KNOWLEDGE ON MENTAL HEALTH SERVICE UTILIZATION AMONGST
IU-MIEN ADULTS
A Project
Presented to the faculty of the Department of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Cheng Ton Saetern
SPRING
2014
© 2014
Cheng Ton Saetern
ALL RIGHTS RESERVED
ii
KNOWLEDGE ON MENTAL HEALTH SERVICE UTILIZATION AMONGST
IU-MIEN ADULTS
A Project
by
Cheng Ton Saetern
Approved by:
__________________________________, Committee Chair
Dr. Serge Lee, Ph.D.
____________________________
Date
iii
Student: Cheng Ton Saetern
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
__________________________, Graduate Coordinator
Dale Russell, Ed.D., LCSW
Department of Social Work
iv
___________________
Date
Abstract
of
KNOWLEDGE ON MENTAL HEALTH SERVICE UTILIZATION AMONGST
IU-MIEN ADULTS
by
Cheng Ton Saetern
Information pertaining to mental health needs of Southeast Asians residing in the United
States is limited but growing. There is still very limited literature on the Iu-Mien, and
little to none is known about them in this country. In many mental health studies, there is
a tendency of grouping all persons of Asian descent together and, therefore, the empirical
literature does not sufficiently address the mental health needs in specific subgroups.
This research project focused on the current knowledge the Iu-Mien possess about mental
illness and the factors causing underutilization. Despite evidence of mental health needs
for Iu-Mien people, most do not present for mental health services. Finding from the
study revealed that there is still inadequate knowledge and perceptions of mental illness
within the Iu-Mien community and there are not sufficient Iu-Mien language interpreters
to meet the needs of the Iu-Mien people.
_______________________, Committee Chair
Dr. Serge Lee, Ph.D.
_______________________
Date
v
ACKNOWLEDGEMENTS
To my Mother Nai Luang Saephanh: I thank you for the sacrifices you have made
in life to provide me with this opportunity. Raising six children on your own as a refugee
in this country taught me that anything is possible. I know we have had our moments
where we did not see eye to eye, but it was within these moments that I discovered your
teachings. You taught me to be strong when I felt helpless; you taught me to be brave
when I was scared; and most importantly you taught me to walk this journey in life for
me and not anyone else. You were my motivation to be better than the person I was
yesterday. I dedicate this project to you and hope that I have made you proud. I love
you!
To my grandfather Fou Ting Saetern and grandmother Kae Orn Saetern: Grandpa,
I know you are gone, but never forgotten. I wish you were here to see me cross the finish
line. I know you cannot be here in person, but I know you will continue to guide me in
the path of life. Thank you for being my guardian angel. I love and miss you. Grandma,
your will power in life has inspired me to pursue outside of my comfort zone. I hope to
one day have a heart as big, kind, warm, generous, and as loving as you are. You
empower me to be the best I can be. Thank you and I love you!
To my favorite big brother Kao Siew Saetern: You played the role of a father
figure, coach, teacher, babysitter, provider, and protector in my life and somehow you
still manage to fulfill the shoes of being my big brother. I cannot thank you enough for
all that you have done for the family. I am so grateful to call you my big brother. You
vi
inspired me to pursue higher education and this journey would not have been possible
without your support. Thank you for being you. I love you!
To my favorite big sister Ching (Lacey) Siew Saetern: You were like a mother to
me during my infant days and the bond I have with you remains strong to this day. I am
so fortunate to have a big sister who I can lean on when my world was falling apart. I
thank you for never judging me for the choices I have made in life. I love you!
To my favorite middle sister Cheng (Fin) Siew Saetern: Despite our distance you
always remain close to heart. You have always been one I could count on to provide me
active listening and validate my feelings. Thank you for being the understanding sister
you are. I love you!
To my favorite little brother Lo Xio Saetern: You have always been there for me
through thick and thin. I would not change a thing about you, as you are one of the few
people I know who has the biggest heart. Believe it or not, you have taught me to accept
the things I cannot change and let go of what suppresses my happiness. I am so grateful
to have you as my little brother. Thank you for being nonjudgmental of whom I am. I
love you!
To my favorite little sissy Kae Siew Saeteurn: My partner in crime! Thank you
for your unconditional support and assistance through the many struggles I encountered
in life. When times were hard and I felt like my world was in darkness you came through
and shed light into my life. You helped guide me to where I am today and no words
vii
could express the gratitude I feel to have you as my little sister. I love you to the moon
and back!
To my Nyiam Farm K. Saetern: I dedicate a poem to you. From the first day that I
met you, I knew you would be my friend. I knew that I could count on you, no matter
what life sends. You always have made time to listen and time to give and share; by all
your words and actions, you show you really care. You are so very special; it shows in
all you do. I have found a special friendship, and I have gained a sister too. As a sisterin-law, you are great, as a friend, you are the best. To have you in our family makes us
all so truly blessed.
To my friends: You were my second family and this journey would not have been
as fun and exciting without you all in it. Thank you for filling my life with endless
memories. My life would be meaningless without our spontaneous moments.
To Professor Lee: This project would not have been possible without your endless
support and strict deadlines. I thank you for your patience and guidance along this
treacherous journey. I wish you many more years of teaching and inspiring Southeast
Asian students to pursue higher education.
viii
TABLE OF CONTENTS
Page
Acknowledgements ...................................................................................................... vi
List of Tables ............................................................................................................... xi
Chapter
1. THE PROBLEM ......................................................................................................1
Background of the Problem ...............................................................................2
Statement of the Research Problem ...................................................................3
Purpose of the Study ..........................................................................................4
Theoretical Framework ......................................................................................5
Definitions of Terms ..........................................................................................6
Assumptions.......................................................................................................6
2. REVIEW OF THE LITERATURE .........................................................................8
Mental Health Definition ...................................................................................9
History of the Iu-Mien Americans ...................................................................11
Mental Health Service Utilization Among Ethnic Minorities .........................13
Mental Health Needs/Issues of Southeast Asians ............................................18
Factors Associated with Mental Health Problems ...........................................20
Acculturation Stressors ....................................................................................20
Somatization ....................................................................................................23
Cultural Competence and Cultural Intervention in Service .............................25
ix
Summary ..........................................................................................................28
3. METHODOLOGY ................................................................................................31
Study Objectives ..............................................................................................31
Study Design ....................................................................................................31
Data Collection Procedures..............................................................................32
Instruments .......................................................................................................33
Human Subject Protection ...............................................................................34
Data Analysis ...................................................................................................35
4. STUDY FINDINGS AND DISCUSSIONS ..........................................................37
Overall Findings...............................................................................................37
Specific Findings .............................................................................................40
5. SUMMARY ...........................................................................................................44
Overall Summary .............................................................................................44
Implications......................................................................................................46
Suggestions for Future Research .....................................................................48
Limitations .......................................................................................................49
Conclusion .......................................................................................................49
Appendix A. Questionnaire .......................................................................................51
References ....................................................................................................................58
x
LIST OF TABLES
Tables
Page
1.
Gender of Participants......................................................................................37
2.
Marital Status of Participants ...........................................................................38
3.
Participant’s Highest Level of Education ........................................................38
4.
Participant’s Primary Language .......................................................................39
5.
Do Participants Have Health Insurance ...........................................................39
6.
Does Participant Have Reliable Transportation ...............................................40
7.
Does Participant Think There Are Enough Good Service Options .................40
8.
Participant’s Family Who Sought Service in Past Three Years ......................41
9.
Does Participant Think Iu-Mien Utilize Mental Health Service Correctly .....41
10.
Does Participant Think Iu-Mien Understand Mental Illness Terminology .....42
11.
Are There Sufficient Iu-Mien Interpreters to Meet the Needs of Iu-Mien ......42
xi
1
Chapter 1
THE PROBLEM
Asian Americans are the fastest growing minority group in the United States as it
has doubled in the past two decades (Yeung & Kung, 2004). According to the U.S.
Census (2002) Asian Americans make up 3.6% of the U.S. population and by 2020 they
are projected to make 6% of the nation’s population. As the United States progressively
become more ethnically diverse, it is important to understand the ethnic and cultural
needs of each group, and to develop appropriate programs and services to meet the needs
of these people. Although America has made significant improvements on programs and
services in the areas of health and human services for immigrants and refugees, there are
groups that are not readily able to access these services/resources. One of these
underutilized groups is the Iu-Mien. In reviewing of the literature, the Iu-Mien are nearly
unidentifiable and nearly unrecognized by human service agencies (Kim, 2006). Most
studies conducted in the past consist of other Asian sub-groups such as Chinese, Koreans,
and Japanese who have been in the United States much longer than the Iu-Mien. In
comparison to other Asian Americans in general, the Iu-Mien’s underutilization of mental
health services can be speculated to their limited exposure to Western cultural traditions
(Kim, 2006). Furthermore, Kim notes that the Iu-Mien were presumably the least
prepared for life in United States as they moved straight from rural environments to
industrialized settings. Like their Southeast Asian counterparts, the Iu-Mien have shown
to be at risk for developing psychiatric illness due to their experience with harsh stressors
resulting from war-related psychological traumas and refugee experiences (Kim, 2006).
2
Background of the Problem
Research has consistently shown that Asian Americans are less likely to seek help
for mental health problems than other racial demographic groups (Chu & Sue, 2011).
According to Yeung and Kung (2004), Asian Americans’ tend to utilize mental health
services as a last resort after unsuccessful attempts to seek help from families, friends,
alternative treatments and primary care physicians. Yeung and Kung states further that
Southeast Asian refugee are at risk for mental illness, particularly post-traumatic stress
disorder (PTSD) and major depressive disorder (MDD) due to their pre and postmigration. In addition, Fung and Wong (2007) and Kim (2006) note that most of the
Southeast Asian refugees endured tremendous hardships in the process of emigration to
the United States from their homeland. In their study, Fung and Wong were able to
demonstrate that Asian refugees in North America have lower rates of mental health
service utilization and by the time they seek or receive treatment, symptoms have become
more severe.
According to Yeung and Kung (2004) Asian immigrants are more reluctant
towards seeking mental health services due to reasons such as stigma, language barrier,
lack of access to care, and lack of culturally competent service. These various barriers
are results of the underutilization of mental health services by Asian Americans. In their
studies, Fung and Wong (2007) rationalized that Asian immigrants are perceived as a
homogeneous group sharing similar culture and beliefs. There is an under exploration of
the different historical and socio-political contexts faced by various Asian ethnic groups
that may have resulted in their attitude towards seeking professional help. As such,
3
ethnicity is an important variable in mental health studies as the characteristics and
intensity of the adverse effects vary from each ethnic group. Thus, making it necessary
for professional providers to be aware of diversity within the Asian immigrant population
to better provide care (Kim, 2006).
As one of the Southeast Asian refugee groups from the Vietnam War, the Iu-Mien
people experienced considerable reprisals, confiscation of land and goods, torture and
slaughter (Barker & Saechao, 1997; Habarad, 1987a, b; & nMoore & Boehnlein, 1991).
Many Iu-Mien were forced to leave their homeland to avoid persecution and in doing so
many stayed in refugee camps for extended periods until they were allowed to enter the
United States. Moving straight from rural environments to industrialized settings, and
compared to other larger global category of Asians such as the Chinese and Japanese who
had greater exposure to Western culture or urban life in their homeland, the Iu-Miens are
presumably the least prepared for life in the U.S. (Kim, 2006). Kim states that migrating
to the U.S. the Iu-Mien people experienced first-hand war and post-war killing fields on
top of current social and cultural obstacles that presents a dire need for mental health
services in this population.
Statement of the Research Problem
Mental illness is evident in the Iu-Mien community; however, utilization of
mental health service has remained low. There are various potential factors contributing
to the underutilization of mental health services by the Iu-Mien people. One of the
reasons can be associated with Iu-Mien perceptions and lack of understanding of mental
health. The most common term used by the Iu-Mien people to describe someone who has
4
a mental illness is butv ndin which translates as crazy/insane. Another factor maybe that
there is a general lack of culturally and linguistically appropriate services available to
meet the needs of Iu-Mien. Majority of the first generation Iu-Mien do not speak English
and do not know how to begin accessing service. Stigma and shame are common factors
that deter Iu-Mien from help-seeking behaviors. Many Iu-Mien feel ashamed and
embarrassed to seek mental health service fearing public knowledge of his/her problem
and being identified as crazy within the Iu-Mien community. Despite the reasons for
non-help-seeking behavior, Iu-Mien people have a mental health need and are in need of
help.
Even after decades of resettling in the U.S., some Iu-Mien people have not yet
addressed their traumatic experience and often report somatic symptoms. Their
horrifying experience from fleeing their home country, witnessing death, losing family
during migration, enduring the hardship of concentration camps, and struggling to
assimilate to mainstream society in America are all components contributing to mental
illness in the Iu-Mien community.
The researcher is interested in researching the underutilization of mental health
service amongst Iu-Mien adults due to the limited literature and data on this population.
The researcher is also interested in exploring the barriers that prevent Iu-Mien from
utilizing mental health service.
Purpose of the Study. The purpose of this study is to investigate knowledge and
perceptions Iu-Mien ages thirty years and older have towards mental health service
utilization. This study aims to provide mental health professionals and social service
5
providers a better understanding of a minority group that continues to face such
disparities even after more than three decades of residing in the U.S. Perhaps having a
better understanding of this population will allow service providers to best tailor their
service to meet the needs of the Iu-Mien population. It is hoped that with more
knowledge, insight, and understanding of the Iu-Mien population providers can help to
decrease the stigmas of mental illness and increase the utilization of mental health
treatment.
Theoretical Framework. The ecosystems perspective, also known as the
ecological perspective as cited by Johnson and Rhodes (2010), is the theoretical
framework used for this study. Johnson and Rhodes define the ecosystems perspective as
the need to view people and environments as a unitary system within a particular cultural
and historic context. Both person and environment can be fully understood only in terms
of their relationship, in which each continually influences the other within a particular
context. This perspective is useful as it takes into consideration the cultural aspects of the
Iu-Mien population and their needs within the new environment here in American
society. The fact that the Iu-Mien possesses inadequate knowledge and awareness
regarding mental illness and mental health services within their community, the
ecological perspective is relevant to consider in order to understand how the individual,
group, and system interact and impact one another within their society. This framework
will help mental health provider understand the Iu-Mien culture, historical experience and
how to maintain a balance between the individual and their environment.
6
Definition of Terms. The following are definition of terms used throughout this
research.
Southeast Asians: refers to people from Vietnam, Cambodia, and Laos, who are
characterized by seemingly common factors, such as geographic region of origin, recent
war experiences, and migration experiences.
Refugee: someone who has been forced to leave a country because of war or for religious
or political reasons.
Iu-Mien: are the smallest major refugee groups in the U.S. and the least known in the
refugee literature.
Immigrant: a person who comes to a country to live there.
Siep mmien: is both a healing and protective ceremony. In the Iu-Mien language the
word mien means people and the word mmien means ancestor spirits.
Soul fright: is a cause of soul loss, which is a symptom complex of sleeplessness,
distractibility, and listlessness believed to indicate that the soul has been frightened from
the body.
Hwen bach: souls that act as a protection for their physical and spiritual well-being.
Assumptions. My experience working in the field of mental health for the last
two years specifically with the Iu-Mien population has provided me direct knowledge of
some of the barriers of mental health utilization. I learned that most Iu-Mien adults
receiving mental health service prefer to work with the same sex mental health providers
such as counselor/clinician/psychiatrist. The idea of disclosing personal information to
the opposite sex is rather inappropriate and can be considered embarrassing. I also
7
learned that many Iu-Mien are isolated in their homes because they do not have a means
of transportation. Most Iu-Mien adults do not know how to drive and there aren’t
interpreters available to assist in conducting the written test often resulting in relying on
their children for transportation needs. In addition, some Iu-Mien families face cultural
and linguistic barriers within the parent and child relationship due to generational gap
issues. Iu-Mien children have become westernized and with the demands of work and
school most children do not have time to support their parents in navigating appropriate
resources to combat their needs of mental health service. Even those who can assist with
navigation are unable to communicate in their native language to their parents. It was
clear to me during my time as a mental health case manager that there is still a large
population of Iu-Mien people who are not getting their mental health needs met. I hope
that in doing this research professionals in the helping field will have better knowledge of
the disparities in the Iu-Mien community and will be able to better outreach to increase
the utilization of mental health services.
8
Chapter 2
REVIEW OF THE LITERATURE
Even after more than three decades of settling into the United States there is still a
lack of mental health utilization in the Southeast Asian population. According to the
National Alliance on Mental Illness (2011), Southeast Asians have a higher risk of posttraumatic stress disorder (PTSD) which is often associated with pre and post-migration to
the United States. Southeast Asians are defined as former refugees from Cambodia,
Laos, and Vietnam. Multiple research studies have been conducted elucidating the
manifestation of mental illness within the Southeast Asian refugee population; Southeast
Asians still remain a population that underutilizes mental health services. To increase the
utilization of mental health services by the Southeast Asian population, especially the IuMien people, it is important to further explore the existing barriers that continue to be
factors causing underutilization. The focus of this research is to help readers understand
the mental health needs of the Iu-Mien people age thirty and older. In addition, the IuMien’s knowledge and understanding of mental health services will be explored as a
possible determinant of underutilization of mental health services.
This research will consist of six major themes: (1) mental health definition; (2)
the history of Iu-Mien Americans; (3) mental health service utilization among ethnic
minorities; (4) mental health needs/issues of Southeast Asians; (5) factors associated with
mental health problems; and (6) cultural competence and cultural intervention in service.
In discussing these themes, the researcher hopes to help identify and explain some of the
barriers that prevent Iu-Mien Americans from seeking out mental health services.
9
Mental Health Definition
Mental health, as defined by the World Health Organization (2014), is a state of
well-being where every individual realizes his or her own potential, is able to cope with
life stressors, can work productively, and is able to make a contribution to his or her
community. According to the National Alliance on Mental Illness (2011), mental
illnesses are medical conditions that result in diminished capacity for coping with life
demands. Mental illness disrupts the person’s thinking, feeling, mood, ability to relate to
others and daily functioning. Before immigrating to the United States, the Iu-Mien
people had little to no exposure to Western life including Western culture and Western
perceptions of the world (Saetern, 1998). According to Saetern, due to their lack of
exposure to Western life the Iu-Mien had little to no knowledge of Western perceptions
of mental health and mental illness. Individuals from the Iu-Mien population may have
difficulty understanding the term mental illness because the Iu-Mien language does not
have a word for mental illness. The word used to describe mental illness in the Iu-Mien
language has a very negative connotation. For example, in the Iu-Mien English
Dictionary mental illness translated in Iu-Mien is butv ndin, which is defined by Purnell
(2012) as being insane, crazy, mad, and out of one’s mind. This strong association of
psychiatry with craziness and being insane has led many Iu-Miens to avoid utilizing
mental health treatment.
To obtain a complete picture of the mental health needs of Southeast Asians,
primarily the Iu-Mien, mental health problems must be examined within a cultural
context. Many of the Iu-Mien beliefs are similar to the Chinese beliefs which are a
10
mixture of Tao and Buddhist philosophies and ancestor worship. The Chinese also
believe in a pantheon of powerful spirits that can be influenced by humans through
certain rituals. These spiritual beings become the mediums through their trances and deal
with devils and deities to bring a change in the suffering person (Haque, 2010). Just like
the Chinese, the Iu-Mien people believe the spiritual world has a direct influence over
their lives, well-being, health and happiness. They worship their ancestral spirits and see
them as primarily helpful spirits who offer protection and assistance. However, in the IuMien culture the ancestor spirits can also be the cause of illnesses should they be
offended or not given the proper offering of food and money. Based on studies by
Moore, Sager, Keopraseuth, Chao, Riley, and Robinson (2001), shamans or spiritual
leaders are called upon to perform spiritual healings when an ancestor or other spirits are
believed to have caused the illness. Moore and colleagues further note that the shaman
acts as an intermediary between the two worlds and treats the illness by performing
spiritual ceremonies, rituals, and animal sacrifices.
Soul fright is another cause of mental illness in which the Iu-Mien believes. A
study by Moore et al., (2001) indicates that the Iu-Mien believe mental illness is a result
of or failure to comply with rituals, spirit possession, soul loss or bad luck. Moore and
colleagues state that soul loss is a complex symptom that consists of sleeplessness,
distractibility, and listlessness believed to indicate that the soul has been frightened from
the body. An earlier study by Moore and Boehnlein (1991) found that the Iu-Mien
people believe that an individual has many souls or hwen bach that act as a protection for
their physical and spiritual well-being. In the more recent study, Moore and colleagues
11
state that being cursed, experiencing a fearful or tragic event, and having sickness are
results of the soul being lost leading to the cause of mental illness. Traditionally the IuMien relied on herbalists, nutrition and environmental changes to treat the problem of a
soul loss. Problems that do not respond to these interventions would then require the
intervention of religious healing ceremonies to bring back the hwen bach through the
process of sip mmien. Moore and colleagues further note that during ceremonies the evil
spirits are called upon to appease them and ancestor spirits are called to protect living
family members.
History of Iu-Mien Americans
Worldwide, there is no correct way to refer to the Iu-Mien people. For example,
in China they are better known as Yao, while in Laos and Thailand, they are known as
Mienh or Iu-Mien (Barker & Saechao, 1997). History indicates that hundreds of years
ago some Iu-Mien migrated out of Southwest China to the mountainous areas of
Vietnam, eventually reaching Laos and Thailand. The reasons for this huge migration
were due to the Iu-Mien’s desire to maintain their freedom, escape famine, and avoid
taxes. Barker and Saechao state that there was an estimated 1.4 million Iu-Mien residing
in China until the 1700s when some of them migrated to Vietnam, and during the midnineteenth century a part of this group migrated further south to the highlands of Laos
and Thailand. They added that by 1954 the population of Iu-Mien in Vietnam was
estimated to number around 200,000 and approximately 50,000 in Laos and Thailand
combined.
12
During the Vietnam War era, 1960s to 1975, the Iu-Mien entered an important
alliance with the American forces, especially the Central Intelligence Agency (CIA).
According to Barker and Saechao (1997), during the Vietnam War many Iu-Miens were
recruited by the CIA along with other tribal groups in Laos to fight communists and in
return were promised protection from reprisals and relocation to the United States if
needed. Unfortunately, the royal Lao government forces fell to the communists in May
1975. The Iu-Mien, along with thousands of Laotian refugees, fled Laos to seek
temporary refuge in neighboring countries, particularly Thailand. During this journey of
escape many Iu-Mien people died, some were captured, shot, and killed by the
Communist soldiers and others drowned in the river or died of sickness related to the
difficult travel (Hsu, Davies, & Hansen, 2004; Saetern, 1998; Howard, 1989). The
Vietnam War severely ruptured the lives of the Iu-Mien, who not only lost their land and
goods, but experienced the trauma of war. Grieving for loved ones who were killed and
they were now left poverty stricken and homeless (Barker & Saechao, 1997).
It was not until 1980 that the U.S. made asylum widely available to the Iu-Mien
in refugee camps in Thailand by offering a refugee rescue program that gave the Iu-Mien
and other hill tribes the choice to resettle in the United States (Saelee & Saeteurn, 2011).
This was also known as the 1980 Refugee Act. The Refugee Act of 1980 defines a
refugee as someone who has a well-founded fear of being persecuted in their homeland,
for reasons of their race, religion, nationality, social group or political opinion (Hsu et al.,
2004; Vu, 1990). Under the Refugee Act, during the first two years of their residence
refugees are considered living under a parole status and are prohibited to apply for legal
13
alien resident status until after that duration. Public assistance is usually needed for
newly migrated refugees to allow them time to adjust culturally and emotionally to their
new settings; therefore, refugees enter the United States under conditions that affect their
readjustment to the new country (Hsu et al., 2004). It was reported by Barker and
Saechao (1997) that by the late 1980’s only about 15,000 Iu-Mien remained in Southeast
Asia, primarily in the hills of Laos, comprising traditional farmers, rice growers, and
artisans living in small villages. Barker and Saechao further state that about 85% of the
Iu-Mien immigrated to the United States while others went to France or Australia.
Mental Health Service Utilization Among Ethnic Minorities
Asian Americans have a distinct pattern of underutilizing psychological services
compared to other ethnic groups (Yeung & Kung, 2004). Among Asian Americans with
a probable mental disorder, only 28% utilized specialty mental health service, in contrast
to 54% of the general population (Chu & Sue, 2011). A study done by Chung and Lin,
(1994) examined the intergroup differences between the Vietnamese, Cambodians,
Laotian, Hmong, and Chinese Vietnamese in their help-seeking behavior in Asia and the
United States. The results showed the percentage of each group utilizing Western
medicine in their home country with Vietnamese (68%), Laotian (53%), Cambodians
(44%), Chinese Vietnamese (44%), and the Hmong (11%). These results indicate that
Vietnamese had significantly higher odds of utilizing Western medicine in their home
county, whereas Hmong had significantly lower odds (Chung & Lin, 1994).
Furthermore, these results indicating that there is substantial overlap in the utilization of
traditional and Western medicine in Asia strongly suggest that in general this refugee
14
population, apart from the Hmong, was utilizing a dual health care system in Asia (Chung
& Lin, 1994). Similar to their Hmong counterparts, Iu-Mien share with the Hmong a
common history and pattern of daily life in Asia. Although there is no data to back this
up due to such similarities between the Hmong and Iu-Mien, one can speculate that
utilizing Western medicine in their home country was very minimal.
Help-seeking patterns in the United States by Southeast Asians were no different
compared to help-seeking patterns in Asia. The percentage of each group seeking
Western medicine in the United States were Cambodians (88%), Lao (86%), Vietnamese
(76%), Chinese Vietnamese (69%), and Hmong (56%). According to Chung and Lin the
greatest disparity in help-seeking behavior in the United States were the Hmong.
Although help-seeking patterns in the United States show a dramatic increase compared
to help-seeking patterns in Asia, traditional methods of health care continue to be utilized
in conjunction with Western health care methods by the Southeast Asians especially the
Hmong. Chung and Lin further asserts that upon resettlement in the United States, the
Hmong reported utilizing Western medicine five times more than in Laos, but nearly 40%
of the Hmong also reported that they still utilize traditional medicine in the U.S. The
main reason for continued usage of alternative or unconventional medicine is due to
cultural conceptions of illness. This is also true for the Iu-Mien as studies done by
Gilman, Justice, Saepharn, and Charles (1992) report that Iu-Mien takes a different
approach to assessing illness causation. The Iu-Mien focus on the origin of the condition
and emphasis on what caused the symptom and why it started. Only after there are no
indications of spiritual involvement, illnesses are then treated with physical remedies
15
such as medical interventions. Furthermore, Gilman and colleagues state that health
professionals in both public and private medical facilities treating the Iu-Mien were
unaware that they might be taking unapproved and controlled medications that could
have notable side effects.
The intergroup difference in the utilization of health care services in Asia could
be accredited to the level of exposure to Westernization and the availability of Western
medicine (Chung & Lin, 1994). The analysis of help-seeking patterns in Asia suggests
that Vietnamese were more likely to utilize Western medicine in their native country
partially due to Western medical practices being introduced to Vietnam by the French
colonials. Furthermore, the Vietnamese were from urban areas and had relatively longer
exposure to the French culture which made them more familiar with Western medicine
(Chung & Lin, 1994). In contrast, Western health professionals were scarce in Cambodia
and Laos prior to 1975 which explains why the Cambodians, Laotian, and Hmong rely
heavily on indigenous healers and folk medicine. Studies by Chung and Lin showed that
the Hmong were the least likely to utilize Western medicine compared to other groups
because they had little exposure to Westernization and they were from rural areas in
Laos.
English proficiency is a prerequisite for utilizing Western medicine in the United
States where many of the mainstream service may not have translators or
bilingual/bicultural staff (Chung & Lin. 1994). Findings by Chung and Lin have suggest
that the educated, younger people and those with English proficiency acculturated at a
greater pace and therefore sought Western medicine compared to traditional medicine.
16
Sue, Cheng, Saad, and Chu (2012) argued that among the U.S. born and immigrant Asian
Americans alternative services either facilitated or inhibited specialty mental health
service use, depending on the individual’s English proficiency. Specifically, those with
poor or fair English language proficiency, alternative services seemed to compete with
specialty mental health care. For those with good or excellent English proficiency, the
use of alternative service increased the likelihood of utilizing specialty mental health
services (Sue et al., 2012). Compared to their Vietnamese counterparts, the Iu-Mien were
not highly educated and had low level of literacy in their own language and they cannot
speak English. Therefore, the Iu-Mien underutilizes such services as mental health here
in the United States due to their low English proficiency. Commonly, children were
utilized as interpreters for the family when a professional interpreter was unavailable;
however, this is not necessarily an effective method of communicating with health care
professionals.
The concept of stigma and shame also play an important role in the
underutilization of mental health services. The fear of stigma and shame play a vital role
in Asian American’s low service utilization of mental health. The intense stigma
attached to mental illness among Asians is believed to attribute to character flaws and
hereditary defects (Yeung & Kung, 2004). The Asian culture is commonly concerned
over the loss of face and impacts of genetic defects can go beyond the patient to affect the
marriageability of family members. In Asian societies, strong emphasis on saving face
and bringing harmony is crucial to the family and mental illness is not perceived as a
personal matter, but as a threat to the harmony of the family. Therefore, avoid utilizing
17
public services such as welfare agencies, mental health agencies, health service agencies,
and legal systems because the utilization of service is considered a tacit admission of the
existence of these problems and could potentially result in shame, embarrassment, and
disappointment to the family (Chu & Sue, 2011).
In a study conducted by the Primary Care Research in Substance Abuse and
Mental Health for the Elderly (PRISM-E) as reported by Jimenez, Bartels, Cardenas, and
Alegria (2013), 2244 clients were referred by their primary care clinician to participate in
two specific interventions: an integrated care model and an enhance referral model. The
integrated model provided mental health/substance abuse services in the primary care
clinic by a mental health provider. The enhanced referral model provided mental
health/substance abuse service in a specialty setting that was physically separate and
designated as a mental health/substance abuse clinic. These interventions seek to identify
cultural attitudes towards health care and mental illness as well as cultural sensitivity
desired from the health care system from a cross-sectional perspective. According to
Jimenez and colleagues the results of this study showed that 25.9% of Asian Americans
felt shame or embarrassment with regard to having mental illness compared with nonLatino Whites at 15.3%. Asian Americans also stated having greater difficulty engaging
in mental health treatment if others knew, less comfort in speaking with their primary
care physicians (PCPs) about mental health issues, and greater difficulty seeking mental
health treatment in specialty mental health settings. Due to the intense stigma and shame
attached to mental illness, Asian American prefer informal solutions for their mental
health problems by seeking support from family and friends and delaying professional
18
mental health service until problems become severe. Asian Americans who make the
difficult decision to obtain help often turn to primary care physicians, herbalists,
acupuncturists or other health care professionals for help instead of mental health
professionals (Yeung & Kung, 2004).
Mental Health Needs/Issues of Southeast Asians
Chung and Bemak’s (2002) findings show that Southeast Asian refugees are at
risk for developing serious mental health disorders. This includes PTSD resulting from
the traumatic events experienced during the war, the escape from their homeland, and
refugee camp experience (Chung & Bemak, 2002). Hsu et al., (2004) state that many
Southeast Asians endured government-sponsored intimidation and threats to their lives
after communist gained control of their homeland. Some of the migration stressors
include separating from or witnessing deaths of family and relatives while fleeing their
home county. Even after Southeast Asians escaped their native countries, they
experienced additional stressors such as assaults by border guards while entering
neighboring countries. Furthermore, while detained in refugee camps, they were faced
with the uncertainty of their future and the fate of separated family and friends.
Southeast Asians still continue to experience PTSD even after decades of fleeing from
their country of origin.
Southeast Asian refugee patients are most commonly diagnosed with mental
health problems such as depression, somatization and physical disorders, adjustment
disorders, anxiety, and PTSD. Hsu et al., (2004) reports on a study conducted in nine
counties in California sampling 2773 Southeast Asian refugees regarding mental health
19
needs. The sample comprised of 867 Vietnamese, 291 Chinese Vietnamese, 589
Cambodians, 722 Laotians, and 302 Hmong. The percentages of traumatization among
Southeast Asian groups were presented: Cambodians (43%); Laotians (17%); Hmong
(17%); and Vietnamese (14). These results indicate that Cambodians experienced the
most PTSD. Another extensive study on PTSD surveyed 322 patients at a psychiatric
clinic for Indochinese refugees to determine the presence of PTSD. This study found that
226 patients (70%) met the diagnosis of PTSD with Iu-Mien having the highest rate of
PTSD (93%) compared to the Vietnamese refugees who had the lowest (54%).
Compared to the Iu-Mien, Cambodians and Hmong refugees, the Vietnamese refugees
appear to be better adjusted than other Southeast Asian refugees because they have a
lower prevalence rate of PTSD, greater happiness, and less depression (Hsu et al., 2004).
In the aforementioned mental health needs assessment conducted on 2773 Southeast
Asian refugees, the findings for Cambodian, Laotian, and Hmong subgroups were six to
seven times more likely to be in severe need of services such as intensive outpatient, day
treatment, or residential care.
Cultural factors are also important to consider when conceptualizing their mental
health needs. In Asian culture, the family is the primary social unit and a source of
strong identity for its members. Roles and positions of hierarchy are evident in
traditional Asian families as elders are placed in roles of authority and men are
considered higher than women (Hsu et al., 2004). These traditional values were affected
upon resettlement in the United States. Given the language barriers and little to no
formal Western education and vocational experiences, elders lost their status within the
20
family and the society. Due to death encounters from war and pre-migration, many
families were without male personnel which changed the family structure. Single
mothers became primary caregiver as well as taking over responsibility of the family.
Traditional gender roles have also been challenged after resettling in the United States as
women are provided occupational opportunities to support their families. In Southeast
Asia, higher education was only provided to men and women were discouraged from
gaining skills that would allow work outside of the home. Language barriers made it
difficult for parents to adjust to mainstream society often relying on their children for
language support. This transfer of authority from elders to the children severely
disrupted traditional cultural values and roles within the family structure making parents
and elders feeling helpless. These possible effects of trauma on a person such as
depression, irritability, hyper vigilance, startle reaction, and nightmares can severely
impact one’s ability to function in the family let alone in society.
FACTORS ASSOCIATED WITH MENTAL HEALTH PROBLEMS
Acculturation Stressors
Since the fall of Laos in 1975, the Iu-Mien’s residency in the United States has
surpassed three decades. Even after three decades, it is still important to examine the
transition and adjustment of the Iu-Mien people as it has an effect on their mental health.
Acculturation is defined in Merriam-Webster Dictionary (2014) as cultural modification
of an individual, group, or people by adapting to or borrowing traits from another culture;
also: a merging of cultures as a result of prolonged contact. Most Asian Americans have
difficulty acculturating in American society as they endured tremendous hardships in the
21
process of immigration to the U.S. from their homeland (Kim, 2006). Like many other
immigrants and refugees, the Iu-Mien face unique distress such as acculturation stress
related to loss of family/social network, social isolation, shifting gender roles, racism,
language barriers, loss of employment and socioeconomic status, and intergenerational
conflicts all which directly impacts their mental health (Fung & Wong, 2007).
Some acculturation challenges that the Iu-Mien face include expectations,
socioeconomic and environmental stressors, racial discrimination, and health care
consequences (Hsu et al., 2004). Other stressors such as educational attainment and
ethnic and cultural identity are additional factors that are also important to consider
regarding Iu-Mien mental health. Refugees encounter acculturation challenges as they
leave their native countries and attempt to reconstruct a new life in a new country. They
essentially experience the sense of loss as majority of Southeast Asian refugees have lost
significant others and are often not aware of the whereabouts of loved one. In addition to
personal loss, refugees also endure the loss of material belongings, the loss of their
country, and the loss of a familiar way of life. Hsu and colleagues further asserts that as
refugees enter a new country they are immersed in a context of new and unknown culture
where they lack familiar social support and knowledge to access resources for economic
self-sufficiency. The refugees’ emotional resilience and coping resources are challenged
as these situations are highly demanding and often are not in direct control of the
refugees causing severe psychological distress.
Life in Thai refugee camps was long and hard and did not adequately prepare the
Iu-Mien for the move to the U.S. According to Barker and Saechao (1997) some Iu-Mien
22
people stayed in the refugee camps for ten years or more, which took a great toll on their
physical and mental health. The Iu-Mien knowledge about the Western world were
frequently distorted by unfounded rumors as Moore and Boehnlien (1991), report a camp
rumor being that people in the U.S. were cannibals. When the Iu-Mien arrived in the
U.S. they had little knowledge of urban life. Most Iu-Mien adults have never ridden in a
passenger car, seen buildings more than two stories high, used a telephone, cooked on a
stove, eaten with a fork or knife, used a flushable toilet, or used a refrigerator (Barker &
Saechao, 1997). The American resettlement agencies were not aware or prepared for the
degree to which the Iu-Mien needed to be oriented to urban life and consequently did not
provide much in the way of specific training. The neighborhoods where the Iu-Mien
resided were poverty stricken with high crime and provided few opportunities for
economic success. City living made it difficult for Iu-Mien to grow subsistent crops and
to make the necessary animal sacrifices for rituals to be performed correctly (Barker &
Saechao, 1997; Crystal & Saepharn, 1992; Habarad, 1987b; Gilman et al., 1992; Waters,
1990).
Southeast Asian women encounter specific acculturation stressors due to their
lack of education and limited job skills. Most of them do not have extended family
support, are single parents with no experience or role models to emulate, facing rolereversal problems and shift of power when the woman is the wage earner and the man
stays at home (Hsu et al., 2004). Furthermore, Southeast Asian woman are challenged by
their disciplinary methods. It is very common in the Iu-Mien culture to discipline a child
through physical forms, which at times may leave bruises and marks. These bruises and
23
marks have in the past been intervened by Child Protective Service, which has severely
affected the discipline system in the Iu-Mien family, and parents fear losing control of
their children. Children also experience acculturation stressors from living and thinking
in two languages such as one for home and one for school. These adjustments may result
in identity confusion for refugee children (Hsu et al., 2004). Iu-Mien children are also
required to serve as interpreters and culture-brokers for adults in their family resulting in
reversal role of authority, power, and respect. The memories and trauma of their premigration and the challenges that the Iu-Mien have encountered during post-migration
has further isolated them from being able to acculturate or assimilate into the new
society.
Somatization
Somatization is defined by Moore et al., (2001) as the presentation of physical
symptoms without demonstrable organic pathology. When Southeast Asians do seek
help for mental illness, they often interpret psychological problems in physical terms to
avoid stigmatization. Somatic complaints including pain are frequent in migrant
population and in Southeast Asian refugees they have been associated with greater
psychopathology, socio-economic distress and poorer adaptation. Furthermore, one
explanation of somatic complaints would be to see them as part of a general stress
response to trauma. Another possibility is that somatic symptoms can be part of
psychiatric syndromes such as chest pain, tachycardia, dizziness, faintness, weakness and
other complaints that accompany panic attacks.
24
A research on disorder and somatization by Moore and colleagues through the
Indochinese Psychiatric Program (IPP) in Portland, Oregon, found that the most common
primary complaint of the Iu-Mien was pain. The participants in this study consisted of 70
Iu-Mien and 30 Laotian patients. The Iu-Mien and Laotian had access to the same
treatment within the IPP; however, when compared with other ethnic groups, the Iu-Mien
provided the least improvement and continued to complain of persistent, wide spread
pain. Despite their prevalence, the study also found that the Iu-Mien patients did not
volunteer any psychological complaints, failed to report nightmares, panic attacks,
depression or insomnia. In contrast, the Laotian did describe emotional complaints and
other psychiatric symptoms consistent with diagnostic criteria for mental disorders. The
Iu-Mien had proven to have difficulties with medications, showed poor tolerance and
response to specific antidepressant medications. The study also found that all the
subjects with complaints of pain suffered from depression, either alone, with PTSD, or
with PTSD and psychotic symptoms. Moore and colleague further notes that the Iu-Mien
had little to no experience with Western health care systems and was often confused
about the role of specialists, and frequently failed to attend medical appointments. Due to
the complexity of providers and lack of appropriate interpreters made negotiating medical
care extremely difficult for the Iu-Mien. The findings in this study suggest that the high
somatization rates of the Iu-Mien may be due to mental health illnesses being highly
stigmatizing in their cultures and psychiatric care is sought only after failed attempts
from traditional avenues of help.
25
Cultural Competence and Cultural Intervention in Service
Culture is defined by Livingston et al., (2008) as an integrated pattern of behavior
shared among a group of people that includes ideology, thoughts, beliefs, speech, action,
and artifacts and is passed from one generation to the next through ceremonies, rituals,
and traditions. Base on this definition, the primary purpose of culture is to give a group
of people a general guideline for living and interpreting reality. Health care professionals
having a greater understanding of each ethnic culture can help better implement culturally
appropriate interventions. There is some evidence suggesting that treating patients in a
more culturally sensitive manner can reduce premature treatment termination (Hwang,
Myers, Abe-Kim, & Ting, 2008). Among English speaking Asian Americans, the
beneficial effects of receiving treatment at a culturally sensitive treatment center seem to
outweigh the positive effects of being matched with an ethnically similar therapist
(Hwang et al., 2008). This finding indicates that training therapist to be culturally
competent and developing culturally congruent interventions can serve as a form of
quality improvement in mental health settings.
According to most contemporary anthropologists, educators, and social scientist,
cultural competence is a set of behaviors, attitudes, and policies that enables a system,
agency, and/or individuals to function effectively with culturally diverse clients and
communities (Livingston et al., 2008; Lynch & Hanson, 1998; Rorie et al., 1996). The
development of cultural competence allows mental health professionals to be able to
think, feel, and develop interventions that acknowledge, respect, and build upon ethnic
and sociocultural diversity. Developing cultural competence requires becoming
26
knowledgeable and respectful of another culture’s values, beliefs, customs, and traditions
(Livingston et al., 2008). For example, those working with population where reliance
upon shamans and herbalists, may find that knowledge regarding health from the
mainstream health care service may not be valued. In order to be effective in working
with the Iu-Mien population one must be cognizant of what the community values as
knowledge and what is consistent with traditional and cultural practices.
Even though in recent years there have been culturally-specific services available
for the mental health needs of Asian Americans, Livingston and colleagues point out that
service professionals have only been trained to understand superficial differences
between cultures such as differences in clothing, language, and food. Livingston and
colleagues suggest that in order to understand culture, psychologist and those who study
human behavior must be abreast of deep, structural factors that undergird aspects of
surface-level behavioral manifestations among ethnic minority population. In trying to
bridge the gap between cultural understanding and improving treatment efforts, mental
health professionals need to be more culturally competent.
Asian Americans also experience restricted access to available mental health
services because of limited English proficiency and a lack of providers with appropriate
language-matched abilities (Chu & Sue, 2011). The shortage of ethnic minority mental
health professionals and the limited availability of services in various ethnic languages
have made ethnic matching a barrier for treatment. This issue becomes even more salient
because many ethnic minority groups already have less than positive attitudes towards
mental health service (Hwang et al., 2008). According to Gilman et al., (1992) in a study
27
they did on cross-cultural medicine by Laotian refugees, specifically the Iu-Mien,
indicate that patients in Richmond, California experienced problems navigating public
health care service. Not only did the Iu-Mien encounter long waiting time and difficulty
with transportation to health care service, they also encountered language barriers. There
are two clinics that provide Iu-Mien language interpreters, but only on a limited
scheduled basis. Often times when Iu-Mien patients go into the clinic for urgent or walkin care interpreters are not available. In cases where interpreters were unavailable
school-age children were relied on to provide interpretation service for their parents. One
of the challenges that the Iu-Mien continues to face today is the lack of ethnic-matching
providers. As Iu-Mien children experience considerable exposure to American norms
especially via schools and the educational process, they have become alienated from
adults and older generations, skills in the Iu-Mien language are diminished and religious
traditions and the people performing traditional rites appear old-fashioned or strange to
the younger Iu-Mien population (Barker & Saechao, 1997). The effects of diminished
Iu-Mien language in the younger population now will result in language gaps for future
health care service as Iu-Mien children will not be able to communicate and understand
their Iu-Mien elders.
Research from the past decades indicate little progress have been made to reduce
the disparities in mental health service access for Asian Americans. As of 2001, several
solutions have been pursued to address the problem of low utilization of service by Asian
Americans. According to Sue et al., (2012) several mental health service organizations
have targeted community education and outreach efforts to increase the acceptability of
28
utilizing services, developed ethnic-specific programs, or increased the availability of
bilingual staff. Directed attention to developing and increasing the availability of
culturally competent treatments has also been explored. Cultural psychologists also
recognized that treatments proven to work for Caucasian populations might not work for
ethnic minority populations such as Asian Americans. As a result, clinical scientist
recognized the need to culturally adapt these treatments to make them understandable and
effective for Asian American population. Cultural adaptations have also emerged in
recent years. Chu and Sue (2011) reports that cultural treatment adaptation refers to the
method which evidence-based practices (EBPs) proven in mainstream populations are
tested and modified for the specific cultural needs of ethnic minorities such as Asian
Americans. Furthermore, Chu and Sue states that culturally adapted EBPs methodically
consider language, culture, and contextual issues consistent with client’s cultural values,
beliefs, and practices, and have demonstrated beneficial outcomes in diverse populations.
These innovations are showing considerable promise to provide treatment options that are
culturally congruent with the needs of Asian Americans.
Summary
There is very limited literature on the Iu-Mien, and little to none is known about
them in this country. In many mental health studies, the idiosyncratic needs of Southeast
Asian ethnic groups are frequently overlooked or subsumed under the larger global
category. Asian Americans have routinely been treated as a single ethnic group resulting
in misunderstanding, stereotyping, and overgeneralization (Kim, 2006). Studies
conducted on Southeast Asians only consisted mostly of Cambodians, Vietnamese,
29
Laotian, and Hmong. If the Iu-Mien were mentioned at all, they were often clumped
together into one homogenous group with Southeast Asians, which resulted in erroneous
conclusions. Despite the fact that the Iu-Mien share similar experiences with other
Southeast Asians, they are still a different ethnic group with their own culture, language,
traditions, values, and customs and their need of mental health service could be very
different compared to the needs of other Southeast Asians. The different culture of each
ethnic group also moderates the predisposition, interpretation, experience, manifestation,
and responses to mental illness; therefore, making it necessary to understand geo-political
and sociological aspects, as well as the cultural factors of each group in order to grasp the
association between ethnicity and mental health (Kim, 2006).
Some resources found to be beneficial to the Iu-Mien community are to provide
socialization opportunities to help alleviate the worries that they undergo. Many express
their stories of trauma through singing while others find support in dance groups and
weekly social group meetings. Sitting with a health professional and disclosing their
thoughts and feelings is just not a familiar territory nor may it be comfortable for them;
therefore, having these activities incorporated and available as part of mental health
services would greatly help to increase service utilization by Iu-Mien people.
More studies and research on the Iu-Mien people in general is needed to have a
better understanding of how to best provide appropriate health care service to this
population. With such limited literature on this ethnic minority group current services
provided may not be culturally appropriate. In completing this research project, the
researcher hopes to shed light on an underserved population and their mental health
30
needs. The researcher also hopes that this project can provide a better understanding to
help bridge the gap of Iu-Mien people and their mental health service disparities.
31
Chapter 3
METHODOLOGY
Study Objectives
To reiterate, the purpose of this research study is to investigate the knowledge and
perceptions Iu-Mien adults have regarding mental health service utilization. This
research study hypothesized that the Iu-Mien people possess limited or inadequate
knowledge and awareness regarding mental illness and mental health services throughout
the greater Sacramento region. As the researcher is a member of the Iu-Mien community,
knowledge gained will be used to educate the Iu-Mien people about mental illness and
mental health service. The methodology of this research include the study design,
sampling procedures, data collection procedures, measurement instruments, data entry
and data analysis procedures, and discuss protection of human subjects.
Study Design
The design of this study is exploratory due to the limited literature on the Iu-Mien
population. According to Engel and Schutt (2013), the exploratory research involves
learning how people get along in the setting under question, what meanings they give to
their actions, and what issues concern them. Engle and Schutt report that the goal of
exploratory research is to learn “what is going on here” and to investigate social
phenomena without expectations. The exploratory method is appropriate for this study as
it will provide further insight for health and human service professionals to better
understand the ongoing mental health needs within the minority groups including the IuMien people. Most importantly, researchers will need to identify views, knowledge, and
32
perceptions that the Iu-Mien people have towards mental health and mental illness in
order to implement proper programs and services that can be tailored to meet the needs of
this population group.
Data Collection Procedures
To conduct this study, the researcher has developed a survey questionnaire that
consists of four main components: (1) background data; (2) knowledge; (3) access; and
(4) communication barriers. The researcher intends to recruit 40 Iu-Mien adults in
Sacramento County, age 30 and older to participate as research subjects. Adult
participants will be recruited conveniently using the snowball sampling such as relative,
friends, and acquaintances. Since some Iu-Mien adults do not read/write English, the
researcher will conduct all the data collection. The researcher is fluent in Iu-Mien
dialect, so participants that cannot read/write English, the researcher will orally translate
the questions and answers to the respondents and ask him/her to reply to the questions.
The researcher obtained participants phone numbers through relatives who
referred researcher to their friends. The researcher contacted participants through the
telephone for participation as human subjects. The researcher then scheduled meeting
time with participants based on their availability and preference in location. All meetings
took place in the participant’s home. Upon face-to-face meeting, the researcher
introduced herself and explained the purpose and procedure of this study. The researcher
also explained the option of not participating and opting out throughout the process at any
time as well as not answering questions that he/she may feel uncomfortable with.
33
Participants were informed of confidentiality. After receiving implied consent from
participants, the researcher began the interview questionnaire.
Most participants do not read or write English, therefore, the researcher translated
each question as needed and participant’s responses were hand recorded onto the
interview questionnaire form. Questions asked were categorized into four sections
consisting of the participant’s demographic background; knowledge, perception, and
understanding of mental illness; access to mental health service; and the communication
and language barriers faced in mental health service. In concluding the interview, the
researcher reviewed all answers with participant to insure answers were what participants
shared.
A total of 40 individuals were recruited for participation as human subjects and
only 25 participants agreed to participate. Human subjects were recruited during
researcher’s winter break and all interview questionnaires were obtained in the
participant’s home within a month span.
Instruments
The research instrument used in this study was developed by the researcher with
the assistance of her Thesis Advisor. No standardized instrument is used for the research
study. The researcher did not pretest the instrument either; therefore, it has no reliability
or validity. Each question is structured to reflect knowledge, views, and perceptions the
participant has about mental illness and mental health services so to avoid putting the
participant to minimal social and psychological risk.
34
The research instrument contains interview questionnaires that are categorized
into four parts. The first part seeks to explore the participant’s background information.
Participants are asked to identify their age, gender, marital status, highest education level,
primary language, and country of birth. The second part seeks to explore the
participant’s knowledge regarding mental illness. There are four exploratory open-ended
questions, which encourage participants to share their knowledge and understanding of
mental illness. The third part explores the participant’s access to mental health service.
This sections includes questions regarding participants health insurance, knowledge on
how to access mental health service, and experience of accessing mental health services.
Lastly, the fourth part explores the participant’s communication and language barriers.
This section asks questions pertaining to whether there are available interpreters in
mental health profession and if there are sufficient information provided in Iu-Mien.
Human Subject Protection
In order for data collection to begin, the researcher had to complete a human
subject form with the support of her Thesis Advisor. The human subject form entails the
purpose of the study, design of the study, procedure of the study, plan for data analysis,
and plan for the protection of human subjects. The human subject form was completed
by the researcher during the month of September 2013 and was emailed to her Thesis
Advisor for review and somehow got lost in the process of email. The researcher reemailed the human subject application form to her Thesis Advisor in the month of
November 2013 along with interview questionnaires to be submitted for review by
Sacramento State Committee for the Protection of Human Subjects. The committee
35
reviewed the researcher’s application and found this project to be of minimal risk to
participants. The researcher’s human subject application was approved on December 11,
2013 and the approval number for this research project is 13-14-054. The researcher
began collection data after notification of application approval. The application approval
will expire on December 11, 2014.
The implied consent will state that the researcher will orally explain the research
purpose, the voluntary nature of the research study, and confidentiality of information
shared by the participants. The obtained information gathered from participants will be
kept strictly confidential in a locked file cabinet. No identifiable information such as
home address, social security number, and date of birth will be collected. The researcher
will further explain that once the information gathered is entered into a computer format,
the original packet will be destroyed. In addition, the research data will be destroyed six
months after the completion of the research study. In addition, only aggregate
information will be reported and there will be no incentive for participation.
Data Analysis
The data collected from the survey questionnaires were entered into SPSS and
hardcopies were destroyed. There were no identifying factors entered into SPSS to
identify participant’s name. The final report includes only the variables of gender,
marital status, education, primary language, health insurance, reliable transportation,
service options, service utilization, mental illness terminology, and language support that
will be applied to determine the knowledge on mental health service utilization amongst
Iu-Mien adults. Questionnaires were categorized into four parts: part one included
36
questions pertaining to participant’s background; part two contained open-ended
questions regarding participant’s knowledge of mental illness; part three included
participant’s access to mental health service; and part four explored the communication
and language of mental health service and mental illness. All questions were coded as A
to 1, B to 2 and so on and so forth. The researcher analyzed eleven questions through
SPSS system and explained the narrative to remainder of open-ended questions. There
were a couple variables that the researcher wanted to talk about but was unable to include
in findings section due to limitation of participants.
37
Chapter 4
STUDY FINDINGS AND DISCUSSIONS
This chapter reports findings from the participants about their knowledge and
understanding of mental health/mental illness, access to mental health service, and the
communication and language barriers that prevent participants from utilizing mental
health services. The data was conducted in Iu-Mien and outreach was targeted at
drawing out the Iu-Mien residing in Sacramento.
Overall Findings
This research surveyed twenty-five (25) participants from the Iu-Mien community
who were ages thirty and older.
Table 1
Gender of Participants
Frequency
Female
Male
Total
Valid
19
6
25
Percent
76.0
24.0
100.0
Valid Percent
76.0
24.0
100.0
Cumulative
Percent
76.0
100.0
One of the interests in any research study is background information of the
respondents. This research study is interested in knowing the gender of the respondents.
As shown in table one, 76.0% (n = 19) were female and 24.0% (n = 6) were male (see
Table 1).
38
Table 2
Marital Status of Participants
Frequency
Single never married
Married
Divorced
Valid
Separated
Widowed
Living w/partner
Total
Percent
Valid Percent
1
16
2
4.0
64.0
8.0
4.0
64.0
8.0
Cumulative
Percent
4.0
68.0
76.0
3
12.0
12.0
88.0
2
1
25
8.0
4.0
100.0
8.0
4.0
100.0
96.0
100.0
The marital status of participants is presented in Table 2. Of the twenty-five
participants surveyed, 4.0% (n = 1) marked single never married, 64.0% (n = 16) marked
married, 8.0% (n = 2) marked divorced, 12.0% (n = 3) marked separated, 8.0% (n = 2)
marked widowed, and 4.0% (n = 1) marked living with partner (see Table 2).
Table 3
Participant’s Highest Level of Education
Frequency
none
Some college or
technical school
Undergraduate
Valid
Post-graduate or
professional
Prefer not to say
Total
Percent Valid Percent
10
6
40.0
24.0
40.0
24.0
Cumulative
Percent
40.0
64.0
5
3
20.0
12.0
20.0
12.0
84.0
96.0
1
4.0
4.0
100.0
25
100.0
100.0
39
With regards to education level, 40.0% (n = 10) participants marked “none,”
24.0% (n = 6) marked “some college or technical school,” 20.0% (n = 5) marked
“undergraduate,” 12.0% (n = 3) marked “post-graduate or professional,” and 4.0% (n = 1)
marked “prefer not to say” (see Table 3).
Table 4
Participant’s Primary Language
Frequency
English only
Mien only
English and Mien
Total
Valid
Percent
3
13
9
25
12.0
52.0
36.0
100.0
Valid Percent
12.0
52.0
36.0
100.0
Cumulative
Percent
12.0
64.0
100.0
The participants were surveyed on their primary language and 12.0% (n = 3) of
the respondents marked English only, 52.0% (n = 13) of the respondents marked Mien
only, and 36.0% (n = 9) of the respondents marked English and Mien (see Table 4).
Table 5
Do Participants Have Health Insurance?
Frequency
Valid
Percent
Valid Percent
Yes
21
84.0
84.0
No
Total
4
25
16.0
100.0
16.0
100.0
Cumulative
Percent
84.0
100.0
When asked whether participants have health insurance 84.0% (n = 21) of the
respondents marked “yes,” and 16.0% (n = 4) of the respondents marked “no” (see Table
5).
40
Table 6
Does Participant Have Reliable Transportation?
Frequency
Yes
No
Total
Valid
Percent
24
1
25
Valid Percent
96.0
4.0
100.0
96.0
4.0
100.0
Cumulative
Percent
96.0
100.0
With regards to reliable transportation 96.0% (n = 24) participants marked “yes,”
and 4.0% (n = 1) participant marked “no” (see Table 6).
Specific Findings
One of the purposes of this research is to study the knowledge and perceptions IuMien people have towards mental health service utilization. The survey implemented
contained three different variables used to measure access to mental health service.
Table 7
Does Participant Think There Are Enough Good Service Options?
Frequency
Valid
Yes
No
Total
Percent
5
20
25
20.0
80.0
100.0
Valid Percent
20.0
80.0
100.0
Cumulative
Percent
20.0
100.0
When asked whether participants thought there are enough good mental health
service options 20.0% (n = 5) of the respondents marked “yes,” and 80.0% (n = 20) of the
respondents marked “no” (see Table 7).
41
Table 8
Participant’s Family Who Sought Service in Past Three Years
Frequency
Valid
Percent
Valid Percent
Yes
No
Don't know
4
20
1
16.0
80.0
4.0
16.0
80.0
4.0
Total
25
100.0
100.0
Cumulative
Percent
16.0
96.0
100.0
In regards to whether participants had/have any family members who sought
mental health service in the past three years 16.0% (n = 4) respondents answered “yes,”
80.0% (n = 20) respondents answered “no,” and 4.0% (n = 1) respondent answered “don’t
know” (see Table 8).
Table 9
Does Participant Think Iu-Mien Utilize Mental Health Service Correctly?
Frequency
Valid
Yes
No
Don't know
Total
3
16
6
25
Percent
12.0
64.0
24.0
100.0
Valid Percent
12.0
64.0
24.0
100.0
Cumulative
Percent
12.0
76.0
100.0
Table 9 inquired into whether participants thought Iu-Mien people utilize mental
health service correctly. Of the twenty-five participants 12.0% (n = 3) answered “yes,”
64.0% (n = 16) answered “no,” and 24.0% (n = 6) answered “don’t know” (see Table 9).
42
Table 10
Does Participant Think Iu-Mien Understand Mental Illness Terminology?
Frequency
Valid
Percent
Valid Percent
Yes
No
Don't know
1
20
4
4.0
80.0
16.0
4.0
80.0
16.0
Total
25
100.0
100.0
Cumulative
Percent
4.0
84.0
100.0
In regards to Iu-Mien’s understanding of mental illness terminology 4.0% (n = 1)
of the respondent reported “yes” Iu-Mien people understand mental illness terminology,
80.0% (n = 20) of the respondents reported “no” Iu-Mien people do not understand
mental illness terminology, and 16.0% (n = 4) of the respondents reported they “don’t
know” if Iu-Mien people understand mental illness terminology (see Table 10).
Table 11
Are There Sufficient Iu-Mien Interpreters to Meet the Needs of Iu-Mien?
Frequency
Yes
Valid
No
Don't know
Total
Percent
Valid Percent
3
12.0
12.0
17
5
25
68.0
20.0
100.0
68.0
20.0
100.0
Cumulative
Percent
12.0
80.0
100.0
When asked if participants feel there are sufficient Iu-Mien language interpreters
to meet the needs of the Iu-Mien people, 12.0% (n = 3) answered “yes,” 68.0% (n = 17)
answered “no,” and 20.0% (n = 5) answered “don’t know” (see Table 11).
43
The participants in the survey were asked to indicate which following Southeast
Asian group they thought knew best about mental illness and mental health service.
Participants were asked to rank the group from a scale of 1 to 5 with 1 as knowing least
about mental illness and mental health service to 5 as knowing best about mental illness
and mental health service. The researcher tallied the scores and the results indicate the
Vietnamese population as knowing best about mental illness and mental health service
and the Iu-Mien population as knowing least.
The same scale was used to rank which Southeast Asian group understand and are
able to utilize mental health service best to fulfill their mental illness needs. The
participant’s results indicate that the Vietnamese population understand and are able to
utilize mental health service best to fulfill their mental illness needs. The Iu-Mien
population was ranked as least to understand and utilize mental health service to fulfill
their mental illness needs.
44
Chapter 5
SUMMARY
Overall Summary
As a member of the Iu-Mien community who has worked in the mental health
field in Sacramento, this researcher is aware of the mental health disparities within the
community and the lack of utilization of mental health services. Even though there has
been some progress made to reduce the disparities in mental health service utilization for
Asian Americans, there still is a low utilization by the Southeast Asian population
specifically the Iu-Mien. The researcher conducted this study to gain better insight into
the cause of underutilization by Iu-Mien and their current knowledge of and perceptions
towards mental health service utilization.
The findings of this research suggest that knowledge and perceptions of mental
illnesses within the Iu-Mien community are still inadequate. A common Iu-Mien
perception of mental illness is one who is crazy or has a brain disease. This suggests that
the Iu-Mien people still associate mental illness with the negative connotation of crazy,
which may deter one from seeking mental health services due to fear of being
stigmatized. The findings also propose that mental illness is caused by bad spirits,
genetics, one who is cursed, past life doings, bad luck, and soul loss. These results
indicate that the Iu-Mien people still continue to uphold their traditional views regarding
causes of mental illness. Other factors causing mental illness identified by participants
were stress, family, work, life experience, accidents, school, generational gap issues, and
45
worrying. These findings suggest that perhaps the Iu-Mien people are also aware of the
environmental causes of mental illness.
Although the findings indicate that a majority of the Iu-Mien have health
insurance and reliable transportation to access mental health services, they also indicate
that the Iu-Mien do not think there are good enough mental health service options to
choose from here in Sacramento County. A majority of participants reported that the IuMien people do not understand mental illness terminologies and do not utilize mental
health services correctly. These could be factors associated with education level as ten
out of the twenty five participants identified as having no education, or lack of English
proficiency, as fifteen out of the twenty five identified Iu-Mien as their primary language.
There were only four participants who reported that they have family members who have
sought mental health services within the past three years. Their response to the family’s
mental health service experience was mostly negative, and the main reason for the
negative experience related to language barriers and language support. It is evident that
there are just not enough Iu-Mien interpreters to meet the needs of the Iu-Mien people,
mostly due to loss of their native language in the younger generation or the older
generation not having the education to provide interpreting services that are English
proficient.
These findings supplement the literature review on causes of underutilization of
mental health services by the Iu-Mien community based on their current knowledge of
mental illness, access to mental health services, and communication barriers. The IuMien still possess inadequate knowledge and awareness of mental illness and mental
46
health service throughout the greater Sacramento region. It is evident that the Iu-Mien
people continue to associate the causes of their mental illness with their traditional views
such as mental illness is caused by soul loss. Although there have been improvements in
access to mental health services such as health insurance and reliable transportation most
Iu-Mien people continue to face challenges accessing services with language support. IuMien people continue to experience restricted access to available mental health service
due to limited English proficiency and lack of providers with appropriate language
matched abilities. As a result, many of them rely on family members and friends to
translate for them.
Implications
This research project highlighted the mental health disparities within the Iu-Mien
community and found a predominant reason for underutilization is the lack of culturally
competent services. On the micro level the development of culturally and linguistically
competent services should be of the highest priority in providing mental health care for
the Iu-Mien population. By providing mental health services in the Iu-Mien language it
helps to build trust and allows for one to feel comfortable in expressing their needs in
their own words. There is already such a fear of stigma for one who is mentally ill, and
having services provided in the Iu-Mien language helps reduce the stigma as it makes one
feel as though they are not alone. The ethnic matching of therapists with clients can also
assist in more positive mental health outcomes, especially for a population who is
relatively less acculturated to U.S. society. Ethnic matching of therapists can help
47
increase length of treatment, as Asian Americans are known to leave treatment
prematurely.
On a mezzo level, to help increase utilization of mental health services it is
important to understand the hierarchy system of the Iu-Mien community. Within each
clan of the Iu-Mien people there are Iu-Mien leaders of their community. The
community leaders often offer guidance for their clan and most Iu-Mien people highly
value their leader’s opinion. By establishing a strong relationship with the Iu-Mien
community leaders, one can help launch awareness of mental illness into the community
to increase adequate knowledge of mental illness and mental health service utilization. In
addition, providers may want to consider support groups in the community tailored to
their client’s cultural activities such as gardening. Gardening was one of the means of
survival for the Iu-Mien as they lived in the mountainous regions of Laos. They survived
off of the crops they grew and this was their way of life. Providing Iu-Mien clients with
a sense of a familiar way of life can assist with more positive mental health outcomes as
it helps them feel normal in a society in which they have difficulty acculturating. Support
groups that allow the Iu-Mien to preserve their traditions may also benefit one’s mental
health. One of the environmental attributes of mental illness for the Iu-Mien was the
generational gap. Younger generations have lost sense of the Iu-Mien’s tradition, culture,
and language. Iu-Mien parents currently face challenges of communicating with their
children and worry that their children will not be able to continue with traditions when
they pass away and fear that their souls will not be honored properly in the afterlife.
48
At the macro level, perhaps providers can advocate for the development and
implementation of programs and services that are ethnic-specific. Asian Americans
represent such very diverse populations in terms of ethnicity, language, culture,
education, income level, English proficiency, and sociopolitical experiences that it is
important to recognize the differences among the groups. Advocating for the
development and implementation of programs that best cater to the needs of specific
subgroups such as the Iu-Mien can help increase mental health service utilization as well
as increase the likelihood that mental health services will be effective for the individual.
Suggestions for Future Research
Currently, there is some literature examining the mental health needs of Asian
Americans, but most literature does not focus specifically on subgroups such as the IuMien. Given the limitations of literature on the Iu-Mien people, additional empirical
research investigating the mental health needs of this population is necessary in many
areas. First, it is important when diagnosing Iu-Mien individuals to avoid using the
traditional mental status exam. Iu-Mien typically do not express their psychological
problems the way individuals from the Western culture would; therefore, there is a need
for culturally sensitive assessment tools to be developed and validated for use with IuMien clients. Secondly, there have been generational gap issues within the Iu-Mien
families. Future research needs to examine the social and familial context as family
members acculturate at different rates that can often stress the family system. Thus, an
important area to examine is the long-term adjustment of Iu-Mien youth and how it
affects the family dynamics with their parents who are first generation refugees. Another
49
recommendation for future studies is to examine the complex multidimensional
interaction of the experiences endured by Iu-Mien to better address the mental health
needs of this population. Studies suggest that each Southeast Asian group has different
pre-immigration and post-immigration factors that are related to levels of depression,
anxiety, and psychosocial dysfunctions. Moreover, further research could examine the
presence of somatic complaints in Iu-Mien who are not suffering from psychiatric
disorders to distinguish this syndrome from that occurring in association with depression
and PTSD. Finally, future studies can focus on the unique resilience of this population
that plays a vital role in successful adjustment. Examining the strengths and resiliency of
this population has direct implications for the development of prevention and intervention
programs for future refugees.
Limitations
Due to the small sample size of participants in this research project findings are
not reflective and are not a representation of the Iu-Mien community as a whole. Also,
the findings of this research project included only participants from the greater
Sacramento region; therefore, the results do not apply to other Iu-Mien residing in any
other areas. Considering the limited literature on the Iu-Mien people this project was
developed by using literature on other Southeast Asian subgroups that had similar war
and immigration related experiences.
Conclusion
This research intended to explore the knowledge on mental health service
utilization among Iu-Mien adults. In doing this research project, the finding presents that
50
there are still mental health disparities within the Iu-Mien community here in Sacramento
County. Results indicate that the Iu-Mien people have little improvement in utilizing
mental health services as their understanding of mental illness continues to deter one
from seeking out service. In addition, the Iu-Mien people feel that there are not enough
good mental health service options due to lack of ethnic-matching health professionals or
providers that provide sufficient Iu-Mien language interpreters. In order to help bridge
the gap of mental health service utilization it is important for service providers to
consider the Iu-Mien’s culture, traditional belief system, and their understanding of
mental illness to help facilitate a more appropriate treatment that meets the needs of the
individual.
51
APPENDIX A
QUESTIONNAIRE
52
KNOWLEDGE ON MENTAL HEALTH SERVICE
PART I: Background data
1. What is your gender?
a.
Female
b.
Male
2. What is your age?
a)
30-39
b)
40-49
c)
50-59
d)
60+
3. What is your marital status?
a)
Single never married
b)
Married
d)
Divorced
e)
Separated
f)
Widowed
g)
Living w/ partner
4. What is the highest level of education you completed?
a)
None
b)
Some high school
c)
High school
d)
Some college or technical school
53
e)
Undergraduate
f)
Post-graduate or professional
g)
Prefer not to say
5. What do you consider as your primary language to be?
a)
English only
b)
Mien only
c)
English and Mien
6. Where is your birth country?
a)
Laos
b)
Thailand
c)
United States
PART II: The following questions ask you for your knowledge regarding mental illness
1. What is the first thing that comes to mind when hearing the word mental illness?
Please explain to me how you would define mental illness.
__________________________________________________________________
__________________________________________________________________
2. What do you think causes mental illness? Please explain your thoughts on how
mental illness occurs.
__________________________________________________________________
__________________________________________________________________
3. What do you think are some of the symptoms presented in one who is mentally
ill? Describe symptoms.
54
__________________________________________________________________
__________________________________________________________________
4. This question applies only to those who are born outside the United States. If
participant is born in the US, skip to part III. Since arriving and living in the
United States, does your perception of mental illness change?
a)
Yes; please explain why/how: ___________________________________
b)
No; please explain why/how: ____________________________________
PART III: Access to mental health services
1. Do you have medical insurance/healthcare insurance?
a)
Yes
b)
No
2. Do you have reliable transportation to get to where you need to go?
a)
Yes
b)
No
3. Do you know where to go for help if you or a family member was in need of
mental health service?
a)
Yes
b)
No
4. If you or a family member was in need of mental health service, do you think
there are enough good service options to choose from?
a)
Yes
b)
No
55
5. Have any family of yours ever sought mental health service in past three years?
a)
Yes
b)
No
c)
Don’t remember
6. Incase YES to the above question, describe your experience of that service.
Either talk about the positive or negative experience.
__________________________________________________________________
__________________________________________________________________
7. In your personal knowledge, do you think the Iu-Mien people utilize mental
health service correctly?
a)
Yes
b)
No
c)
Don’t know
8. Which of the following Southeast Asian groups do you think know best about
mental illness mental health services? Please rank them from 1-5 with 1 knowing
least and 5 knowing best.
____
The Cambodian
____
The Hmong
____
The Mien
____
The Laotian
____
The Vietnamese
56
9. Which of the following Southeast Asian groups do you think understand and are
able to utilize mental health services best to fulfill their mental illness needs?
Please rank them from 1-5 with 1 understanding least and 5 understand most.
____
The Cambodian
____
The Hmong
____
The Mien
____
The Laotian
____
The Vietnamese
PART IV: Communication and Language
1. Do you think the Iu-Mien understand mental illness terminology?
a)
Yes
b)
No
c)
Don’t know
2. Do you think mental health service providers in the greater Sacramento region
provide sufficient information in Iu-Mien to the Iu-Mien people?
a)
Yes
b)
No
c)
Don’t know
3. Do you feel that mental health service providers in the greater Sacramento region
provide sufficient Iu-Mien language interpreters to meet the needs of the Iu-Mien
people?
a)
Yes
57
b)
No
c)
Don’t know
Do you have any additional comments regarding mental illness in the Iu-Mien
community that you would like to share with me today? If not, thank you for your time.
58
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59
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