, Utah 84112, USA. Tel.: +1 8015855496; fax: +1 8015853784. E-mail address: [email protected] (A. Kamimura).
D
There were differences in the perceptions between Vietnamese and US participants. Vietnamese perspectives showed some stigma toward individuals with mental illness. Vietnamese showed the low likelihood of seeking formal help for mental illness.
TE
M
A
Highlights
Abstract
A
CC
EP
The global burden of mental health disorders is a significant public health issue. One population that has significant risk for mental health issues is college students. Little is known about perceptions of mental illness and mental health services among college students in Vietnam. The purpose of this study is to describe perceptions of mental illness and mental health services among college students in Vietnam, and to compare them with those in the United States (US). The cross-sectional data were collected using a self-administered survey from January to March in 2018 at a national university in Vietnam, and a state university in the US. The study revealed differences in perceptions of causes of mental health between Vietnamese and US participants. Vietnamese participants tended to believe that individuals with mental illness were dangerous and need to be kept out from the community, while US participants perceived that mental illnesses are the same as other illnesses. An important indicator of Vietnamese perceptions of mental health was the low likelihood of seeking formal help because of preference for seeking help from family or friends for mental illness. Interventions, such as mental health awareness campaigns or training courses should be provided for college students in Vietnam. Some
1
strategies to improve mental health among college students used in the US may help to reduce stigma toward mental illness in Vietnam. Keywords: perception; mental illness; mental health services; college students; Vietnam
SC RI PT
1. Introduction
The global burden of mental health disorders is a significant public health issue (World Health Organizations, 2017). Mental health is one of the most recent additions to the United
U
Nations Sustainable Development Goals, while historically the majority of the goals were for
N
communicable diseases (World Health Organizations, 2018). One population that has significant
A
risk for mental health issues is college students (Balon et al., 2015; Bruffaerts et al., 2018). A
M
previous study conducted in the United States (US) shows that mental health issues including
D
anxiety, depression, and relationship problems among college students are increasing concerns
TE
(Mistler et al., 2012). Among college students in Singapore, the prevalence of social networking addiction, which is also related to other sorts of addiction and affective disorder, is high (Tang &
EP
Koh, 2017). A study on psychological distress among college students in India suggests that psychological distress, which is associated with other negative outcomes (e.g. academic failures,
CC
substance abuse, suicidality), is common (Jaisoorya et al., 2017). Adolescents and young adults
A
who reported self-injurious behaviors were more likely to have suicidal intent in India (Bhola, Manjula, Rajappa, & Phillip, 2017). Social phobia is also a problem among university students in India (Joseph, Rasheeka, Nayar, Gupta, Manjeswar, & Mohandas, 2018). Vietnam is a country that does not have much research on mental health, since its main public health focuses are still on infectious diseases (USAID, 2018). The high burden of mental 2
illness and a lack of mental health legislation and resources are problems in Vietnam (Vuong et al., 2011). A household study conducted in Vietnam found that the issues stem from a lack of knowledge about mental illness, and the preference of combining medical treatment and family
SC RI PT
care to cure mental illness (van der Ham et al., 2011). A study conducted in Southeast Asian countries, including Vietnam, suggested that suicidal ideation rates among college students were 11.7%, while similar rates for this age group in the U.S. were at 8.8% (Peltzer et al., 2017). Yet, little is known about perceptions of mental illness and mental health services among college students in Vietnam.
U
The purpose of this study is to describe perceptions of mental illness and mental health
N
services among college students in Vietnam and to compare them with those in the US. The US
A
comparison groups were added due to the prevalent nature of mental health research in the US
M
(Semrau et al., 2015). This will focus on clearly understanding the nature of perceptions of mental health among college students in Vietnam. This study intends to contribute to promoting
EP
2. Methods
TE
D
mental health services for college students in Vietnam.
CC
2.1.Participants and data collection
A
The cross-sectional data were collected using a self-administered survey from January to March of 2018 at a national university in Vietnam and a state university in the US. The Vietnamese university is located in a large city and has approximately 22,000 students. The US university is the state’s flagship university located in a metropolitan area, and it has approximately 32,000
3
students. Prior to data collection, the Institutional Review Board (IRB) of the US university approved this study. The Vietnamese University did not have an IRB at the time of this study. The US university’s IRB has a policy on conducting international research including cases in
SC RI PT
which there is no local IRB in other countries. This study followed the US university’s IRB policy to ensure research ethics in Vietnam were respected as well as those in the US.
Participants were undergraduate students ages 18 to 30 years old attending a social
science-related class. Consent was obtained from each participant. Undergraduate students were given a consent cover letter and paper survey in class, and turned in the survey during or after
U
class. No identifiable information was collected. The survey instrument was translated into
N
Vietnamese from English for participants in Vietnam. The survey was forward-translated from
A
English to Vietnamese by a translator, and was back-translated by another translator into
M
English. The accuracy of the translation was checked by both translators and two of the authors who are native Vietnamese speakers also fluent in English. To ensure the questions were relevant
D
in Vietnam as well as the US, the Vietnamese researchers carefully reviewed the entire survey
TE
instrument. There was no compensation or incentive offered to participants who completed the
CC
EP
survey.
A
2.2.Measures
2.2.1. Perceptions of mental illness and individuals with mental illness
4
Perceptions of mental illness and individuals with mental illness were described using some of the items from the Borinstein’s study (1992). The original version had 15 items. This study used 10 of the 15 items since some of the items were contextually overlapped with each other.
SC RI PT
Participants were asked what extent they agreed with the following statements using a 5-point Likert scale (5= strongly agree; 1 = strongly disagree): 1) Virtually anyone can become mentally ill; 2) There is still a lot of stigma attached to mental illness; 3) Most people with serious mental illness can, with treatment, get well and return to productive lives; 4) Having mental illness is no different from having any other kind of illness; 5) I do not believe mental illness can ever really
U
be cured; 6) People with chronic mental illness are, by far, more dangerous than the general
N
population; 7) Mental health facilities should be kept out of residential neighborhoods; 8) Even if
A
they seem OK, people with chronic mental illness always have the potential to commit violent
M
acts; 9) It is easy to recognize someone who once had a serious mental illness; and 10) The best way to handle the mentally ill is to keep them behind locked doors.
D
In addition, three other questions were included from the Borinstein’s study (1992). The
TE
first question asked participants to choose one for “The number of people with a mental illness in
EP
your country has _____________over the past 20 years” from Increased a lot, Increased a little, Stayed the same, Decreased a little, Decreased a lot, or Not sure. The second question was
CC
“Which of the factors listed below do you believe to play a role in causing mental illnesses? Please pick all that apply.” Participants picked from the following list: Alcohol/ drug abuse;
A
Chemical imbalance; Stress of life; Accidental injury; Inherited; Lack of discipline; and Other. The third question was “In your opinion, what is the most common cause of mental illness? Please pick one.”
5
2.2.2. Perceptions of mental health services
One question developed based on the study conducted by van der Ham et al. (2011) was
SC RI PT
asked to describe perceptions of mental health services: “In your opinion, what would be preferred treatment options for a mental illness for college students? Please pick all that apply.” There were six answers for the question: 1) Department of Psychiatry/ Psychiatric Hospital; 2)
Health care facility other than psychiatry; 3) Counseling or psychological services; 4) Drugs; 5) Support from family and friends; and 6) Traditional healer/ alternative medicine.
U
Moreover, the perceptions of mental health services related to help-seeking were asked
N
using the scale developed by Czyz et al. (2013). The scale asks “To what extent do you agree
A
with or disagree with the following reasons that may prevent college students in your country
M
from not seeking help from professional mental healthcare services (for example, counseling or therapy)?” using a 5-point Likert scale (5=Strongly agree, 1=Strongly disagree). There are eight
D
items: 1) “Perception that professional help is not needed due to problems being minor or
TE
transient;” 2) “Lack of time;” 3) “Preference for self-management of problems;” 4) “Preference
EP
for seeking help from family or friends;” 5) “Pragmatic barriers to accessing services such as long waiting period to see professionals, financial concerns, not knowing where to go for help;”
CC
6) “Concerns about stigma and discomfort related to discussing problems with professionals;” 7) “Doubt that professional help would be beneficial;” and 8) Negative past experiences with
A
professional help seeking.”
2.2.3. Participant characteristics
6
The survey questioned the following socio-demographic characteristics: gender, age, year in
SC RI PT
school, major and race/ethnicity (US participants only).
2.3.Data analysis
Data were analyzed using IBM SPSS Statistics version 22. Vietnamese and US participants were compared using independent samples t-tests for continuous variables and chi-square tests for
N
U
categorical variables (for variables with each cell having five or greater number).
M
A
3. Results
Table 1 presents participant characteristics and descriptive statistics. There were 952
D
participants in total (533 in Vietnam and 419 in the US). The response rate was 80.7% in
TE
Vietnam (collected at 10 classes) and 46.6 % in the US (collected at 11 classes). Over 70% of the
EP
participants were female (72.5%). Less than one-third of the participants were freshman (28%). Social science in general was the most common major among Vietnamese participants (28.3%)
CC
while sociology was the most common major among US participants (24.5%). The average age
A
of the participants was 20.4 (SD=1.9). For the question of “The number of people with a mental illness in your country has
___________over the past 20 years,” the most common answer was “increased a lot” for both countries (49.2% in Vietnam and 57.7% in the US.). As for causes of mental illness (multiple answers), there was a significant difference by country. Vietnamese participants were more
7
likely to believe that stress of life (p<0.01) and accidental injury (p<0.05) were causes of mental illness than US participants. US participants were more likely to believe that alcohol (p<0.05), chemical imbalance (p<0.01), inherited traits (p<0.01), and lack of discipline (p<0.01) were
SC RI PT
causes of mental illness than Vietnamese participants. When participants picked only one most common cause of mental illness, stress of life was most common among Vietnamese participants (77.1%) while chemical imbalance was most common among US participants (42%).
As for treatment options, there was also a significant difference by country, except
regarding support from family and friends. More than 70% of the participants in both countries
U
chose support from family and friends to be the best treatment option. Vietnamese participants
N
were more likely to prefer the department of psychiatry/ psychiatric hospital compared to US
A
participants (p<0.01). US participants were more likely to prefer health care facilities other than
M
psychiatric hospitals, counseling or psychological services, drugs and traditional healer/ alternative medicine compared to Vietnamese participants (p<0.01).
D
Table 2 shows the comparison of perceptions of mental illness and reasons not to seek
TE
help between Vietnamese and US participants. US participants were more likely to agree with
EP
the following statements than Vietnamese participants (p<0.01): “There is still a lot of stigma attached to mental illness;” “Most people with serious mental illness can, with treatment, get
CC
well and return to productive lives;” and “Having mental illness is no different from having any other kind of illness.” Vietnamese participants were more likely to agree with the following
A
statements than US participants: “People with chronic mental illness are, by far, more dangerous than the general population;” “Mental health facilities should be kept out of residential neighborhoods,” “Even if they seem OK, people with chronic mental illness always have the potential to commit violent acts,” “It is easy to recognize someone who once had a serious
8
mental illness,” and “The best way to handle the mentally ill is to keep them behind locked doors.” Regarding perceptions of reasons not to seek help, the only statement that Vietnamese participants were more likely to agree with than US participants was “Preference for seeking
SC RI PT
help from family or friends.”
4. Discussion
This study described perceptions of mental illness and mental health services among college
U
students in Vietnam and the US and has three main findings. First, there were differences in the
N
perceptions of causes of mental health by country. In particular, while Vietnamese participants
A
believed that stress of life was the most common cause, US participants believed chemical
M
imbalance was the most common cause. Second, Vietnamese participants tended to have images that individuals with mental illness were dangerous and need to be kept out from the community,
D
while US participants perceived that mental illness was same as other illness. Third, Vietnamese
TE
participants reported that preference for seeking help from family or friends was one of the main
EP
reasons not to seek help for mental illness. Vietnamese and US participants had a different view about the most common cause of
CC
mental illness: stress of life among Vietnamese participants vs. chemical imbalance among US participants. A study conducted in Vietnam found that power and hierarchy in workplaces affect
A
occupational stress among academic women (Thanh, 2016). The same study indicates that cultural factors in Vietnam could affect types of stressors (Thanh, 2016). College students may have specific stressors which tie with their student life and young age. Future studies should examine cultural factors which may affect stress among college students in Vietnam. US
9
participants reported the view of mental illness as chemical imbalance. However, such view is already outdated due to the advancement of mental health research (National Institute of Mental Health, 2011). Educational programs may help US college students better understand the causes
SC RI PT
of mental illness. The differences in perceptions of individuals with mental illness by country indicate that Vietnamese participants may have stronger stigmas toward those with mental illnesses. Stigma toward individuals with a mental illness is common in developing countries in Asia (Do et al., 2014; Lauber & Rossler, 2007). A previous study suggested that urban residents have more
U
perceived stigma and discrimination toward people with mental illness than rural residents in
N
Vietnam (Ta et al., 2016). All Vietnamese participants of the current study lived in an urban area.
A
Although the participants are not necessarily originally from an urban area, their current
M
residential location might have an impact on their perception of people with mental illness. Moreover, stigma toward mental illness among Asians has been reported (Tran, 2018). Further
D
studies are necessary to obtain more detailed information about the potential stigmas in order to
TE
develop strategies to reduce such stigma.
EP
Vietnamese participants’ views of help-seeking may be related to the levels of their knowledge about mental illness, potential stigma, and views of family and friends as important
CC
help resources (van der Ham et al., 2011; Han & Pong, 2015). A study conducted in Vietnam shows that more than 80% of college students who had the accurate knowledge about depression
A
said they would seek help (Thai & Nguyen, 2018). Health education to increase the accurate knowledge about mental illness would help promote help-seeking. Besides the knowledge, stigma toward mental illness is associated with reduced help-seeking from mental health professionals (Clement et al., 2015). In Vietnam, stigma is not just toward people with mental
10
illness but also toward psychiatrists (Ta et al., 2018). It is important to deal with the issue of stigmatization so college students with mental illness can seek appropriate help (Lauber & Rössler, 2007). Finally, family members and close friends are important resources in supporting
SC RI PT
college students with mental health issues, especially for being listened to and encouraged (Thai & Nguyen, 2018). Vietnamese family structure includes extended family members in which people are obligated to obey and respect from the perspectives of morality and spirituality
(http://www.molinahealthcare.com/providers/nm/medicaid/resource/PDF/health_nm_vietnamese culture-influencesandimplicationsforhealthcare_materialandtest.pdf). Among Vietnamese
U
Americans, those who are less spiritual are more likely to seek mental health services than those
N
who are more spiritual (Luu & Leung, 2009). It would be culturally relevant to consider this
A
when developing approaches, so college students who need formal mental health care will seek
M
not only informal but formal help resources as well.
While this study contributes to increasing the knowledge about perceptions of mental
D
illness and mental health services, it has limitations. This study is cross-sectional and descriptive.
TE
Therefore, it is limited in determining causal relationships among factors. In addition, only one
EP
university from each country was studied. Thus, it may be limited in generalizing the results. Furthermore, even though the relevance of the questions for Vietnamese participants were
CC
carefully examined by Vietnamese researchers, it must be noted that the questions were primarily
A
developed based on the US-based materials.
5. Conclusion This study examined the perceptions of mental health and mental health service seeking
behaviors among college students in Vietnam and the US. Although the study utilized cross-
11
sectional data from two universities, it highlighted the understudied mental health illnesses among college students in Vietnam compared to those in the US. The findings for Vietnamese students were in line with previous studies among Vietnamese immigrant communities across the
SC RI PT
world, and several mental health studies in Vietnam. The findings reflected the stigma towards mental health that remains prevalent among Vietnamese. Vietnamese participants often perceive the causes of mental illnesses as “bad karma” from “wrong-doing” in the past, or even being
possessed by an evil spirit. Thus, they often see mental health patients as shameful individuals who ruin the family reputation. They also see them as violent, and feel those struggling with
U
mental illness should be kept isolated (Lauber & Rossler, 2007; Phan, 2000). These common
N
perceptions of mental health among people in Vietnam are well-documented in our findings and
A
imply several strategic interventions.
M
Although the country health profile of Vietnam mainly focuses on infectious diseases, and individuals are more concerned about their state of physical health, it is important to provide
D
adequate knowledge on mental health illnesses. As a group of young and qualified professionals,
TE
college students can be a target group for mental health education to change common knowledge
EP
and attitudes surrounding the topic. The practice of mental health help seeking behaviors in their communities needs to be promoted as well. Interventions, such as mental health awareness
CC
campaigns or training courses, should be provided for college students in Vietnam for such purpose. Some strategies to improve mental health among college students used in the US (e.g. a
A
counseling center at a university) may help to reduce stigma toward mental illness in Vietnam. The next phase of the research could focus on potential variabilities within countries to
help target the most beneficial mental health services that could be extrapolated to all regions. Additionally, providing the survey to students across a broader range of classes/majors at the
12
universities would have enhanced generalizability of the data. Finally, educational campaigns
Conflict of interest statement: The authors declare that there are no conflicts of interests. Financial disclosure:
SC RI PT
will be key to reduce the stigma as identified.
U
No financial disclosures were reported by the authors of this paper.
N
Funding
M
A
None.
D
Conflict of interests
EP
TE
The authors declare that there are no conflicts of interests.
CC
Acknowledgements
A
We gratefully acknowledge the students who participated in this study and the contributions of Lazarus Adua, Sara Dewitt, Theresa Dvorak, Bethany Everett, Julia Franklin, Sara Grineski, Theresa Martinez, Heather Melton, Frank Page, Allison Riederer, and Bruce Rigby for data collection or entry.
13
SC RI PT
References
Balon R, Beresin EV, Coverdale JH, Louie AK, Roberts LW., 2015. College Mental Health: A Vulnerable Population in an Environment with Systemic Deficiencies. Academic
U
Psychiatry. 39(5), 495-497.
N
Bhola P, Manjula M, Rajappa V, Phillip M., 2017. Predictors of non-suicidal and suicidal self-
A
injurious behaviours, among adolescents and young adults in urban India. Asian Journal
M
of Psychiatry, 29, 123-128.
Borinstein AB., 1992. Public attitudes toward persons with mental illness. Health Affairs. 11(3),
D
186-196.
TE
Bruffaerts R, Mortier P, Kiekens G, et al., 2018. Mental health problems in college freshmen:
EP
Prevalence and academic functioning. Journal of Affective Disorders. 225, 97-103. Clement S, Schauman O, Graham T, et al., 2015. What is the impact of mental health-related
CC
stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine. 45(1), 11-27.
A
Czyz EK, Horwitz AG, Eisenberg D, Kramer A, King CA., 2013. Self-reported barriers to professional help seeking among college students at elevated risk for suicide. Journal of American College Health. 61(7), 398-406. Do M, Pham NNK, Wallick S, Nastasi BK., 2014. Perceptions of mental illness and related
14
stigma among Vietnamese populations: Findings from a mixed method study. Journal of Immigrant and Minority Health. 16(6), 1294-1298. Han M, Pong H., 2015. Mental health help-seeking behaviors among Asian American
Journal of College Student Development. 56(1), 1-14.
SC RI PT
community college students: The effect of stigma, cultural barriers, and acculturation.
Jaisoorya TS, Rani A, Menon PG, Jeevan CR, Revamma M, Jose V, . . . Nair BS., 2017.
Psychological distress among college students in Kerala, India-Prevalence and correlates. Asian Journal of Psychiatry, 28, 28-31.
U
Joseph N, Rasheeka VP, Nayar V, Gupta P, Manjeswar MP, Mohandas A., 2018. Assessment of
N
determinants and quality of life of university students with social phobias in a coastal city
A
of south India. Asian Journal of Psychiatry, 33, 30-37.
M
Lauber C, Rössler W., 2007. Stigma towards people with mental illness in developing countries in Asia. International Review of Psychiatry. 19(2), 157-178.
D
Luu TD, Leung P., 2009. Help-seeking attitudes among Vietnamese Americans: The impact of
EP
476-493.
TE
acculturation, cultural barriers, and spiritual beliefs. Social Work in Mental Health. 7(5),
Mistler BJ, Reetz DR, Krylowicz B, Barr V, 2012. The Association for University and College
CC
Counseling Center Directors Annual Survey. Available at http://files.cmcglobal.com/Monograph_2012_AUCCCD_Public.pdf (accessed 05.06.18)
A
National Institute of Mental Health, 2011. Post by Former NIMH Director Thomas Insel: Mental Illness Defined as Disruption in Neural Circuits. Available at https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2011/mental-illnessdefined-as-disruption-in-neural-circuits.shtml (accessed 05.06.18)
15
Peltzer K, Yi SY, Pengpid S., 2017. Suicidal behaviors and associated factors among university students in six countries in the Association of Southeast Asian Nations (ASEAN). Asian Journal of Psychiatry. 26, 32-38.
SC RI PT
Phan T., 2000. Investigating the use of services for Vietnamese with mental illness. Journal of Community Health. 25(5), 411-425.
Semrau M, Evans-Lacko S, Alem A et al., 2015. Strengthening mental health systems in low-and middle-income countries: the Emerald programme. BMC Medicine. 13(1), 79.
Ta TMT, Boge K, Cao TD, et al., 2018. Public attitudes towards psychiatrists in the metropolitan
U
area of Hanoi, Vietnam. Asian Journal of Psychiatry. 32, 44-49.
N
Ta TMT, Zieger A, Schomerus G, et al., 2016. Influence of urbanity on perception of mental
A
illness stigma: a population based study in urban and rural Hanoi, Vietnam. International
M
Journal of Social Psychiatry. 62(8), 685-695.
Tang CSK, Koh YYW., 2017. Online social networking addiction among college students in
D
Singapore: Comorbidity with behavioral addiction and affective disorder. Asian Journal
TE
of Psychiatry, 25, 175-178.
EP
Thai QCN, Nguyen TH., 2018. Mental health literacy: knowledge of depression among undergraduate students in Hanoi, Vietnam. International Journal of Mental Health
CC
Systems. 12, 8.
A
Thanh LV., 2016. Relationship at work as a cause of occupational stress: the case of academic women in Vietnam. International Journal of Mental Health Systems. 10, 15.
Tran B., 2018. Understanding and addressing the stigma in mental health within the Asian and Asian-American culture. In Deconstructing Stigma in Mental Health (pp. 70-107). IGI Global.
16
USAID, 2018. Global Health: Vietnam. Available at https://www.usaid.gov/vietnam/global-health (accessed 05.06.18) van der Ham L, Wright P, Van TV, Doan VDK, Broerse JEW., 2011. Perceptions of mental
SC RI PT
health and help-seeking behavior in an urban community in Vietnam: An explorative study. Community Mental Health Journal. 47(5), 574-582.
Vuong DA, Van Ginneken E, Morris J, Ha ST, Busse R., 2011. Mental health in Vietnam:
Burden of disease and availability of services. Asian Journal Psychiatry. 4(1), 65–70. World Health Organizations, 2017. Mental Disorders.
U
Available at http://www.who.int/en/news-room/fact-sheets/detail/mental-disorders.
N
(accessed 05.06.18)
A
World Health Organizations, 2018. Mental Health Included in the UN Sustainable Development
A
CC
EP
TE
D
M
Goals. Available at http://www.who.int/mental_health/SDGs/en/. (accessed 05.06.18)
17
Table 1 Descriptive statistics
Freshman Major (Top 3)* Sociology
Vietnam n= 533
USA n = 419
P value
689 (72.5) 265 (28.0)
405 (76.0) 155 (29.2)
284 (67.8) 110 (26.5)
<0.01
99 (20.5)
99 (24.5) 27 (6.7)
Psychology
N
The number of people with a mental illness in your country has ___________over the past 20 years* Increased a lot
EP
TE
Which of the factors listed below do you believe to play a role in causing mental illnesses? (multiple answers) Alcohol
CC
Chemical imbalance Stress of life
A
Accidental injury Inherited Lack of discipline
In your opinion, what is the most common cause of mental illness?*
18
58 (14.4)
502 (52.9) 256 (27.0) 27 (2.8) 16 (1.7) 2 (0.2) 146 (15.4)
261 (49.2) 144 (27.1) 5 (0.9) 11 (2.1) 1 (0.2) 109 (20.5)
241 (57.7) 112 (26.8) 22 (5.3) 5 (1.2) 1 (0.2) 37 (8.9)
770 (80.9) 558 (58.6) 891 (93.6) 676 (71.0) 629 (66.1) 137 (14.4)
419 (78.6) 185 (34.7) 516 (96.8) 392 (73.5) 272 (51.0) 51 (9.6)
351 (83.8) 373 (89.0) 375 (89.5) 284 (67.8) 357 (85.2) 86 (20.5)
A D
M
Increased a little
137 (28.3) 18 (3.7)
N.S.
U
198 (22.3) 164 (18.5) 76 (8.6)
Social Science in general
Stayed the same Decreased a little Decreased a lot Not sure
SC RI PT
Frequency (%) Female
Total N = 952
<0.05 <0.01 <0.01 <0.05 <0.01 <0.01
Chemical imbalance Stress of life Accidental injury Inherited Lack of discipline In your opinion, what would be preferred treatment options for a mental illness for college students? (multiple answers) Department of Psychiatry/ Psychiatric Hospital Health care facility other than psychiatry
5 (0.6)
3 (0.7)
506 (53.2) 265 (27.8) 728 (76.5) 136 (14.3) 693 (72.8) 159 (16.7)
Support from family and friends
M
Traditional healer/ alternative medicine
A
N
Drugs
Mean (SD) Age
46 (11.2) 5 (1.2) 316 (77.1) 16 (3.9) 17 (4.1)
328 (61.5) 101 (18.9) 366 (68.7) 37 (6.9)
U
Counseling or psychological services
91 (11.3) 172 (21.3) 432 (53.5) 21 (2.6) 68 (8.4)
45 (11.3) 167 (42.0) 116 (29.1) 5 (1.3) 51 (12.8) 2 (0.5)
SC RI PT
Alcohol
393 (73.7) 40 (7.5)
178 (42.5) 164 (39.1) 362 (86.4) 99 (23.6) 300 (71.6) 119 (28.4)
<0.01 <0.01 <0.01 <0.01 N.S. <0.01
A
CC
EP
TE
D
20.4 20.2 (1.7) 20.6 <0.01 (1.9) (2.2) P values are based on chi square tests for categorical variables (number for each cell >=5 only) and independent samples t-tests for continuous variables comparing between Vietnamese and US participants. N.S. – Not significant. *P-value not listed because there is at least one cell which has less than 5.
19
USA n = 419
P value
4.37 (0.86) 4.44 (0.77) 3.78 (0.98)
N.S.
3.53 (1.33) 2.51 (1.12) 2.15 (1.11) 2.10 (1.08) 2.40 (1.19)
P<0.01
1.70 (0.84) 1.24 (0.63)
P<0.01
3.87 (1.00) 3.89 (0.98) 3.89 (0.79) 3.42 (0.96) 4.22 (0.92)
P<0.01
4.30 (0.84) 3.85 (0.96)
P<0.01
A
CC
EP
TE
D
M
A
N
U
SC RI PT
Table 2 Perspectives of mental illness and reasons not to seek help Total Vietnam N = 952 n= 533 Perceptions of mental illness Virtually anyone can become mentally ill. 4.37 4.38 (0.83) (0.81) There is still a lot of stigma attached to mental 3.77 3.24 illness. (1.19) (1.19) Most people with serious mental illness can, 3.13 2.62 with treatment, get well and return to (1.43) (1.52) productive lives Having mental illness is no different from 3.12 2.80 having any other kind of illness. (1.37) (1.31) I do not believe mental illness can ever really 2.45 2.40 cured. (1.25) (1.35) People with chronic mental illness are, by far, 2.71 3.15 more dangerous than the general population. (1.36) (1.37) Mental health facilities should be kept out of 2.52 2.85 residential neighborhoods. (1.26) (1.30) Even if they seem OK, people with chronic 3.00 3.41 mental illness always have the potential to (1.35) (1.31) commit violent acts. It is easy to recognize someone who once had a 2.04 2.32 serious mental illness. (1.23) (1.41) The best way to handle the mentally ill is to 1.49 1.68 keep them behind locked doors. (0.82) (0.90) Perceptions of reasons not to seek help Perception that professional help is not needed 3.35 2.93 due to problems being minor or transient (1.18) (1.14) Lack of time 3.27 2.78 (1.15) (1.04) Preference for self-management of problems 3.64 3.42 (0.96) (1.04) Preference for seeking help from family or 3.60 3.75 friends (0.96) (0.77) Pragmatic barriers to accessing services such as 4.05 3.90 long waiting period to see professionals, (0.93) (0.91) financial concerns, not knowing where to go for help Concerns about stigma and discomfort related 4.02 3.79 to discussing problems with professionals (1.00) (1.06) Doubt that professional help would be 3.35 2.95 beneficial (1.06) (0.96)
20
P<0.01 P<0.01
N.S.
P<0.01 P<0.01 P<0.01
P<0.01
P<0.01 P<0.01 P<0.01 P<0.01
P<0.01
A
CC
EP
TE
D
M
A
N
U
SC RI PT
Negative past experiences with professional 3.40 3.23 3.61 P<0.01 help seeking (0.96) (0.92) (0.97) Mean (SD). P values are based on independent samples t-tests comparing between Vietnamese and US participants. Higher numbers indicate stronger levels of agreement (range 1-5).
21
S1876-2018(18)30537-9 https://doi.org/10.1016/j.ajp.2018.07.012 AJP 1495
To appear in: Received date: Revised date: Accepted date:
6-6-2018 23-7-2018 23-7-2018
Please cite this article as: Kamimura A, Trinh HN, Johansen M, Hurley J, Pye M, Sin K, Nguyen H, Perceptions of mental health and mental health services among college students in Vietnam and the United States, Asian Journal of Psychiatry (2018), https://doi.org/10.1016/j.ajp.2018.07.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Original Article Perceptions of mental health and mental health services among college students in Vietnam and the United States
SC RI PT
Akiko Kamimuraa,*, Ha N. Trinhb, Mitch Johansena, Jazmine Hurleya, Mu Pyea, Kai Sina, Hanh Nguyenc a
University of Utah, Salt Lake City, Utah, USA University of Kansas Medical Center, Kansas City, Kansas, USA C Vietnam National University, Ho Chi Minh City, Vietnam b
*
N
U
Corresponding author at: Department of Sociology, University of Utah, 380 S 1530 E, Salt Lake City, Utah 84112, USA. Tel.: +1 8015855496; fax: +1 8015853784. E-mail address: [email protected] (A. Kamimura).
D
There were differences in the perceptions between Vietnamese and US participants. Vietnamese perspectives showed some stigma toward individuals with mental illness. Vietnamese showed the low likelihood of seeking formal help for mental illness.
TE
M
A
Highlights
Abstract
A
CC
EP
The global burden of mental health disorders is a significant public health issue. One population that has significant risk for mental health issues is college students. Little is known about perceptions of mental illness and mental health services among college students in Vietnam. The purpose of this study is to describe perceptions of mental illness and mental health services among college students in Vietnam, and to compare them with those in the United States (US). The cross-sectional data were collected using a self-administered survey from January to March in 2018 at a national university in Vietnam, and a state university in the US. The study revealed differences in perceptions of causes of mental health between Vietnamese and US participants. Vietnamese participants tended to believe that individuals with mental illness were dangerous and need to be kept out from the community, while US participants perceived that mental illnesses are the same as other illnesses. An important indicator of Vietnamese perceptions of mental health was the low likelihood of seeking formal help because of preference for seeking help from family or friends for mental illness. Interventions, such as mental health awareness campaigns or training courses should be provided for college students in Vietnam. Some
1
strategies to improve mental health among college students used in the US may help to reduce stigma toward mental illness in Vietnam. Keywords: perception; mental illness; mental health services; college students; Vietnam
SC RI PT
1. Introduction
The global burden of mental health disorders is a significant public health issue (World Health Organizations, 2017). Mental health is one of the most recent additions to the United
U
Nations Sustainable Development Goals, while historically the majority of the goals were for
N
communicable diseases (World Health Organizations, 2018). One population that has significant
A
risk for mental health issues is college students (Balon et al., 2015; Bruffaerts et al., 2018). A
M
previous study conducted in the United States (US) shows that mental health issues including
D
anxiety, depression, and relationship problems among college students are increasing concerns
TE
(Mistler et al., 2012). Among college students in Singapore, the prevalence of social networking addiction, which is also related to other sorts of addiction and affective disorder, is high (Tang &
EP
Koh, 2017). A study on psychological distress among college students in India suggests that psychological distress, which is associated with other negative outcomes (e.g. academic failures,
CC
substance abuse, suicidality), is common (Jaisoorya et al., 2017). Adolescents and young adults
A
who reported self-injurious behaviors were more likely to have suicidal intent in India (Bhola, Manjula, Rajappa, & Phillip, 2017). Social phobia is also a problem among university students in India (Joseph, Rasheeka, Nayar, Gupta, Manjeswar, & Mohandas, 2018). Vietnam is a country that does not have much research on mental health, since its main public health focuses are still on infectious diseases (USAID, 2018). The high burden of mental 2
illness and a lack of mental health legislation and resources are problems in Vietnam (Vuong et al., 2011). A household study conducted in Vietnam found that the issues stem from a lack of knowledge about mental illness, and the preference of combining medical treatment and family
SC RI PT
care to cure mental illness (van der Ham et al., 2011). A study conducted in Southeast Asian countries, including Vietnam, suggested that suicidal ideation rates among college students were 11.7%, while similar rates for this age group in the U.S. were at 8.8% (Peltzer et al., 2017). Yet, little is known about perceptions of mental illness and mental health services among college students in Vietnam.
U
The purpose of this study is to describe perceptions of mental illness and mental health
N
services among college students in Vietnam and to compare them with those in the US. The US
A
comparison groups were added due to the prevalent nature of mental health research in the US
M
(Semrau et al., 2015). This will focus on clearly understanding the nature of perceptions of mental health among college students in Vietnam. This study intends to contribute to promoting
EP
2. Methods
TE
D
mental health services for college students in Vietnam.
CC
2.1.Participants and data collection
A
The cross-sectional data were collected using a self-administered survey from January to March of 2018 at a national university in Vietnam and a state university in the US. The Vietnamese university is located in a large city and has approximately 22,000 students. The US university is the state’s flagship university located in a metropolitan area, and it has approximately 32,000
3
students. Prior to data collection, the Institutional Review Board (IRB) of the US university approved this study. The Vietnamese University did not have an IRB at the time of this study. The US university’s IRB has a policy on conducting international research including cases in
SC RI PT
which there is no local IRB in other countries. This study followed the US university’s IRB policy to ensure research ethics in Vietnam were respected as well as those in the US.
Participants were undergraduate students ages 18 to 30 years old attending a social
science-related class. Consent was obtained from each participant. Undergraduate students were given a consent cover letter and paper survey in class, and turned in the survey during or after
U
class. No identifiable information was collected. The survey instrument was translated into
N
Vietnamese from English for participants in Vietnam. The survey was forward-translated from
A
English to Vietnamese by a translator, and was back-translated by another translator into
M
English. The accuracy of the translation was checked by both translators and two of the authors who are native Vietnamese speakers also fluent in English. To ensure the questions were relevant
D
in Vietnam as well as the US, the Vietnamese researchers carefully reviewed the entire survey
TE
instrument. There was no compensation or incentive offered to participants who completed the
CC
EP
survey.
A
2.2.Measures
2.2.1. Perceptions of mental illness and individuals with mental illness
4
Perceptions of mental illness and individuals with mental illness were described using some of the items from the Borinstein’s study (1992). The original version had 15 items. This study used 10 of the 15 items since some of the items were contextually overlapped with each other.
SC RI PT
Participants were asked what extent they agreed with the following statements using a 5-point Likert scale (5= strongly agree; 1 = strongly disagree): 1) Virtually anyone can become mentally ill; 2) There is still a lot of stigma attached to mental illness; 3) Most people with serious mental illness can, with treatment, get well and return to productive lives; 4) Having mental illness is no different from having any other kind of illness; 5) I do not believe mental illness can ever really
U
be cured; 6) People with chronic mental illness are, by far, more dangerous than the general
N
population; 7) Mental health facilities should be kept out of residential neighborhoods; 8) Even if
A
they seem OK, people with chronic mental illness always have the potential to commit violent
M
acts; 9) It is easy to recognize someone who once had a serious mental illness; and 10) The best way to handle the mentally ill is to keep them behind locked doors.
D
In addition, three other questions were included from the Borinstein’s study (1992). The
TE
first question asked participants to choose one for “The number of people with a mental illness in
EP
your country has _____________over the past 20 years” from Increased a lot, Increased a little, Stayed the same, Decreased a little, Decreased a lot, or Not sure. The second question was
CC
“Which of the factors listed below do you believe to play a role in causing mental illnesses? Please pick all that apply.” Participants picked from the following list: Alcohol/ drug abuse;
A
Chemical imbalance; Stress of life; Accidental injury; Inherited; Lack of discipline; and Other. The third question was “In your opinion, what is the most common cause of mental illness? Please pick one.”
5
2.2.2. Perceptions of mental health services
One question developed based on the study conducted by van der Ham et al. (2011) was
SC RI PT
asked to describe perceptions of mental health services: “In your opinion, what would be preferred treatment options for a mental illness for college students? Please pick all that apply.” There were six answers for the question: 1) Department of Psychiatry/ Psychiatric Hospital; 2)
Health care facility other than psychiatry; 3) Counseling or psychological services; 4) Drugs; 5) Support from family and friends; and 6) Traditional healer/ alternative medicine.
U
Moreover, the perceptions of mental health services related to help-seeking were asked
N
using the scale developed by Czyz et al. (2013). The scale asks “To what extent do you agree
A
with or disagree with the following reasons that may prevent college students in your country
M
from not seeking help from professional mental healthcare services (for example, counseling or therapy)?” using a 5-point Likert scale (5=Strongly agree, 1=Strongly disagree). There are eight
D
items: 1) “Perception that professional help is not needed due to problems being minor or
TE
transient;” 2) “Lack of time;” 3) “Preference for self-management of problems;” 4) “Preference
EP
for seeking help from family or friends;” 5) “Pragmatic barriers to accessing services such as long waiting period to see professionals, financial concerns, not knowing where to go for help;”
CC
6) “Concerns about stigma and discomfort related to discussing problems with professionals;” 7) “Doubt that professional help would be beneficial;” and 8) Negative past experiences with
A
professional help seeking.”
2.2.3. Participant characteristics
6
The survey questioned the following socio-demographic characteristics: gender, age, year in
SC RI PT
school, major and race/ethnicity (US participants only).
2.3.Data analysis
Data were analyzed using IBM SPSS Statistics version 22. Vietnamese and US participants were compared using independent samples t-tests for continuous variables and chi-square tests for
N
U
categorical variables (for variables with each cell having five or greater number).
M
A
3. Results
Table 1 presents participant characteristics and descriptive statistics. There were 952
D
participants in total (533 in Vietnam and 419 in the US). The response rate was 80.7% in
TE
Vietnam (collected at 10 classes) and 46.6 % in the US (collected at 11 classes). Over 70% of the
EP
participants were female (72.5%). Less than one-third of the participants were freshman (28%). Social science in general was the most common major among Vietnamese participants (28.3%)
CC
while sociology was the most common major among US participants (24.5%). The average age
A
of the participants was 20.4 (SD=1.9). For the question of “The number of people with a mental illness in your country has
___________over the past 20 years,” the most common answer was “increased a lot” for both countries (49.2% in Vietnam and 57.7% in the US.). As for causes of mental illness (multiple answers), there was a significant difference by country. Vietnamese participants were more
7
likely to believe that stress of life (p<0.01) and accidental injury (p<0.05) were causes of mental illness than US participants. US participants were more likely to believe that alcohol (p<0.05), chemical imbalance (p<0.01), inherited traits (p<0.01), and lack of discipline (p<0.01) were
SC RI PT
causes of mental illness than Vietnamese participants. When participants picked only one most common cause of mental illness, stress of life was most common among Vietnamese participants (77.1%) while chemical imbalance was most common among US participants (42%).
As for treatment options, there was also a significant difference by country, except
regarding support from family and friends. More than 70% of the participants in both countries
U
chose support from family and friends to be the best treatment option. Vietnamese participants
N
were more likely to prefer the department of psychiatry/ psychiatric hospital compared to US
A
participants (p<0.01). US participants were more likely to prefer health care facilities other than
M
psychiatric hospitals, counseling or psychological services, drugs and traditional healer/ alternative medicine compared to Vietnamese participants (p<0.01).
D
Table 2 shows the comparison of perceptions of mental illness and reasons not to seek
TE
help between Vietnamese and US participants. US participants were more likely to agree with
EP
the following statements than Vietnamese participants (p<0.01): “There is still a lot of stigma attached to mental illness;” “Most people with serious mental illness can, with treatment, get
CC
well and return to productive lives;” and “Having mental illness is no different from having any other kind of illness.” Vietnamese participants were more likely to agree with the following
A
statements than US participants: “People with chronic mental illness are, by far, more dangerous than the general population;” “Mental health facilities should be kept out of residential neighborhoods,” “Even if they seem OK, people with chronic mental illness always have the potential to commit violent acts,” “It is easy to recognize someone who once had a serious
8
mental illness,” and “The best way to handle the mentally ill is to keep them behind locked doors.” Regarding perceptions of reasons not to seek help, the only statement that Vietnamese participants were more likely to agree with than US participants was “Preference for seeking
SC RI PT
help from family or friends.”
4. Discussion
This study described perceptions of mental illness and mental health services among college
U
students in Vietnam and the US and has three main findings. First, there were differences in the
N
perceptions of causes of mental health by country. In particular, while Vietnamese participants
A
believed that stress of life was the most common cause, US participants believed chemical
M
imbalance was the most common cause. Second, Vietnamese participants tended to have images that individuals with mental illness were dangerous and need to be kept out from the community,
D
while US participants perceived that mental illness was same as other illness. Third, Vietnamese
TE
participants reported that preference for seeking help from family or friends was one of the main
EP
reasons not to seek help for mental illness. Vietnamese and US participants had a different view about the most common cause of
CC
mental illness: stress of life among Vietnamese participants vs. chemical imbalance among US participants. A study conducted in Vietnam found that power and hierarchy in workplaces affect
A
occupational stress among academic women (Thanh, 2016). The same study indicates that cultural factors in Vietnam could affect types of stressors (Thanh, 2016). College students may have specific stressors which tie with their student life and young age. Future studies should examine cultural factors which may affect stress among college students in Vietnam. US
9
participants reported the view of mental illness as chemical imbalance. However, such view is already outdated due to the advancement of mental health research (National Institute of Mental Health, 2011). Educational programs may help US college students better understand the causes
SC RI PT
of mental illness. The differences in perceptions of individuals with mental illness by country indicate that Vietnamese participants may have stronger stigmas toward those with mental illnesses. Stigma toward individuals with a mental illness is common in developing countries in Asia (Do et al., 2014; Lauber & Rossler, 2007). A previous study suggested that urban residents have more
U
perceived stigma and discrimination toward people with mental illness than rural residents in
N
Vietnam (Ta et al., 2016). All Vietnamese participants of the current study lived in an urban area.
A
Although the participants are not necessarily originally from an urban area, their current
M
residential location might have an impact on their perception of people with mental illness. Moreover, stigma toward mental illness among Asians has been reported (Tran, 2018). Further
D
studies are necessary to obtain more detailed information about the potential stigmas in order to
TE
develop strategies to reduce such stigma.
EP
Vietnamese participants’ views of help-seeking may be related to the levels of their knowledge about mental illness, potential stigma, and views of family and friends as important
CC
help resources (van der Ham et al., 2011; Han & Pong, 2015). A study conducted in Vietnam shows that more than 80% of college students who had the accurate knowledge about depression
A
said they would seek help (Thai & Nguyen, 2018). Health education to increase the accurate knowledge about mental illness would help promote help-seeking. Besides the knowledge, stigma toward mental illness is associated with reduced help-seeking from mental health professionals (Clement et al., 2015). In Vietnam, stigma is not just toward people with mental
10
illness but also toward psychiatrists (Ta et al., 2018). It is important to deal with the issue of stigmatization so college students with mental illness can seek appropriate help (Lauber & Rössler, 2007). Finally, family members and close friends are important resources in supporting
SC RI PT
college students with mental health issues, especially for being listened to and encouraged (Thai & Nguyen, 2018). Vietnamese family structure includes extended family members in which people are obligated to obey and respect from the perspectives of morality and spirituality
(http://www.molinahealthcare.com/providers/nm/medicaid/resource/PDF/health_nm_vietnamese culture-influencesandimplicationsforhealthcare_materialandtest.pdf). Among Vietnamese
U
Americans, those who are less spiritual are more likely to seek mental health services than those
N
who are more spiritual (Luu & Leung, 2009). It would be culturally relevant to consider this
A
when developing approaches, so college students who need formal mental health care will seek
M
not only informal but formal help resources as well.
While this study contributes to increasing the knowledge about perceptions of mental
D
illness and mental health services, it has limitations. This study is cross-sectional and descriptive.
TE
Therefore, it is limited in determining causal relationships among factors. In addition, only one
EP
university from each country was studied. Thus, it may be limited in generalizing the results. Furthermore, even though the relevance of the questions for Vietnamese participants were
CC
carefully examined by Vietnamese researchers, it must be noted that the questions were primarily
A
developed based on the US-based materials.
5. Conclusion This study examined the perceptions of mental health and mental health service seeking
behaviors among college students in Vietnam and the US. Although the study utilized cross-
11
sectional data from two universities, it highlighted the understudied mental health illnesses among college students in Vietnam compared to those in the US. The findings for Vietnamese students were in line with previous studies among Vietnamese immigrant communities across the
SC RI PT
world, and several mental health studies in Vietnam. The findings reflected the stigma towards mental health that remains prevalent among Vietnamese. Vietnamese participants often perceive the causes of mental illnesses as “bad karma” from “wrong-doing” in the past, or even being
possessed by an evil spirit. Thus, they often see mental health patients as shameful individuals who ruin the family reputation. They also see them as violent, and feel those struggling with
U
mental illness should be kept isolated (Lauber & Rossler, 2007; Phan, 2000). These common
N
perceptions of mental health among people in Vietnam are well-documented in our findings and
A
imply several strategic interventions.
M
Although the country health profile of Vietnam mainly focuses on infectious diseases, and individuals are more concerned about their state of physical health, it is important to provide
D
adequate knowledge on mental health illnesses. As a group of young and qualified professionals,
TE
college students can be a target group for mental health education to change common knowledge
EP
and attitudes surrounding the topic. The practice of mental health help seeking behaviors in their communities needs to be promoted as well. Interventions, such as mental health awareness
CC
campaigns or training courses, should be provided for college students in Vietnam for such purpose. Some strategies to improve mental health among college students used in the US (e.g. a
A
counseling center at a university) may help to reduce stigma toward mental illness in Vietnam. The next phase of the research could focus on potential variabilities within countries to
help target the most beneficial mental health services that could be extrapolated to all regions. Additionally, providing the survey to students across a broader range of classes/majors at the
12
universities would have enhanced generalizability of the data. Finally, educational campaigns
Conflict of interest statement: The authors declare that there are no conflicts of interests. Financial disclosure:
SC RI PT
will be key to reduce the stigma as identified.
U
No financial disclosures were reported by the authors of this paper.
N
Funding
M
A
None.
D
Conflict of interests
EP
TE
The authors declare that there are no conflicts of interests.
CC
Acknowledgements
A
We gratefully acknowledge the students who participated in this study and the contributions of Lazarus Adua, Sara Dewitt, Theresa Dvorak, Bethany Everett, Julia Franklin, Sara Grineski, Theresa Martinez, Heather Melton, Frank Page, Allison Riederer, and Bruce Rigby for data collection or entry.
13
SC RI PT
References
Balon R, Beresin EV, Coverdale JH, Louie AK, Roberts LW., 2015. College Mental Health: A Vulnerable Population in an Environment with Systemic Deficiencies. Academic
U
Psychiatry. 39(5), 495-497.
N
Bhola P, Manjula M, Rajappa V, Phillip M., 2017. Predictors of non-suicidal and suicidal self-
A
injurious behaviours, among adolescents and young adults in urban India. Asian Journal
M
of Psychiatry, 29, 123-128.
Borinstein AB., 1992. Public attitudes toward persons with mental illness. Health Affairs. 11(3),
D
186-196.
TE
Bruffaerts R, Mortier P, Kiekens G, et al., 2018. Mental health problems in college freshmen:
EP
Prevalence and academic functioning. Journal of Affective Disorders. 225, 97-103. Clement S, Schauman O, Graham T, et al., 2015. What is the impact of mental health-related
CC
stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine. 45(1), 11-27.
A
Czyz EK, Horwitz AG, Eisenberg D, Kramer A, King CA., 2013. Self-reported barriers to professional help seeking among college students at elevated risk for suicide. Journal of American College Health. 61(7), 398-406. Do M, Pham NNK, Wallick S, Nastasi BK., 2014. Perceptions of mental illness and related
14
stigma among Vietnamese populations: Findings from a mixed method study. Journal of Immigrant and Minority Health. 16(6), 1294-1298. Han M, Pong H., 2015. Mental health help-seeking behaviors among Asian American
Journal of College Student Development. 56(1), 1-14.
SC RI PT
community college students: The effect of stigma, cultural barriers, and acculturation.
Jaisoorya TS, Rani A, Menon PG, Jeevan CR, Revamma M, Jose V, . . . Nair BS., 2017.
Psychological distress among college students in Kerala, India-Prevalence and correlates. Asian Journal of Psychiatry, 28, 28-31.
U
Joseph N, Rasheeka VP, Nayar V, Gupta P, Manjeswar MP, Mohandas A., 2018. Assessment of
N
determinants and quality of life of university students with social phobias in a coastal city
A
of south India. Asian Journal of Psychiatry, 33, 30-37.
M
Lauber C, Rössler W., 2007. Stigma towards people with mental illness in developing countries in Asia. International Review of Psychiatry. 19(2), 157-178.
D
Luu TD, Leung P., 2009. Help-seeking attitudes among Vietnamese Americans: The impact of
EP
476-493.
TE
acculturation, cultural barriers, and spiritual beliefs. Social Work in Mental Health. 7(5),
Mistler BJ, Reetz DR, Krylowicz B, Barr V, 2012. The Association for University and College
CC
Counseling Center Directors Annual Survey. Available at http://files.cmcglobal.com/Monograph_2012_AUCCCD_Public.pdf (accessed 05.06.18)
A
National Institute of Mental Health, 2011. Post by Former NIMH Director Thomas Insel: Mental Illness Defined as Disruption in Neural Circuits. Available at https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2011/mental-illnessdefined-as-disruption-in-neural-circuits.shtml (accessed 05.06.18)
15
Peltzer K, Yi SY, Pengpid S., 2017. Suicidal behaviors and associated factors among university students in six countries in the Association of Southeast Asian Nations (ASEAN). Asian Journal of Psychiatry. 26, 32-38.
SC RI PT
Phan T., 2000. Investigating the use of services for Vietnamese with mental illness. Journal of Community Health. 25(5), 411-425.
Semrau M, Evans-Lacko S, Alem A et al., 2015. Strengthening mental health systems in low-and middle-income countries: the Emerald programme. BMC Medicine. 13(1), 79.
Ta TMT, Boge K, Cao TD, et al., 2018. Public attitudes towards psychiatrists in the metropolitan
U
area of Hanoi, Vietnam. Asian Journal of Psychiatry. 32, 44-49.
N
Ta TMT, Zieger A, Schomerus G, et al., 2016. Influence of urbanity on perception of mental
A
illness stigma: a population based study in urban and rural Hanoi, Vietnam. International
M
Journal of Social Psychiatry. 62(8), 685-695.
Tang CSK, Koh YYW., 2017. Online social networking addiction among college students in
D
Singapore: Comorbidity with behavioral addiction and affective disorder. Asian Journal
TE
of Psychiatry, 25, 175-178.
EP
Thai QCN, Nguyen TH., 2018. Mental health literacy: knowledge of depression among undergraduate students in Hanoi, Vietnam. International Journal of Mental Health
CC
Systems. 12, 8.
A
Thanh LV., 2016. Relationship at work as a cause of occupational stress: the case of academic women in Vietnam. International Journal of Mental Health Systems. 10, 15.
Tran B., 2018. Understanding and addressing the stigma in mental health within the Asian and Asian-American culture. In Deconstructing Stigma in Mental Health (pp. 70-107). IGI Global.
16
USAID, 2018. Global Health: Vietnam. Available at https://www.usaid.gov/vietnam/global-health (accessed 05.06.18) van der Ham L, Wright P, Van TV, Doan VDK, Broerse JEW., 2011. Perceptions of mental
SC RI PT
health and help-seeking behavior in an urban community in Vietnam: An explorative study. Community Mental Health Journal. 47(5), 574-582.
Vuong DA, Van Ginneken E, Morris J, Ha ST, Busse R., 2011. Mental health in Vietnam:
Burden of disease and availability of services. Asian Journal Psychiatry. 4(1), 65–70. World Health Organizations, 2017. Mental Disorders.
U
Available at http://www.who.int/en/news-room/fact-sheets/detail/mental-disorders.
N
(accessed 05.06.18)
A
World Health Organizations, 2018. Mental Health Included in the UN Sustainable Development
A
CC
EP
TE
D
M
Goals. Available at http://www.who.int/mental_health/SDGs/en/. (accessed 05.06.18)
17
Table 1 Descriptive statistics
Freshman Major (Top 3)* Sociology
Vietnam n= 533
USA n = 419
P value
689 (72.5) 265 (28.0)
405 (76.0) 155 (29.2)
284 (67.8) 110 (26.5)
<0.01
99 (20.5)
99 (24.5) 27 (6.7)
Psychology
N
The number of people with a mental illness in your country has ___________over the past 20 years* Increased a lot
EP
TE
Which of the factors listed below do you believe to play a role in causing mental illnesses? (multiple answers) Alcohol
CC
Chemical imbalance Stress of life
A
Accidental injury Inherited Lack of discipline
In your opinion, what is the most common cause of mental illness?*
18
58 (14.4)
502 (52.9) 256 (27.0) 27 (2.8) 16 (1.7) 2 (0.2) 146 (15.4)
261 (49.2) 144 (27.1) 5 (0.9) 11 (2.1) 1 (0.2) 109 (20.5)
241 (57.7) 112 (26.8) 22 (5.3) 5 (1.2) 1 (0.2) 37 (8.9)
770 (80.9) 558 (58.6) 891 (93.6) 676 (71.0) 629 (66.1) 137 (14.4)
419 (78.6) 185 (34.7) 516 (96.8) 392 (73.5) 272 (51.0) 51 (9.6)
351 (83.8) 373 (89.0) 375 (89.5) 284 (67.8) 357 (85.2) 86 (20.5)
A D
M
Increased a little
137 (28.3) 18 (3.7)
N.S.
U
198 (22.3) 164 (18.5) 76 (8.6)
Social Science in general
Stayed the same Decreased a little Decreased a lot Not sure
SC RI PT
Frequency (%) Female
Total N = 952
<0.05 <0.01 <0.01 <0.05 <0.01 <0.01
Chemical imbalance Stress of life Accidental injury Inherited Lack of discipline In your opinion, what would be preferred treatment options for a mental illness for college students? (multiple answers) Department of Psychiatry/ Psychiatric Hospital Health care facility other than psychiatry
5 (0.6)
3 (0.7)
506 (53.2) 265 (27.8) 728 (76.5) 136 (14.3) 693 (72.8) 159 (16.7)
Support from family and friends
M
Traditional healer/ alternative medicine
A
N
Drugs
Mean (SD) Age
46 (11.2) 5 (1.2) 316 (77.1) 16 (3.9) 17 (4.1)
328 (61.5) 101 (18.9) 366 (68.7) 37 (6.9)
U
Counseling or psychological services
91 (11.3) 172 (21.3) 432 (53.5) 21 (2.6) 68 (8.4)
45 (11.3) 167 (42.0) 116 (29.1) 5 (1.3) 51 (12.8) 2 (0.5)
SC RI PT
Alcohol
393 (73.7) 40 (7.5)
178 (42.5) 164 (39.1) 362 (86.4) 99 (23.6) 300 (71.6) 119 (28.4)
<0.01 <0.01 <0.01 <0.01 N.S. <0.01
A
CC
EP
TE
D
20.4 20.2 (1.7) 20.6 <0.01 (1.9) (2.2) P values are based on chi square tests for categorical variables (number for each cell >=5 only) and independent samples t-tests for continuous variables comparing between Vietnamese and US participants. N.S. – Not significant. *P-value not listed because there is at least one cell which has less than 5.
19
USA n = 419
P value
4.37 (0.86) 4.44 (0.77) 3.78 (0.98)
N.S.
3.53 (1.33) 2.51 (1.12) 2.15 (1.11) 2.10 (1.08) 2.40 (1.19)
P<0.01
1.70 (0.84) 1.24 (0.63)
P<0.01
3.87 (1.00) 3.89 (0.98) 3.89 (0.79) 3.42 (0.96) 4.22 (0.92)
P<0.01
4.30 (0.84) 3.85 (0.96)
P<0.01
A
CC
EP
TE
D
M
A
N
U
SC RI PT
Table 2 Perspectives of mental illness and reasons not to seek help Total Vietnam N = 952 n= 533 Perceptions of mental illness Virtually anyone can become mentally ill. 4.37 4.38 (0.83) (0.81) There is still a lot of stigma attached to mental 3.77 3.24 illness. (1.19) (1.19) Most people with serious mental illness can, 3.13 2.62 with treatment, get well and return to (1.43) (1.52) productive lives Having mental illness is no different from 3.12 2.80 having any other kind of illness. (1.37) (1.31) I do not believe mental illness can ever really 2.45 2.40 cured. (1.25) (1.35) People with chronic mental illness are, by far, 2.71 3.15 more dangerous than the general population. (1.36) (1.37) Mental health facilities should be kept out of 2.52 2.85 residential neighborhoods. (1.26) (1.30) Even if they seem OK, people with chronic 3.00 3.41 mental illness always have the potential to (1.35) (1.31) commit violent acts. It is easy to recognize someone who once had a 2.04 2.32 serious mental illness. (1.23) (1.41) The best way to handle the mentally ill is to 1.49 1.68 keep them behind locked doors. (0.82) (0.90) Perceptions of reasons not to seek help Perception that professional help is not needed 3.35 2.93 due to problems being minor or transient (1.18) (1.14) Lack of time 3.27 2.78 (1.15) (1.04) Preference for self-management of problems 3.64 3.42 (0.96) (1.04) Preference for seeking help from family or 3.60 3.75 friends (0.96) (0.77) Pragmatic barriers to accessing services such as 4.05 3.90 long waiting period to see professionals, (0.93) (0.91) financial concerns, not knowing where to go for help Concerns about stigma and discomfort related 4.02 3.79 to discussing problems with professionals (1.00) (1.06) Doubt that professional help would be 3.35 2.95 beneficial (1.06) (0.96)
20
P<0.01 P<0.01
N.S.
P<0.01 P<0.01 P<0.01
P<0.01
P<0.01 P<0.01 P<0.01 P<0.01
P<0.01
A
CC
EP
TE
D
M
A
N
U
SC RI PT
Negative past experiences with professional 3.40 3.23 3.61 P<0.01 help seeking (0.96) (0.92) (0.97) Mean (SD). P values are based on independent samples t-tests comparing between Vietnamese and US participants. Higher numbers indicate stronger levels of agreement (range 1-5).
21