Racial/ethnic disparities in physical health and health care have for more than two decades represented priority areas for research and public policies (Smedley, Stith, & Nelson, 2003
). Initiated by the Surgeon General’s report (US Department of Health and Human Services, 1999
) and further reinforced by the President’s New Freedom Commission on Mental Health (2003)
, attention has been extended to mental health arena. It is now recognized that racial/ethnic minorities are more likely to have mental health problems than non-Hispanic whites, while at the same time minorities are less likely to utilize mental health services (Lin & Cheung, 1999
; US Department of Health and Human Services, 2001
). In the findings from the National Comorbidity Survey Replication, unmet needs for mental health services were pronounced among elders and racial and ethnic minorities (Wang et al., 2005
). Numerous studies have explored risk factors of mental distress in minorities (e.g. low socioeconomic status, poor health conditions and acculturative stress) and potential barriers to service use (e.g. lack of insurance, limited English proficiency, stigma and cultural misconceptions; US Department of Health and Human Services, 2001
One of the major challenges in research with ethnic minorities is oversimplification or lack of attention to within-group variations. Little attention has been paid to the effects of age and aging on a wide variety of psychological functioning and behavior. Indeed, few researchers have focused on age-group differences in mental health service utilization even within nonminority populations. Studies using actual utilization as an outcome criterion have usually found that older adults are less likely to use mental health services than their younger counterparts (e.g. Crabb & Hunsley, 2006
; Wang et al., 2005
). For attitudinal outcomes, however, findings are mixed, with some studies suggesting more negative views held by older populations (e.g. Lundervold & Young, 1992
) and others finding no age differences (e.g. Robb, Haley, Becker, Polivka, & Chwa, 2003
; Segal, Coolidge, Mincic, & O’Riley, 2005
Because younger and older adults represent distinct cohorts with different life experiences and exposures to mental health issues, their perceptions of and attitudes toward mental health and service utilization may vary. Information on age difference will be useful to develop interventions that effectively address the specific needs of different age groups of minorities. The goal of the present study was to explore whether attitudes toward mental health services and their predictors differ between younger and older adults of one ethnic group, Korean Americans.
Korean Americans are currently ranked as the fourth largest Asian American subgroup, and they are projected to have continuous demographic growth over the next few decades (US Census Bureau, 2000
). Despite their population demographics, relatively little is known about the psychological experiences of Korean Americans. The limited literature that is available suggests that Korean Americans may be at particular risk for mental distress (Hughes, 2002
). Studies using standard depressive symptom inventories (e.g. the Center for Epidemiologic Studies – Depression, CES-D, scale and the Geriatric Depression Scale, GDS) have found higher scores for Koreans than for other racial/ethnic groups. This is the case both in younger adult samples (e.g. Yeh, 2003
) and in older samples (e.g. Min, Moon, & Lubben, 2005
). Although the high scores may be partly attributed to cultural response patterns to symptom inventories, the findings call attention to the heightened needs for mental health services in Korean American communities.
Although there are reasons to suspect that Korean Americans may be experiencing considerable distress, studies indicate they tend to underutilize available mental health services and hold negative perceptions of service use (Kim, 1995
; Shin, 2002
). Because negative perception is a critical impediment to service use (Diala et al., 2000
; Leaf et al., 1988
), exploration of correlates of attitudes toward mental health services is an essential step in understanding the target population’s conceptions of mental health and help-seeking behaviors and in developing intervention strategies. However, previous work (e.g. Jang, Kim, Hansen, & Chiriboga, 2007b
; Yi & Tidwell, 2005
) has been limited by the restricted age ranges of samples and lack of attention to age-group difference.
Another limitation in existing research with Korean Americans is the lack of appropriate theoretical models. The present study incorporated Andersen’s (1968)
model of health services use. This model has been frequently employed in research not only on actual utilization of mental health services but also on attitudinal outcomes (e.g. Leaf et al., 1988
). The original model proposes that health services use is determined by societal factors, health services system factors and individual factors. Furthermore, individual factors are categorized as needs, enabling factors and predisposing factors. The model has been successfully applied to various racial/ethnic groups, including Asians, with recommendations to incorporate cultural factors (Andersen, Harada, Chiu, & Makinodan, 1995
). In the present study, demographic characteristics such as age, gender, marital status and education were conceptualized as predisposing factors. Individuals’ overall mental health condition, as indicated by anxiety and depressive symptoms, was considered to represent needs. The third component, enabling factors, deserves much attention because it explains barriers and facilitators to service use, which in turn can be targets of interventions.
The enabling variables included in the current assessment were acculturation, health insurance coverage, prior experiences with counseling and personal beliefs about mental illness. Studies with immigrant populations have consistently shown that higher acculturation levels are positively linked to favorable perceptions of mental health services (Tata & Leong, 1994
). Given that health insurance is an important enabler for service use and that minorities are more likely to be uninsured than nonminorities (Brown, Ojeda, Wyn, & Levan, 2000
; Lillie-Blanton & Hoffman, 2005
), lack of insurance may lead to negative attitudes toward mental health services. Having had prior contact with mental health professionals has been shown to be associated with more openness to service use (Tijhuis, Peters, & Foets, 1990
Personal belief about mental illness is thought to shape one’s openness to service use (Karasz, 2005
). Minority elders in particular are known to be subject to cultural misconceptions and stigma related to mental illness (Lin & Cheung, 1999
; US Department of Health and Human Services, 2001
). Many Asian Americans view depressive symptoms as a sign of weakness or lack of discipline and willpower (Leong & Lau, 2001
). It is also known that Asian Americans tend not to accept the medical model of depression that portrays depression as a disease requiring professional treatment (Karasz, 2005
). Based on Confucian ethics, Asians tend to believe that self-concealment of emotional trouble is a virtue (Yi & Tidwell, 2005
). Given these cultural characteristics, emotional symptoms and distress are often internally tolerated, and stoic approaches are usually encouraged in response to emotional distress (Lin & Cheung, 1999
Stigma and discrimination against people with mental disorders, indeed, are common throughout world (World Health Organization, 2001
). Asian cultures, however, are relatively unique in that stigma is attached not only to the affected individual but often to the individual’s family as well (Lin & Cheung, 1999
; Okazaki, 2000
). In many Asian cultures, one’s mental illness is perceived not only as a personal matter but also as a threat to the homeostasis and harmony of the whole family (Lin & Cheung, 1999
; Okazaki, 2000
), as having a family member with a mental illness negatively reflects on family lineage and brings dishonor to the family name. It is generally recognized that cultural misconceptions and stigma against mental illness have adverse impacts on attitudes toward mental health services (Karasz, 2005
; Lin & Cheung, 1999
). Although older adults are expected to be more subject to disbeliefs in the medical model of depression and in cultural stigma, it is unclear how those culture-related beliefs about mental illness contribute to the attitudes toward mental health services in different age groups.
Using samples of young and old Korean Americans, our objective with this exploratory study was to assess (a) whether there is an age-group difference in attitudes toward mental health services and (b) whether the predictability of predisposing, need and enabling variables to attitudes differ by age group.