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Increasing mental health awareness and appropriate service use in older Chinese Americans: A pilot intervention
Patient Education and Counseling 76 (2009) 143–146
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short Communication
Increasing mental health awareness and appropriate service use in older Chinese Americans: A pilot intervention Ellen J. Teng a,b,c,*, Lois C. Friedman b,1 a
Michael E. DeBakey VA Medical Center, Houston, United States Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, United States c Houston Center for Quality of Care & Utilization Studies, Houston, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 May 2008 Received in revised form 6 November 2008 Accepted 11 November 2008
Objective: This study evaluated the effectiveness of a community intervention in increasing awareness of mental health issues and available resources among elderly Chinese Americans. Methods: Twenty-seven members of a community church received a 1-h didactic presentation, in English and Mandarin, and completed surveys regarding their help-seeking preferences before and after the intervention. Results were analyzed using a series of Wilcoxon matched-pair signed rank tests and comparing pre- and post-test scores. Results: Findings indicated an increase (p < .05) in intention to consult a mental health professional for psychiatric symptoms at post-test. A significant increase also was found in preference for consulting a physician for physical symptoms. Conclusion: The pilot educational intervention increased awareness of mental health and treatment issues and the role of mental health professionals, lending support to evaluate the intervention on a larger scale. Practice implications: Greater awareness of mental health among Chinese Americans can be promoted via education forums provided through faith-based organizations. Stigma of mental illness leads many Chinese individuals to seek help for psychiatric problems from primary care physicians. Integrating mental health practitioners in primary care settings may help decrease stigma and encourage appropriate help-seeking behavior. Published by Elsevier Ireland Ltd.
Keywords: Mental health services Americans Chinese Aged Health education
1. Introduction Low utilization of mental health services among racial and ethnic minorities is related to acculturation, cultural values, physical barriers, lack of mental health knowledge [1–3] and negative attitudes toward seeking professional help [4]. These factors contribute to delays in seeking treatment and affect helpseeking patterns [2,5]. Asian Americans frequently perceive seeking psychiatric services as a last resort, which often means that they present with more severe disorders when they seek professional help and have longer hospital stays when admitted to psychiatric facilities [6]. Chinese Americans are up to 94% less likely to seek professional help for anxiety and depressive disorders, compared with somatoform disorders [7]. Delays in
* Corresponding author at: Veterans Affairs Medical Center, 116-MHCL 2002 Holcombe Blvd, Houston, TX 77030, United States. Tel.: +1 713 791 1414x5513; fax: +1 713 794 8769. E-mail address: [email protected] (E.J. Teng). 1 Currently at University Hospitals Ireland Cancer Center at Case Medical Center, Cleveland, OH, United States. 0738-3991/$ – see front matter . Published by Elsevier Ireland Ltd. doi:10.1016/j.pec.2008.11.008
seeking treatment among Asian Americans also may be related to an over-reliance upon medical doctors for psychiatric symptoms [7] and unawareness of how psychiatric problems can impact physical well-being. Additional variables in Asian culture discouraging professional consultation include the involvement of extended-family and the highly stigmatizing nature of mental illness. Hence, informal caregivers (e.g., family and friends) are likely to be consulted first [1,8,10] and are the ones who subsequently initiate and facilitate the process of introducing symptomatic relatives to mental health caregivers [11]. Despite the identified need to increase community education/ outreach to facilitate access to mental health services among the Asian population [12], relatively little progress has been made in addressing delays in seeking treatment and underutilization of available services in the Asian American community through education [9]. Although church-based interventions have shown success in promoting physical health [13,14], little effort has been made to access these venues to promote mental health. The purpose of the current study was to evaluate the effectiveness of a church-based educational intervention in increasing the awareness (i.e., knowledge) of mental health and available resources in a
144
E.J. Teng, L.C. Friedman / Patient Education and Counseling 76 (2009) 143–146
Table 1 Demographic data of participants who received the intervention and completed the survey. Characteristics
n = 18a
Mean age (S.D.; years) Mean acculturation (S.D.; scale range 1–5)
74 (9.41) 2.80 (.48)
Gender (%) Female Male
66.7 33.3
Marital status (%)b Single Widowed Married
10.5 26.3 63.2
Education (%) <12 years High school College
16.7 61.1 22.2
Table 3 Percentage of participants specifying resource preference for items on the help seeking preference questionnaire at pre-test and post-test. HSPQ items
Pre-test
Post-test
Wilcoxon signed ranks test
P-value
Psychiatric symptoms Family friend Primary care doctor Mental health professional Spiritual healer Not seek help
40.56 22.5 20.44 5.81 11
30.56 22.81 32.94 2.13 10.94
2.37 .317 2.59 1.34 .378
.009 .375 .005 .09 .353
Physical symptoms Family friend Primary care doctor Mental health professional Spiritual healer Not seek help
29 57.46 4.54 0 9.08
18.46 66.38 6.85 .38 6.31
2.83 2.05 1.09 1.0 1.02
.003 .02 .14 .158 .153
Although the total sample was n = 27, not everyone reported all or some of the requested demographic information but completed the remainder of the survey. b Based on n = 19.
Note: In completing the HSPQ, participants were given the following instructions: ‘‘Suppose the following situations were affecting your daily life. Would you seek help or advice from others? If yes, from whom would you seek help or advice? Please mark only one box for each item.’’
community sample of older Chinese American adults. We hypothesized that the intervention would increase intention of our sample to seek help for psychiatric symptoms from mental health professionals.
The second part described psychiatric disorders most relevant to an elderly Chinese population (e.g., mood and anxiety disorders, somatoform disorders, etc.). See Table 2 for a detailed outline of intervention objectives and methods of implementation.
2. Methods
2.2.2. Help-seeking preferences questionnaire The Help-Seeking Preferences Questionnaire (HSPQ) is a 29item self-report inventory of help-seeking patterns for psychological and physical symptoms modified from the original Langner Scale [15]. Participants were instructed to choose one resource for each specified problem (see Table 3 for full instructions) and were provided an answer sheet (written in English and Chinese) with four different resources (e.g., family/friend, mental health professional) listed across the top of the page and a fifth option to indicate that they would not seek help.
a
2.1. Participants In this study, EJT was invited to give a presentation on increasing mental health awareness to approximately 40 older Chinese American members of a Protestant church located in a middle-class region of Houston. A total of 27 members elected to complete anonymous surveys regarding their help-seeking preferences before and after the presentation (see Table 1 for demographic data). Participants indicated consent to participate in the study by anonymously completing and returning surveys. 2.2. Materials 2.2.1. Psychoeducational intervention Participants attended a 1-h didactic presentation entitled, ‘‘Mental Health Awareness Among Older Chinese Adults: The Relationship Between Mind and Body,’’ presented in English and translated into Mandarin. The lecture began with an introduction to mental health, followed by an outline of types of mental health professionals, differences in training, and types of services offered.
2.2.3. Brief acculturation scale This scale measures acculturation level by combining each participant’s generation with language and social-activity preferences [16]. Generation was assigned a numerical value (e.g., first generation in the United States received a score of 1; third generation received a score of 3). Language preference (reverse scored) ranged from 1 (only English) to 5 (only Chinese), and social-activity preference ranged from 1 (Chinese only) to 5 (Only non-Chinese). Total score was derived by calculating the average. Low, medium, and high acculturation was reflected by scores between 1 and 1.75, 1.76–3.25, and 3.26–5, respectively.
Table 2 Goals of psychoeducational intervention. Objective
Method
Increase understanding of mental health Establish mind-body connection
Define mental health; illustrate how thoughts/feelings affect physical health Explain the reciprocal relationship between brain chemistry and emotions/thoughts; influence of genetic factors; restoring the balance via drug therapy and psychotherapy Outline the various resources available in the mental health field; their primary roles and levels of training; different settings among practitioners Explain different forms of psychotherapy (primarily behavioral/cognitive-behavioral treatments) and how they help effect change Review symptoms of several major disorders in DSM-IV (e.g., psychosis, spectrum of anxiety and mood disorders, somatoform disorders) Discuss prevalence of depression among elderly, including reasons why it is so common; etiology and risk factors for developing depression; how depression may manifest differently in older individuals Outline availability of medication and/or non-pharmacological alternatives (i.e., psychotherapy) Discuss ‘‘normal’’ vs clinical depression/anxiety; when self-help methods are not enough; importance of early intervention on positive outcomes
Increase awareness of professional resources Demystify psychotherapy Increase familiarity of psychiatric disorders Recognize depression among the elderly Be familiar with treatments for depression Know when to seek professional help
DSM-IV: Diagnostic and Statistical Manual, 4th edition.
E.J. Teng, L.C. Friedman / Patient Education and Counseling 76 (2009) 143–146
2.3. Procedure All participants attended a pilot intervention intended to increase their awareness of mental health issues and completed a pre-post survey assessing their help-seeking patterns for a number of physical and psychological symptoms. Survey items were projected onto a screen and read aloud, permitting items to be addressed individually for clarification purposes. Upon completing the post-test, participants provided demographic information and completed a brief measure of acculturation. The effect of the intervention on participants’ help-seeking preferences was assessed using a series of Wilcoxon matched-pairs signed ranks tests. The data set was analyzed by first summing the frequency with which each participant indicated each of the five resources would be sought for all items. Comparisons were then made using their pre-to-post test scores. 3. Results Overall, inclination to seek help from mental health professionals increased significantly (Z = 2.42, p = .008) following the intervention. No significant differences were found in preferences for seeking out non-psychiatric physicians (Z = 1.19, p > .05) or spiritual counselors (Z = 1.27, p > .05) for help. Examination of pre-to-post test scores on psychiatric symptom items revealed a significant increase in intention to seek help from mental health professionals. No differences were found in intention to consult medical doctors or spiritual counselors for psychiatric problems, nor were there differences in those reporting no intention to seek help. Examination of physical symptom items showed a significant increase in preference for medical doctors. No significant pre-topost changes were found for using mental health professionals or spiritual counselors for help with physical symptoms, nor was there any difference in intention not to seek help for such symptoms. See Table 3 for complete results.
145
this is likely because they were asked to select only one of several potential resources. Future studies would benefit from allowing multiple selections or a rank ordering of resource preferences, as the involvement of informal caregivers such as family members is important and should be encouraged [17,18]. Future research should examine whether these intentions translate into actual practice. Finally, because of the small sample size, we were not able to adjust or account for variables such as education, health status, and acculturation level. This may also explain the absence of change among those indicating no intention to seek treatment after the intervention. Although limitations are inherent in conducting communitybased effectiveness research (i.e., increasing external validity), the scientific community has identified a rising need to translate research into practice [19] and to improve help-seeking attitudes and willingness to seek mental health services through education [20]. Researchers specifically examining help-seeking preferences among Asian Americans [12] emphasize the importance and need for community education toward integrating Asian individuals into the healthcare delivery system. This pilot study made such an effort and demonstrated that greater awareness of mental health and knowledge of available resources among Chinese Americans can be promoted via educational forums provided through faith-based organizations, while at the same time increasing the visibility and accessibility of mental health professionals to the Asian community. This research also demonstrates the importance for primary care physicians to be aware that Chinese individuals may be more inclined to seek help from them for psychiatric problems because of the stigmatization of mental illness, despite having knowledge about mental health issues. Thus, future efforts focusing on integrating mental health specialists within primary care settings may be more effective in addressing psychiatric concerns among the Chinese population. 5. Conclusion
4. Discussion and conclusion 4.1. Discussion This study evaluated the effectiveness of an educational intervention in increasing mental health awareness among older Chinese Americans by measuring help-seeking preferences for physical and psychiatric symptoms before and after the intervention. Similar to other church-based interventions promoting physical health [13,14], results suggest our intervention successfully increased knowledge of mental health and appropriate resources in older Chinese Americans. Specifically, intention to consult mental health professionals for psychiatric concerns increased significantly following the intervention. That intention to seek help for psychiatric issues from medical doctors did not decrease may reflect the multiple barriers (e.g., stigma) preventing this population from consulting mental health experts. Although not designed to increase awareness of medical issues, we found that intention to consult medical doctors regarding physical symptoms increased following the intervention. Possibly an unintended result of the intervention was to heighten awareness of the importance of consulting professional health care providers for mental and physical health problems. As this research was conducted as part of a community intervention, it has several limitations. The absence of a control group precludes causal inferences regarding the effectiveness of the intervention in modifying participants’ help-seeking preferences. Although the percentage of participants indicating they would turn to family and friends for help decreased at post-test,
Educational interventions are important and potentially effective ways to increase mental health awareness and utilization of services within the Asian American community. Preliminary evidence indicates that increasing the visibility of mental health professionals within this community will likely promote greater awareness of mental health needs and treatment. Acknowledgments This material is based upon work supported in part by the Office of Academic Affiliations, VA Special Mental Illness Research Education and Clinical Center Fellowship Program in Advanced Psychiatry and Psychology, Department of Veteran Affairs. This material is also the result of work supported with resources and the use of facilities at the Houston Center for Quality of Care & Utilization Studies, Houston, Veterans Affairs Medical Center. References [1] Lawrence V, Banerjee S, Bhugra D, Sangha K, Turner S, Murray J. Coping with depression in later life: a qualitative study of help-seeking in three ethnic groups. Psychol Med 2006;36:1375–83. [2] Ho KP, Hunt C, Li S. Patterns of help-seeking behavior for anxiety disorders among the Chinese speaking Australian community. Soc Psych Psych Epid 2008;23 [Epub ahead of print]. [3] Chan B, Parker G. Some recommendations to assess depression in Chinese people in Australasia. Aust NZ J Psychiat 2004;38:141–7. [4] Spencer MS, Chen J. Effect of discrimination on mental health service utilization among Chinese Americans. Am J Public Health 2004;94:809–14. [5] Leong FTL, Lau ASL. Barriers to providing effective mental health services to Asian Americans. Ment Health Serv Res 2001;3:201–14.
146
E.J. Teng, L.C. Friedman / Patient Education and Counseling 76 (2009) 143–146
[6] Lin KM, Cheung F. Mental health issues for Asian-Americans. Psychiatr Serv 1999;50:774–80. [7] Kung WW, Lu PC. How symptom manifestations affect help seeking for mental health problems among Chinese Americans. J Nerv Ment Dis 2008;196:46–54. [8] Kung WW. Consideration of cultural factors in working with Chinese American families with a mentally ill patient. Fam Soc 2001;82:97–107. [9] Barry DT, Grilo CM. Cultural, psychological, and demographic correlates of willingness to use psychological services among East Asian immigrants. J Nerv Ment Dis 2002;190:32–9. [10] Pang EC, Jordan-Marsh M, Silverstein M, Cody M. Health-seeking behaviors of elderly Chinese Americans. Shifts Expect Gerontol 2003;43:864–74. [11] Lin KM, Cheung F. Mental health issues for Asian Americans. Psychiatr Serv 1999;50:774–80. [12] Shin JK. Help-seeking behaviors by Korean immigrants for depression. Issues Ment Health Nurs 2002;23:461–76. [13] Campbell MK, Resnicow K, Carr C, Wang T, Williams A. Process evaluation of an effective church-based diet intervention: body & soul. Health Educ Behav 2007;34:864–80.
[14] Duan N, Fox A, Drose K, Carson S. Maintaining mammography adherence through telephone counseling in a church-based trial. Am J Public Health 2000;90:1468–71. [15] Langner TS. A twenty-two item screening score of psychiatric symptoms indicating impairment. J Health Hum Behav 1962;3:269–76. [16] Burnham MA, Hough RL, Karno M, Escobar JI, Telles CA. Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles. J Health Soc Behav 1987;28:89–102. [17] Gaugler JE. Family involvement in residential long-term care: a synthesis and critical review. Aging Ment Health 2005;9:105–18. [18] Lyons KS, Zarit SH. Formal and informal support: the great divide. Int J Geriatr Psych 1999;14:183–96. [19] Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health 2003;93:1261–7. [20] Mackenzie CS, Gekoski WL, Knox VS. Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes. Aging Ment Health 2006;10:574–82.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short Communication
Increasing mental health awareness and appropriate service use in older Chinese Americans: A pilot intervention Ellen J. Teng a,b,c,*, Lois C. Friedman b,1 a
Michael E. DeBakey VA Medical Center, Houston, United States Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, United States c Houston Center for Quality of Care & Utilization Studies, Houston, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 May 2008 Received in revised form 6 November 2008 Accepted 11 November 2008
Objective: This study evaluated the effectiveness of a community intervention in increasing awareness of mental health issues and available resources among elderly Chinese Americans. Methods: Twenty-seven members of a community church received a 1-h didactic presentation, in English and Mandarin, and completed surveys regarding their help-seeking preferences before and after the intervention. Results were analyzed using a series of Wilcoxon matched-pair signed rank tests and comparing pre- and post-test scores. Results: Findings indicated an increase (p < .05) in intention to consult a mental health professional for psychiatric symptoms at post-test. A significant increase also was found in preference for consulting a physician for physical symptoms. Conclusion: The pilot educational intervention increased awareness of mental health and treatment issues and the role of mental health professionals, lending support to evaluate the intervention on a larger scale. Practice implications: Greater awareness of mental health among Chinese Americans can be promoted via education forums provided through faith-based organizations. Stigma of mental illness leads many Chinese individuals to seek help for psychiatric problems from primary care physicians. Integrating mental health practitioners in primary care settings may help decrease stigma and encourage appropriate help-seeking behavior. Published by Elsevier Ireland Ltd.
Keywords: Mental health services Americans Chinese Aged Health education
1. Introduction Low utilization of mental health services among racial and ethnic minorities is related to acculturation, cultural values, physical barriers, lack of mental health knowledge [1–3] and negative attitudes toward seeking professional help [4]. These factors contribute to delays in seeking treatment and affect helpseeking patterns [2,5]. Asian Americans frequently perceive seeking psychiatric services as a last resort, which often means that they present with more severe disorders when they seek professional help and have longer hospital stays when admitted to psychiatric facilities [6]. Chinese Americans are up to 94% less likely to seek professional help for anxiety and depressive disorders, compared with somatoform disorders [7]. Delays in
* Corresponding author at: Veterans Affairs Medical Center, 116-MHCL 2002 Holcombe Blvd, Houston, TX 77030, United States. Tel.: +1 713 791 1414x5513; fax: +1 713 794 8769. E-mail address: [email protected] (E.J. Teng). 1 Currently at University Hospitals Ireland Cancer Center at Case Medical Center, Cleveland, OH, United States. 0738-3991/$ – see front matter . Published by Elsevier Ireland Ltd. doi:10.1016/j.pec.2008.11.008
seeking treatment among Asian Americans also may be related to an over-reliance upon medical doctors for psychiatric symptoms [7] and unawareness of how psychiatric problems can impact physical well-being. Additional variables in Asian culture discouraging professional consultation include the involvement of extended-family and the highly stigmatizing nature of mental illness. Hence, informal caregivers (e.g., family and friends) are likely to be consulted first [1,8,10] and are the ones who subsequently initiate and facilitate the process of introducing symptomatic relatives to mental health caregivers [11]. Despite the identified need to increase community education/ outreach to facilitate access to mental health services among the Asian population [12], relatively little progress has been made in addressing delays in seeking treatment and underutilization of available services in the Asian American community through education [9]. Although church-based interventions have shown success in promoting physical health [13,14], little effort has been made to access these venues to promote mental health. The purpose of the current study was to evaluate the effectiveness of a church-based educational intervention in increasing the awareness (i.e., knowledge) of mental health and available resources in a
144
E.J. Teng, L.C. Friedman / Patient Education and Counseling 76 (2009) 143–146
Table 1 Demographic data of participants who received the intervention and completed the survey. Characteristics
n = 18a
Mean age (S.D.; years) Mean acculturation (S.D.; scale range 1–5)
74 (9.41) 2.80 (.48)
Gender (%) Female Male
66.7 33.3
Marital status (%)b Single Widowed Married
10.5 26.3 63.2
Education (%) <12 years High school College
16.7 61.1 22.2
Table 3 Percentage of participants specifying resource preference for items on the help seeking preference questionnaire at pre-test and post-test. HSPQ items
Pre-test
Post-test
Wilcoxon signed ranks test
P-value
Psychiatric symptoms Family friend Primary care doctor Mental health professional Spiritual healer Not seek help
40.56 22.5 20.44 5.81 11
30.56 22.81 32.94 2.13 10.94
2.37 .317 2.59 1.34 .378
.009 .375 .005 .09 .353
Physical symptoms Family friend Primary care doctor Mental health professional Spiritual healer Not seek help
29 57.46 4.54 0 9.08
18.46 66.38 6.85 .38 6.31
2.83 2.05 1.09 1.0 1.02
.003 .02 .14 .158 .153
Although the total sample was n = 27, not everyone reported all or some of the requested demographic information but completed the remainder of the survey. b Based on n = 19.
Note: In completing the HSPQ, participants were given the following instructions: ‘‘Suppose the following situations were affecting your daily life. Would you seek help or advice from others? If yes, from whom would you seek help or advice? Please mark only one box for each item.’’
community sample of older Chinese American adults. We hypothesized that the intervention would increase intention of our sample to seek help for psychiatric symptoms from mental health professionals.
The second part described psychiatric disorders most relevant to an elderly Chinese population (e.g., mood and anxiety disorders, somatoform disorders, etc.). See Table 2 for a detailed outline of intervention objectives and methods of implementation.
2. Methods
2.2.2. Help-seeking preferences questionnaire The Help-Seeking Preferences Questionnaire (HSPQ) is a 29item self-report inventory of help-seeking patterns for psychological and physical symptoms modified from the original Langner Scale [15]. Participants were instructed to choose one resource for each specified problem (see Table 3 for full instructions) and were provided an answer sheet (written in English and Chinese) with four different resources (e.g., family/friend, mental health professional) listed across the top of the page and a fifth option to indicate that they would not seek help.
a
2.1. Participants In this study, EJT was invited to give a presentation on increasing mental health awareness to approximately 40 older Chinese American members of a Protestant church located in a middle-class region of Houston. A total of 27 members elected to complete anonymous surveys regarding their help-seeking preferences before and after the presentation (see Table 1 for demographic data). Participants indicated consent to participate in the study by anonymously completing and returning surveys. 2.2. Materials 2.2.1. Psychoeducational intervention Participants attended a 1-h didactic presentation entitled, ‘‘Mental Health Awareness Among Older Chinese Adults: The Relationship Between Mind and Body,’’ presented in English and translated into Mandarin. The lecture began with an introduction to mental health, followed by an outline of types of mental health professionals, differences in training, and types of services offered.
2.2.3. Brief acculturation scale This scale measures acculturation level by combining each participant’s generation with language and social-activity preferences [16]. Generation was assigned a numerical value (e.g., first generation in the United States received a score of 1; third generation received a score of 3). Language preference (reverse scored) ranged from 1 (only English) to 5 (only Chinese), and social-activity preference ranged from 1 (Chinese only) to 5 (Only non-Chinese). Total score was derived by calculating the average. Low, medium, and high acculturation was reflected by scores between 1 and 1.75, 1.76–3.25, and 3.26–5, respectively.
Table 2 Goals of psychoeducational intervention. Objective
Method
Increase understanding of mental health Establish mind-body connection
Define mental health; illustrate how thoughts/feelings affect physical health Explain the reciprocal relationship between brain chemistry and emotions/thoughts; influence of genetic factors; restoring the balance via drug therapy and psychotherapy Outline the various resources available in the mental health field; their primary roles and levels of training; different settings among practitioners Explain different forms of psychotherapy (primarily behavioral/cognitive-behavioral treatments) and how they help effect change Review symptoms of several major disorders in DSM-IV (e.g., psychosis, spectrum of anxiety and mood disorders, somatoform disorders) Discuss prevalence of depression among elderly, including reasons why it is so common; etiology and risk factors for developing depression; how depression may manifest differently in older individuals Outline availability of medication and/or non-pharmacological alternatives (i.e., psychotherapy) Discuss ‘‘normal’’ vs clinical depression/anxiety; when self-help methods are not enough; importance of early intervention on positive outcomes
Increase awareness of professional resources Demystify psychotherapy Increase familiarity of psychiatric disorders Recognize depression among the elderly Be familiar with treatments for depression Know when to seek professional help
DSM-IV: Diagnostic and Statistical Manual, 4th edition.
E.J. Teng, L.C. Friedman / Patient Education and Counseling 76 (2009) 143–146
2.3. Procedure All participants attended a pilot intervention intended to increase their awareness of mental health issues and completed a pre-post survey assessing their help-seeking patterns for a number of physical and psychological symptoms. Survey items were projected onto a screen and read aloud, permitting items to be addressed individually for clarification purposes. Upon completing the post-test, participants provided demographic information and completed a brief measure of acculturation. The effect of the intervention on participants’ help-seeking preferences was assessed using a series of Wilcoxon matched-pairs signed ranks tests. The data set was analyzed by first summing the frequency with which each participant indicated each of the five resources would be sought for all items. Comparisons were then made using their pre-to-post test scores. 3. Results Overall, inclination to seek help from mental health professionals increased significantly (Z = 2.42, p = .008) following the intervention. No significant differences were found in preferences for seeking out non-psychiatric physicians (Z = 1.19, p > .05) or spiritual counselors (Z = 1.27, p > .05) for help. Examination of pre-to-post test scores on psychiatric symptom items revealed a significant increase in intention to seek help from mental health professionals. No differences were found in intention to consult medical doctors or spiritual counselors for psychiatric problems, nor were there differences in those reporting no intention to seek help. Examination of physical symptom items showed a significant increase in preference for medical doctors. No significant pre-topost changes were found for using mental health professionals or spiritual counselors for help with physical symptoms, nor was there any difference in intention not to seek help for such symptoms. See Table 3 for complete results.
145
this is likely because they were asked to select only one of several potential resources. Future studies would benefit from allowing multiple selections or a rank ordering of resource preferences, as the involvement of informal caregivers such as family members is important and should be encouraged [17,18]. Future research should examine whether these intentions translate into actual practice. Finally, because of the small sample size, we were not able to adjust or account for variables such as education, health status, and acculturation level. This may also explain the absence of change among those indicating no intention to seek treatment after the intervention. Although limitations are inherent in conducting communitybased effectiveness research (i.e., increasing external validity), the scientific community has identified a rising need to translate research into practice [19] and to improve help-seeking attitudes and willingness to seek mental health services through education [20]. Researchers specifically examining help-seeking preferences among Asian Americans [12] emphasize the importance and need for community education toward integrating Asian individuals into the healthcare delivery system. This pilot study made such an effort and demonstrated that greater awareness of mental health and knowledge of available resources among Chinese Americans can be promoted via educational forums provided through faith-based organizations, while at the same time increasing the visibility and accessibility of mental health professionals to the Asian community. This research also demonstrates the importance for primary care physicians to be aware that Chinese individuals may be more inclined to seek help from them for psychiatric problems because of the stigmatization of mental illness, despite having knowledge about mental health issues. Thus, future efforts focusing on integrating mental health specialists within primary care settings may be more effective in addressing psychiatric concerns among the Chinese population. 5. Conclusion
4. Discussion and conclusion 4.1. Discussion This study evaluated the effectiveness of an educational intervention in increasing mental health awareness among older Chinese Americans by measuring help-seeking preferences for physical and psychiatric symptoms before and after the intervention. Similar to other church-based interventions promoting physical health [13,14], results suggest our intervention successfully increased knowledge of mental health and appropriate resources in older Chinese Americans. Specifically, intention to consult mental health professionals for psychiatric concerns increased significantly following the intervention. That intention to seek help for psychiatric issues from medical doctors did not decrease may reflect the multiple barriers (e.g., stigma) preventing this population from consulting mental health experts. Although not designed to increase awareness of medical issues, we found that intention to consult medical doctors regarding physical symptoms increased following the intervention. Possibly an unintended result of the intervention was to heighten awareness of the importance of consulting professional health care providers for mental and physical health problems. As this research was conducted as part of a community intervention, it has several limitations. The absence of a control group precludes causal inferences regarding the effectiveness of the intervention in modifying participants’ help-seeking preferences. Although the percentage of participants indicating they would turn to family and friends for help decreased at post-test,
Educational interventions are important and potentially effective ways to increase mental health awareness and utilization of services within the Asian American community. Preliminary evidence indicates that increasing the visibility of mental health professionals within this community will likely promote greater awareness of mental health needs and treatment. Acknowledgments This material is based upon work supported in part by the Office of Academic Affiliations, VA Special Mental Illness Research Education and Clinical Center Fellowship Program in Advanced Psychiatry and Psychology, Department of Veteran Affairs. This material is also the result of work supported with resources and the use of facilities at the Houston Center for Quality of Care & Utilization Studies, Houston, Veterans Affairs Medical Center. References [1] Lawrence V, Banerjee S, Bhugra D, Sangha K, Turner S, Murray J. Coping with depression in later life: a qualitative study of help-seeking in three ethnic groups. Psychol Med 2006;36:1375–83. [2] Ho KP, Hunt C, Li S. Patterns of help-seeking behavior for anxiety disorders among the Chinese speaking Australian community. Soc Psych Psych Epid 2008;23 [Epub ahead of print]. [3] Chan B, Parker G. Some recommendations to assess depression in Chinese people in Australasia. Aust NZ J Psychiat 2004;38:141–7. [4] Spencer MS, Chen J. Effect of discrimination on mental health service utilization among Chinese Americans. Am J Public Health 2004;94:809–14. [5] Leong FTL, Lau ASL. Barriers to providing effective mental health services to Asian Americans. Ment Health Serv Res 2001;3:201–14.
146
E.J. Teng, L.C. Friedman / Patient Education and Counseling 76 (2009) 143–146
[6] Lin KM, Cheung F. Mental health issues for Asian-Americans. Psychiatr Serv 1999;50:774–80. [7] Kung WW, Lu PC. How symptom manifestations affect help seeking for mental health problems among Chinese Americans. J Nerv Ment Dis 2008;196:46–54. [8] Kung WW. Consideration of cultural factors in working with Chinese American families with a mentally ill patient. Fam Soc 2001;82:97–107. [9] Barry DT, Grilo CM. Cultural, psychological, and demographic correlates of willingness to use psychological services among East Asian immigrants. J Nerv Ment Dis 2002;190:32–9. [10] Pang EC, Jordan-Marsh M, Silverstein M, Cody M. Health-seeking behaviors of elderly Chinese Americans. Shifts Expect Gerontol 2003;43:864–74. [11] Lin KM, Cheung F. Mental health issues for Asian Americans. Psychiatr Serv 1999;50:774–80. [12] Shin JK. Help-seeking behaviors by Korean immigrants for depression. Issues Ment Health Nurs 2002;23:461–76. [13] Campbell MK, Resnicow K, Carr C, Wang T, Williams A. Process evaluation of an effective church-based diet intervention: body & soul. Health Educ Behav 2007;34:864–80.
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