Mental health and access to care in the Montagnard migrant community: Examining perspectives across four generations in North Carolina

Theoretical framework

Health access is a known issue in the Montagnard community, and sociocultural, political, and economic variables can further compound negative health outcomes (Bharmal & Thomas, 2005; Dharod, 2015; Lee et al., 2012; Percheski & Bzostek, 2017). Under a patient-centered access to health care framework, access can be defined as “the opportunity to reach and obtain appropriate health care services in situations of perceived need for care” (Levesque et al., 2013). This framework conceptualizes access in five dimensions: approachability, acceptability, availability and accommodation, affordability, and appropriateness. Approachability, or ability to perceive, is the idea that people with a health-related need can identify that a service exists, can be reached, and will have an impact on their health (Levesque et al., 2013). Areas of interest in this dimension include health literacy related to medications, beliefs about herbal remedies, and the idea of mental illness as a spiritual issue (Bailey, 2002; Corby, 2010). Acceptability, or ability to seek, pertains to the cultural characteristics of a service that determine whether it is acceptable to people, and social values in the community that influence the perceived appropriateness of seeking care. Past research involving Montagnards has suggested that stigma may be a major issue within this dimension (Corby, 2010). Availability and accommodation, or ability to reach, pertains to logistical aspects such as location, hours of operation, and appointment making mechanisms. One study suggested that Montagnards sometimes struggle to understand how and why people need to make appointments to see a doctor instead of just walking into the office (Corby, 2010). Affordability, or ability to pay, includes the direct, indirect, and opportunity costs of the service as well as characteristics of the patients like income level and health insurance status. Montagnards are affected by poverty, and, concerningly, almost two-thirds of Montagnards do not have health insurance (Dharod, 2015). Finally, appropriateness, or ability to engage, reflects the alignment of services to client need and the quality of the service. Challenges with appropriateness for Montagnards include the language barrier, cultural discordance that leads to misunderstandings, and confusion around diagnostics involving checkboxes and rating scores (Clough et al., 2013; Corby, 2010).

Gaps and present study

While the literature on health access highlights the many inter-related challenges facing migrant communities throughout the United States, less is known as to the extent to which these findings translate across differing migrant contexts, and equally important, across differing generations of migrants. Additionally, the very limited studies that have been conducted on health access in Montagnards do not go in depth on these issues with respect to mental health or elder care, both of which are stated needs of the Montagnard Community Advisory Council. The Montagnard Community Advisory Council is a voting group of Montagnards which operates under the Montagnard Dega Association to set standards for researchers on behalf of the community. This research aims to answer three primary questions: What is the mental health status of four generations of Montagnards? What issues of access to mental health care are present, and how do perspectives of mental health access vary across generations?

Participants

The 26 participants in this study were adult members of the Montagnard community in North Carolina and were divided into generations based on their year of birth. While the birth date of some elders may not be exact if they were born in the jungle, the year can be estimated. The first and oldest generation was born in 1970 or earlier; the second was born between 1971 and 1985; the third was born between 1986 and 1995; and the fourth and youngest generation was born after 1995. Participants were recruited with the assistance of community members and organizations. The researchers strived to include a mix of genders and generations; however, there was a low number of participants from generations one and two due to complications arising from the Covid-19 pandemic.

Data collection

This qualitative research study utilized semi-structured interviews and framework analysis techniques to analyze five dimensions of access to mental health care across four generations of Montagnards. The project is based on two stated community needs (mental health and elder care) and was developed in partnership with the Montagnard Community Advisory Counsel and other community stakeholders. This was one of the first studies to work with and gain approval from the Community Advisory Council, marking a step forward in community-based research for the Montagnards. The research was also approved by the Elon University Institutional Review Board on December 23, 2019, and an amendment regarding safety during the Covid-19 pandemic was approved on March 28, 2020. The IRB approval number is #20-152. Interviews were conducted by a non-Montagnard researcher who received cultural and historical training from the Community Advisory Council, and most interviews with older participants also included a Montagnard serving as interpreter. Interviews consisted of a mental health screening and a series of open-ended questions about access to mental health care based on the patient-centered access to care framework (Levesque et al., 2013). The open-ended interview questions were formed collaboratively with researchers and two Montagnard individuals. The mental health screening included the PHQ-9 for depression, the GAD-7 for anxiety, the PC-PTSD for post-traumatic stress disorder, and the AUDIT for alcohol abuse (Hanley et al., 2013; Reinert & Allen, 2002; Williams, 2014a, 2014b). The mental health screenings and access to mental health care interview questions are freely available on the Qualitative Data Repository, https://doi.org/10.5064/F6XFC4RG (McGinley, 2023). The access to mental health care interview questions created for this project were not validated. Participants who indicated that they were having suicidal thoughts on the depression screening were immediately connected to a Montagnard community health worker. The two interviews conducted before March 2020 were in-person at the home of the participant. Beginning in March 2020, the mental health screenings were conducted using Qualtrics online survey software and the rest of the interview was done over the phone to ensure safety during the Covid-19 pandemic. A potential open-access alternative to this software is Google Forms. Those unable to take the survey online had the option of taking it over the phone, and an interpreter was available for Montagnards not fluent in English.

Analysis

Audio recordings were taken of each interview. They were transcribed with the assistance of Sonix software in 2020, and manually revised to ensure accuracy. A potential open-access alternative to this software is Descript. A codebook was designed based on the access to care framework, and transcripts were then tagged with codes and analyzed using Dedoose version 9.0.90. A potential open-access alternative to Dedoose is QDA Miner Lite, which can be accessed at https://provalisresearch.com/products/qualitative-data-analysis-software/freeware/. Descriptive analysis was conducted of the mental health screenings. These analytic steps were conducted by non-Montagnard researchers. Following completion of the analysis, results were shared with the community through an educational video (including an English and a Jarai version) produced in collaboration with the Montagnard Dega Association, and through a social media campaign (McGinley, 2023). The plan for this research was not pre-registered with an independent registry.

Mental health status

The demographic characteristics of the sample are displayed in Table 1. The full results of the mental health screenings are displayed in Table 2. The results of the PHQ-9 indicate that 35% of participants had some level of depression, while 65% showed signs of minimal or no depressive symptoms (McGinley, 2023). Cases of depression occurred only among the younger generations. Three participants indicated on the screening that they had thoughts of suicide or self-harm in the preceding two weeks, all of whom were from the youngest group, generation 4. The results of the GAD-7 indicated that 31% of participants showed signs of some level of anxiety, all cases of which occurred in members of generation 3 and generation 4. The PC-PTSD screening found that 15% of participants presented with post-traumatic stress disorder, again occurring exclusively in generations 3 and 4. No participants were indicated to have a likelihood of alcohol dependence in the AUDIT screening, although three participants (all from generations 3 and 4) had a hazardous consumption level.

Four participants had been diagnosed with a mental health condition, and five had utilized professional mental health services, all of whom were members of generations 3 or 4. Nine participants spoke about problems with suicide in the community, and clear themes arose connecting suicides to not talking about mental health, wanting to appear strong, and not asking for help. For example, one participant from generation 3, speaking about a recent case of suicide in the community, said that people hadn’t taken the individual’s problems seriously, making fun of him and calling him “retarded” and “crazy.”

The most common stressors among participants were family wellbeing, money, employment or jobs, and security or safety. The Covid-19 pandemic was another source of stress, and, among young people, school and a pressure to accomplish were also stressful. Five participants brought up the effect of trauma, in the contexts of war, persecution, and refugee camps. One participant suggested that alcohol use or addiction is less stigmatized than mental health because people relate it to being caused by trauma and see that as normal. One individual said that there is also a problem with sexual assault in the community, saying that it is even more stigmatized than mental health.

Approachability

The approachability dimension of access to care is related to the ability of individuals to perceive that a service exists, can be reached, and will have an impact on their health. A majority (n = 18) of participants were able to provide a basic definition of mental health as being related to psychological and/or emotional wellbeing. Participants from the younger two generations were much more likely to be able to define mental health. One member of generation 4 said that “not too many people are educated on the topic to where they can help you out,” and another individual from generation 4 spoke about how elders not understanding mental health leads them to dismiss and ignore it. Others spoke about how the lack of understanding of mental health among older Montagnards can make it challenging for young people to go to their parents for help. This seemed to be a very salient topic, coming up eight times despite there being no explicit question about it in the interviews. One participant, for example, said:

Fifteen participants expressed that they would consider utilizing medical/health care services if they were experiencing symptoms of a mental health condition, while six participants said they would not be interested in professional services. For example, one member of generation 2 said, “I wouldn’t go to doctor for just because I’m sad, you know, I’m not going to go to doctor, man.” Many participants indicated that they would seek other methods of support, such as religion (n = 8), friends (n = 9), or family (n = 7). Six participants discussed a tendency to be self-reliant with regards to coping with mental health challenges, like this participant who said:

Health beliefs are another major factor related to the approachability of health care services. Eight participants talked about the relation between mental health and spirituality, discussing how some members of the Montagnard community believe that mental illnesses are caused by the devil, demon possession, or an absence of God in someone’s life. These beliefs were connected to embarrassment around talking about mental distress and to young people having a hard time getting support from older family members who treat such distress as a spiritual problem. Montagnards value herbal remedies, and another health belief that participants described is the idea of medications being addictive. Three participants discussed a similar idea, which one referred to as a “myth” shared by “a lot of community members,” that if someone takes a medicine from a doctor they will be reliant on it for life, and that if they ever decide to stop taking it, their condition will get worse. One participant shared a story about a friend with schizophrenia, saying “if he don’t take [his medication]… he do crazy stuff.” The participant felt that this could be due to an addiction to the pills rather than the schizophrenia itself, adding “it’s not like his body got hurt or anything.” Explanations provided for the distrust of medications include lack of trust in doctors as well as not understanding the medications.

Acceptability

The acceptability dimension of access to care relates to the ability to seek care. It includes the cultural and social factors that determine whether people accept aspects of the service. There is a tendency among many Montagnards to not discuss issues related to mental health and keep feelings inside. Nearly half of the participants brought this up unprompted, as there was no explicit question in the interviews about openness to discussing feelings/emotions. One participant of generation 3 offered this representative quote:

Participants suggested several potential reasons why mental health is not discussed, such as concern for the family reputation, ignorance, a desire to keep personal matters private, concern about being seen as “crazy”, and the value in appearing strong. The value of strength was an especially salient issue, occurring in conversation with seven participants. A young male from generation 3 spoke to a common mindset, paraphrased as: if our grandparents in Vietnam back in the day didn’t need therapy and still lived through their situation, why would we need it? These same factors, along with the high expense of care, lead to people waiting to get help until their symptoms become severe, an idea that was brought up by 10 participants. A large majority of participants felt that there is stigma surrounding mental health, with 15 participants saying there is stigma and 5 saying there is not. As far as what the stigma actually looks like, negative descriptors about people with a mental illness included the words “crazy,” “retarded,” “maniacal,” “violent,” “lazy,” “stupid,” and “weird.” There was also an association with being unhygienic and with drug use, and one participant said that a lot of community members connected a recent suicide to drugs rather than mental illness. Stigma was also tied to previously addressed cultural norms like wanting to appear strong and not talking about mental health, as well as a lack of mental health literacy. Participants described varying ways that individuals with a mental illness are treated by the community. The most common response was that they will be comforted, supported, or given sympathy (five participants), but others said they would be avoided (three participants), and another participant suggested the older generation would be more likely to blame the individual. While there was a fairly even split among participants about whether the community would look positively or negatively upon someone for seeking professional mental health care, a majority of participants said that the opinions of other community members would not impact their decision to get help if they needed it.

Availability and accommodation

Availability and accommodation pertain to the notion that health services can be physically reached in a timely manner. The most frequently discussed aspect of availability and accommodation was transportation, with six participants saying it can be a problem in the community, especially among older adults. Finding a suitable provider who could understand the individual’s problems and allow them to feel comfortable was a challenge for two participants. Additionally, one participant from generation 4 spoke about how when she was younger and was in a rehabilitation facility, her mom did not understand certain processes and policies, such as the hours that she could visit.

Affordability

The affordability dimension of access to care encompasses both the direct and indirect cost of the service and related expenses, as well as factors that affect the patient’s ability to pay, such as income and insurance. Direct cost was a major issue according to many participants, with 11 participants bringing up the idea of their health care being expensive. This participant from generation 3 said

“I heard a lot of people getting a lot of debt… the bills just get so high and you get overwhelmed.”

Nineteen people (73%) felt that the cost of obtaining services is prohibitive, compared with only five (19%) who felt the cost was not prohibitive. With regards to medication, a similarly high portion (65%) of participants found the cost to be prohibitive. This participant from generation 2 shared a particularly compelling account of why he doesn’t go to the doctor:

Beyond the direct cost of a service or medication, the most significant problem seems to be with taking time off of work, which six participants said could be an issue for accessing a mental health professional. Participants connected this to a culture of being hard-working and not wanting to take time off, as well as company policies that limit sick leave and a limited number of alternative job options. Low family income levels were also a challenge for some participants in obtaining health care, and several individuals spoke about how this is a problem in the community at large. Health insurance was an important issue that was mentioned by 62% of participants, including members of every generation, many of whom spoke about how it is unaffordable.

Appropriateness

The final dimension of access to care is appropriateness. Appropriateness relates to the fit between the service and the clients’ needs, and is concerned with the ability of the patient to engage in the service. Participants who talked about positive qualities of a service or said it was of high-quality expressed appreciation for doctors, spoke about experiences where doctors were able to help them, and said that there are more resources in the United States than they had before immigrating. On the other hand, participants who felt that services were of poor quality had concerns including doctors being overly concerned with making money, issues with cultural competency, inequity, and not being able to connect or the professional not understanding their needs. Professionals not understanding Montagnards and what their needs are was brought up by ten participants, like this one who said, “I don’t think they would understand us. Just because in terms of what we have gone through and, you know, our lives and how our community works.”

Fifteen participants brought up issues related to communication between the patient and provider. One participant said “I feel like doctors… they don’t really try to explain the situation and they don’t go out of their way to make sure that [the patient] understands the concept.” Thirteen participants spoke about the language barrier specifically, addressing the fact that some Montagnards have difficulty finding someone to interpret for them. This is a particularly important issue for older Montagnards who are less fluent in English.

Mental health status

The results of the four mental health screenings (PHQ-9, GAD-7, PC-PTSD, AUDIT) show a sharp distinction between generations 1 and 2 (older Montagnards) and generations 3 and 4 (younger Montagnards). Across all four of the screenings, there were no members of generations 1 or 2 who reported signs of depression, anxiety, PTSD, or hazardous alcohol consumption. Conversely, among members of generations 3 and 4, 43% of participants screened positive for any degree of depression, 38% for anxiety, 19% for PTSD, and 14% for hazardous alcohol consumption. Three participants answered affirmatively to a question on the PHQ-9 asking about thoughts of suicide or self-harm. These findings are surprising because elder participants were expected to have higher levels of certain mental illnesses like PTSD than younger participants, given elder participants’ direct experiences of trauma and persecution in Vietnam.

The lower levels of reported mental illness among generations 1 and 2 could be explained in several ways. First, it could be due to the low sample size of older participants. It could also be that older community members are more hesitant to talk about mental illness candidly and were less open on the screening questionnaires. This is likely contributing to the results at least to some extent, and is consistent with existing research showing that Vietnamese refugees are more likely to report physical than mental symptoms of PTSD, and findings from the present study about older Montagnards seldom talking about mental health and wanting to appear strong (Silove et al., 2007). It is also possible that the older generations of Montagnards indeed do suffer from lower rates of depression, anxiety, PTSD, and alcohol abuse than younger community members. The younger generations may be affected by experiences such as being a child refugee, sexual assault, social disconnection, acculturation stress, and intergenerational trauma. Past research has shown that historical trauma has a significant effect on both physical and mental health, and there is an increasing amount of evidence that stress and trauma have an impact at the cellular and epigenetic level (Walters, Beltran, et al., 2011; Walters, Mohammed, et al., 2011). The results of this study showing older generations (majority foreign-born Montagnards who have not assimilated) had better mental health than the younger generations (majority U.S.-born Montagnards) are consistent with other research showing a similar pattern among Asian American women (Lau et al., 2013; Lee, 2019; Ng & Omariba, 2010).

Approachability

There is a discordant understanding of the concept of mental health between some Montagnards and the CDC definition that is standard in the United States (CDC, 2021). Some Montagnards may not view phenomena such as “sadness” and “craziness” as belonging to an overall domain such as “mental health”, and older Montagnards especially tend to take a more spiritual view of these concepts. The older generations seem to have a poorer understanding of Western mental health ideas, terms, and practices than younger generations, as reflected by the comments of multiple participants as well as the researchers’ rating of whether participants were able to define mental health. The lack of knowledge about mental health is also evidenced by faulty health beliefs that were uncovered during interviews, such as beliefs around the addictiveness of medications. The generational divide in understanding of mental health creates issues for young people who feared their parents would not understand it if they were struggling with their mental health. Additionally, certain Montagnards ideas about mental health likely contribute to the stigma of mental illness and a distrust of health care providers.

Some Montagnards deny that they are struggling mentally and minimize mental health symptoms. This may be motivated by a deeply held belief among some Montagnards (which appears to be more prevalent among older generations) that mental illness is related to spirituality and could be a sign of demon possession. The denial of mental health symptoms may also stem from a high value placed on self-sufficiency. When Montagnards do seek help for mental distress, friends, family, and church are important resources. Thus, religion may be contributing to the stigma but also functioning as an important support mechanism. While most participants indicated they would be open to professional mental health care, a sizeable minority said they would not be interested in professional support even if their symptoms were severe, a finding that aligns with existing research on Asian Americans (Augsberger et al., 2015).

Acceptability

The results of this study demonstrate that there are pervasive negative beliefs about mental illness, and it is heavily stigmatized. Three quarters of participants who provided a clear answer said that there is stigma surrounding mental illness in the community. Some participants felt that elderly people especially have a negative view of those with a mental illness. Having a condition such as depression is seen as shameful and embarrassing, leading people to keep these issues private and seldom discuss mental health openly. A cultural value of strength and stability likely contributes to this, as people do not want to be seen as weak and are concerned for their own and their family’s reputation. As one participant put it, if their grandparents didn’t need therapy while living in the jungle, why would they? As both a product of and contributing factor to mental health stigma, the tendency not to discuss mental health can prevent conditions from being acknowledged until they become severe. Older Montagnards in particular often keep mental distress inside, though it is a problem that spans generations. When mental illness is made public, some may react with sympathy, while others would instead avoid or blame the individual.

Availability and accommodation

The most pressing issue related to availability and accommodation is transportation. Some people do not have consistent access to available rides, which limits ability to obtain care even if someone was able to overcome the previous barriers discussed like stigma and poor mental health literacy. Like many of the other components of access, participants said that the issues with transportation are more severe among older adults.

Affordability

Many Montagnards are not receiving adequate health care because it is too expensive for them, and nearly three quarters of participants said that the cost of a service would be prohibitive for them. Much of this stems from a lack of good job opportunities for Montagnards, who may be making low wages, have limited ability to take time off, and may not have comprehensive benefits like health insurance. Health insurance was one of the most talked about issues related to affordability during interviews. This makes sense, given a 2015 study that found that nearly two-thirds of Montagnards are uninsured (Dharod, 2015).

Appropriateness

Communication between patients and doctors is an issue that has serious repercussions for the ability of Montagnards to engage in health care services. The underlying cause is the language barrier. Past research in the broader context of Asian immigrants has shown problems with linguistic discordance leading to miscommunications and inappropriate treatments, and this study confirms this is an issue in the Montagnard population specifically (Clough et al., 2013). Younger Montagnards often speak English fluently, but older community members who did not leave Vietnam until they were adults are less likely to speak English. The variety of tribal languages also complicates interpretation. Often, the only person able to interpret may be a younger family member or friend, which may lead individuals to not share things with the provider if they are embarrassed or ashamed. In addition to communication challenges, cultural competency of providers who may not be aware of the Montagnard background or health concerns faced by indigenous Vietnamese populations can also be a problem. This can be especially impactful in mental health services, where developing a rapport and connection with the patient is key.