Factors related to help-seeking attitudes about professional mental health services among Jamaican immigrants

Abstract

Using survey data collected from 115 first-generation Jamaican immigrants residing in New York City, this study identified factors that were associated with their attitudes toward seeking professional mental health services. Results indicated that persons reporting psychological distress, negative stigma and attributions about mental illness, and positive social support from friends were less likely than their counterparts to report positive attitudes towards professional mental health services. Implications of the study are discussed in relation to these findings.

Keywords

Jamaican immigrants mental health service attitudes psychological distress social supports stigma

Introduction

In the United States, there is documented evidence of inadequate health care and persistent health disparities among immigrant groups (Camorata, 2007). Compared to native-born Americans, immigrants, especially racial/ethnic minorities, tend to have more mental health problems, are less likely to have a personal physician or medical insurance, have lower knowledge of available social services and, when they become aware of such services, are more reluctant to use them (Chung et al., 2008; Lu and Waidmann, 2003).

In the US, Jamaicans are the largest immigrant group from the English-speaking Caribbean, a community numbering more than a half million and about whom there is a dearth of studies in the extant literature (NYC Department of Planning, 2012). More than half of all Jamaican immigrants reside in New York City (NYC) in the boroughs of Brooklyn and Queens (NYC Department of Planning, 2012).

Similar to other immigrants that settle in the US, Jamaicans are highly likely to encounter personal and social challenges related to their experiences of migration and assimilation (Jones, 2008; Portes and Rumbaut, 2006). Consequently, the primary aim of this study was to examine Jamaican immigrants’ attitudes towards seeking professional mental health services, defined as soliciting assistance from a social worker, psychiatrist, psychologist, or counselor for behavioral, social or emotional concerns.

Jamaican immigrants’ mental health seeking attitudes

There is a dearth of studies on factors associated with help-seeking attitudes about professional mental health services among Jamaican immigrants. However, based on the extant literature among racial/ethnic minority immigrants in the US, phenomenological studies on Jamaican culture, and studies of Caribbean immigrants in Britain, we examine how several psychocultural factors (e.g. psychological distress, stigma and attributions about mental illness, social support appraisals, and selected demographic factors) (Dustmann and Theodoropoulos, 2010; Jones, 2008; Mermin, 2006; Portes and Rumbaut, 2006) might be related to Jamaican immigrants’ attitudes towards professional mental health services. In the following sections, we briefly highlight these factors and hypothesize how they may be related to attitudes towards seeking professional mental health services among first generation Jamaican community in the US. In exploring such information, we aim to increase the body of knowledge on this immigrant community that can be used to develop and deliver culturally responsive services to address their mental health needs.

Degree of psychological distress

Some researchers (e.g. Barker et al., 1990) have noted that persons reporting high psychological distress versus those reporting low psychological distress are more inclined to seek professional mental health services to assist with such stressors. However, findings have sometimes been mixed. For instance, Seiffge-Krenkel (1990) found that increased psychological distress was related to decrease mental health help-seeking behavior. In addition, findings about ethnic minority Caribbean immigrants to Britain (Dustman and Theodoropoulos, 2010) suggest that, compared with Whites, they may be less likely to seek professional mental health services when experiencing psychological distress.

It is highly plausible that Caribbean immigrants may endure distressing symptoms longer, follow different pathways to getting help, may be more likely to delay seeking help, and more often view mental illness as a stigma (Owens et al., 1991). Additionally, Shaw and colleagues (1999) suggest that similar to native-born ethnic minorities, immigrants may tend to complain of somatic rather than psychological symptoms of distress leading to the lack of recognition of mental disorders by both them and their health providers. Consequently, based on these assumptions, we will examine Jamaican immigrant’s perception of psychological distress as it relates to their attitudes towards seeking professional mental health services. Therefore, we hypothesize that persons who perceive themselves as having higher level of distress will have less favorable attitudes towards seeking help from professional health care providers.

Negative stigma and attributions towards mental illness

In Jamaican culture there is significant stigma around having a psychiatric illness (Sobo, 1993). The mentally ill and cognitively impaired are often kept within their households, hidden away from the public view because of fears that they might become psychotic (Sobo, 1993). Stigmatizing views include the fear that mental illness is contagious and that it is a character flaw. This stigmatization of mental illness prevents individuals and families from acknowledging their difficulties and seeking appropriate help (Sobo, 1993). Consistent with this view, Guze (1992) argues that stigma towards mental illness is a harmful force and prevents people from seeking and receiving care, while Kusher and Sher (1991) maintain that attitudes towards mental illness such as whether people are accepting of, and see, mental illness as a real disease negatively impacting daily life; or viewing it as a moral flaw or a character problem, all have important influences on individuals’ help-seeking attitudes.

Additionally, the beliefs Jamaican immigrants hold about the etiology of mental illness can also be barriers to seeking mental help (Cinnirella and Loewenthal, 1999). As in many Caribbean countries, Jamaican cultures often view psychiatric illness through a lens of religion, superstition and prejudice, for example, as God’s punishment for bad behavior, or a lack of will power and weakness in character (Sobo, 1993). In some Caribbean cultures, including Jamaica, the nature and cause of mental distress are often attributed to supernatural or mystical phenomena. Notably, some locals believe that ‘spirits’ cause mental illness through magic, sorcery, and witchcraft. Alternatively, people are thought to experience psychological problems when they study hard or worry too much (Littlewood, 1993). Other cultural beliefs include the view that emotional distress comes from being jilted in love; feeling pressured by work and poverty; being weak, frail, highly strung; or not being physically strong enough to withstand the pressures of everyday life. ‘Science’ is a common term that refers to belief systems related to witchcraft or black magic. Becoming a victim of ‘science’ refers to persons who may try to advance themselves socially and economically by summoning spirits that might sometimes retaliate and cause insanity. This phenomenon is also believed to be a contributor to mental distress and illness (Littlewood, 1993). Consequently, we hypothesize that the stigmatization and negative attitudes towards mental health will be negatively related to positive attitudes towards seeking professional mental health services.

Perceptions of social support from family and friends

Research suggests that ethnic minorities and immigrants compared to whites may first look to family and friends, as opposed to professional services, as a first step in finding psychological support (Pipe et al., 1991). However, the type of social support needed might influence the specific category of social support that might be targeted or mobilized (Amato and Bradshaw, 1985; Foner, 1997). For instance, Horwitz (1978) found that instrumental needs (e.g. parenting help, financial support) were associated with help seeking from family members, while emotional and interpersonal problems (e.g. feelings of anxiety sadness or loss) were directed to personal friends. Thus, we hypothesize that Jamaican immigrants with relatively strong social support from family and friends might have less positive attitudes towards seeking professional mental health services.

Socio-demographic influences

Several sociodemographic factors are likely to be correlated to the attitudes that Jamaican immigrants might have towards seeking professional mental health services. For instance, across varied populations, females are more likely than males to seek mental health support for themselves and their children (US Department of Health and Human Services, 2010). Age is also correlated to mental help seeking; for example, Leong and Zachar (1999) found that younger persons tend to have more favorable views towards professional mental health services than older adults. Higher formal education and having a professional occupation have also been associated with more favorable attitudes towards seeking professional mental health services (Robin and Regiers, 1991). We also anticipate that immigrants who have been in the US longer and those who are legally documented may have more favorable attitudes toward seeking mental health care than those who more recently emigrated and those who are undocumented. Finally, religious involvement may also be related to mental health help seeking in that Caribbean persons are known to seek help, as a first recourse, from spiritual practitioners (Cinnirella and Loewenthal, 1999).

To summarize, we will test the following hypotheses among our Jamaican immigrant sample: 1) those that perceive themselves as having higher level of psychological distress will have less favorable attitudes towards seeking professional mental health services; 2) the combination of mental health stigma and stigmatizing beliefs about causes of mental illness will be associated with less favorable attitudes towards professional mental health services; and 3) higher levels of perceived social support from family and/or friends will also be associated with less favorable attitudes towards professional mental health services. In testing these hypotheses, we will control for the potential cofounding effects of age, gender, education, occupation, length of time in the US, documentation status, and importance on religion.

Methods

Participants

Communities in Brooklyn (East Flatbush, Flatbush, Crown Heights) and Queens (Cambria Heights, Laurelton, Rosedale, Jamaica) were chosen for the research because of their large numbers of English-speaking Caribbean residents (Lobo et al., 1996). In these communities letters soliciting involvement were sent to organizations with high Jamaican membership (e.g. clubs, churches) or that provided services to Jamaican neighborhoods (e.g. barber shops, beauty parlors). Organizations learned about study aims and procedures in follow-up phone calls. A total of 15 organizations agreed to become recruitment sites. At these locations, adults were approached about the study and deemed eligible if they emigrated from the island of Jamaica to the US; had been residing in the US for at least one year; lived in New York City; were at least 18 years old; and were willing to provide written informed consent. The Institutional Review Board of Columbia University, New York approved these study procedures.

Procedures

Once participants were consented by research assistants who were also of Caribbean ancestry, they were asked to complete a paper/pencil self-administered survey. On average, the survey took approximately 40 minutes to complete. Participants that could not complete the survey due to time constraints were given a stamped, addressed envelope to return it by mail. Approximately five percent of participants mailed in their questionnaire responses. Participants were not compensated for their involvement in the research.

Measures

Dependent variable

Attitudes towards professional mental health care were assessed by a 13-item scale from the Help Seeking Attitude Scale (e.g. ‘I would want to get psychological help if I was worried or upset for a long period of time’) (Fischer and Farina, 1995). Items were measured on a four-point scale (0 = partly agree to 3 = agree). Higher scores on this scale were assumed to represent more favorable attitudes. The Cronbach alpha was 0.77.

Independent variables

Psychological distress was measured using the General Health Questionnaire (GHQ-12), a 12-item scale that assesses the presence of common mental disorders (e.g. ‘Recently I have lost much sleep over worrying’) (Goldberg, 1972). Responses were measured on a four-point scale ranging from (0 = not at all to 3 = much more than usual) with higher scores representing greater distress. The Cronbach alpha was 0.68.

Negative attitudes and attributions towards mental illness were assessed by combining two measures. The first measure, the Devaluation-Discrimination Beliefs Scale (Link, 1987) consisted of eight items and assessed mental health stigma (e.g. ‘Most people feel that entering psychiatric treatment is a sign of personal failure’). Items were measured on a four-point scale (1 = strongly agree to 4 = strong disagree) with higher scores representing more stigma towards mental illness. The Cronbach alpha was 0.69. The second measure, the Attribution and Control Scale consisted of 23 items and assessed negative attributions about causes of mental health (e.g. ‘Mental illness is caused by obeah/voodoo/witchcraft’) (Streuning et al., 1992–3). Items were measured on a five-point scale (1 = a lot to 5 = I don’t know/not sure). The overall Cronbach alpha was 0.77. Higher scores on both scales were assumed to represent higher stigma towards professional mental health care and mental illness.

Social support from family and friends (SFF) was measured by 40 items designed to assess an individual’s perceptions of support from family with regards to physical assistance and guidance (e.g. ‘Family and friends give me advice about what to do’) (Vaux and Wood, 1985). Items were measured on a five-point scale (1 = no one would do this to 5 = most family members/friends would certainly do this). In addition to the combined SSA scale we used two subscales, ‘social support from family-SS1’ and ‘social support from friends-SS2’. Each subscale had 20 items with a range of responses from 1 (no one would do it) to 5 (most family or friends would certainly do this). The Cronbach alpha for social support was 0.97 from family and 0.96 from friends, with higher scores representing more positive perceptions of social support.

Demographics factors assessed were marital status, age, education, employment status, annual household income, occupation, gender, length of stay in the US, documentation status, and importance of religion.

Analyses

Analyses were conducted using SPSS18.0. Frequency analyses, T-tests for continuous variables, and Chi-squares for categorical variables were used to understand sample characteristics on key indicators. Next, we computed bivariate correlations to explore the association among major study variables. Finally, hierarchical regression analyses were used to test hypotheses, controlling for empirically driven demographic indicators such age, income, gender, marital status, level of education, employment status, length of stay in the US, documentation status, and importance of religion.

Results

As shown in Table 1, the overall sample included N = 115 participants with mean age of 37.3 (SD = 3.4). The majority of respondents were female (61.7%) and over 40 percent were single, with 37 percent reporting average annual household income between $35,000 and $49,999. Most participants (93%) were US citizens or legal residents and around 70 percent had been in the US for over 20 years. Ninety-three (93%) reported at least a high school education and 63 percent viewed religion as important.

Table 1.

Sociodemographic characteristics of the sample (N = 115).

	Female	Male	Total
	n = 71	n = 44	n = 115
Marital status
Single	42.9	38.6	41.2
Married/living with partner	35.7	38.6	37.0
Widowed	2.9	2.3	2.6
Divorced/separated	18.6	18.2	18.4
Age
18–25	15.9	9.1	13.3
26–40	54.0	50.0	52.2
41–60	29.0	34.1	30.0
61–78	1.4	7.0	3.5
Highest education*
Elementary		9.1	3.5
Secondary/high school	18.6	38.6	26.3
College/business/trade	48.6	43.2	46.5
Graduate	30.0	9.1	21.9
Employment status
Full-time	84.1	84.1	84.1
Part-time	8.7	2.3	6.2
Retired	2.9	4.5	3.5
Unemployed	1.4	2.3	1.7
Student	2.9	4.5	3.5
Other		2.3	3.9
Household annual income
Less than 15,000	4.6	9.1	6.4
15,000–24,999	6.2	4.5	5.5
25,000–34,999	16.9	18.0	17.4
35,000–49,999	23.1	34.1	27.5
50,000–74,999	27.7	11.4	21.1
over 75,000	21.5	22.7	22.0
Occupation*
Professional/specialty/technical	38.8	17.1	30.5
Executive, admins/manager	26.9	14.6	22.2
Sales & clerical	16.4	12.2	14.8
Craft, repair, mechanic	1.5	31.7	12.9
Service	14.9	24.4	18.5
Homemaker		1.5	0.9
Documentation status**
Citizen	71.8	41.9	60.5
Permanent resident	21.1	48.8	31.5
Student or other visa	5.6	4.7	5.2
Other	1.4	4.7	2.6
Length of stay in US
1–10 years	23.9	39.5	29.8
11–20 years	47.9	37.2	43.8
21–30 years	19.7	18.6	19.2
over 30 years	8.5	4.7	7.0
(Continued)
Importance of religion*
not at all/a little	36.2	63.6	46.9
a great deal	63.7	36.3	53.0

p < .05; ** p < .01.

Several significant gender differences were noted with regards to level of education, occupations, documentation status, and importance of religion. Seventy-nine percent (79%) of females, compared to 52 percent of males, reported having completed college and above (M = 17.309, d.f. = 4, p = .002). More females (82%) compared with males (43%) reported that they were professionals, managers, and administrators (M = 25.706, d.f. = 5, p = .001). More females (72%) than males (42%) reported that they were US citizens (M = 11.606, d.f. = 3, p = .009). Finally, females were more likely, than males to report that religion was a source of support (M = 8.102, d.f. = 1, p = .004).

Concerning attitudes towards seeking professional mental health services, participants viewed mental illness as mostly caused by emotional/mental problems (35.4%), too much stress (35.4%), drugs such as crack and cocaine (27.1), and neurological or brain disorders (26%). Over 80 percent attributed mental illness to variables, such as too much stress, using drugs, fate, bad nerves, studying too much, living in a bad neighborhood, powerful people, how a person was raised, being jilted in love, etc. With regards to degree of psychological distress, participants’ scores in this study ranged from .38 to 2.38 with a mean score of 1.12, median 1.56 and (SD = .39); with 45.5 and 56.4 percent of the overall sample reporting low and high psychological distress, respectively, based on the median split. With regards to mental health stigma and attitudes towards mental illness, scores ranged from 0.44 to 2.44, with a mean of 1.53, median 1.92 and (SD = 0.42); with 40.2 and 59.8 percent of the overall sample, respectively, reporting low and high negative stigma and attributions towards mental illness based on the median split.

Correlations among study variables

Table 2 documents bivariate correlations among several study variables. Attributions about mental illness were negatively correlated with psychological distress. Additionally, social support appraisal from family and friends was negatively correlated with religion as a source of support (r = −.26, p < .01) and also negatively correlated with level of education (r = −.23, p < .05). Help-seeking attitudes towards mental health services was negatively correlated with level of education (r = −.27, p < .01) and negatively correlated with total household income (r = −.23, p < .05). Furthermore, external attribution about mental illness was negatively correlated with occupation (r = −.19, p < .01) and negatively correlated with resident status (r = −.20, p < .05). Finally, external attribution about mental illness was positively correlated with total annual income (r = .29, p < .01).

Table 2.

Correlations among study variables (N = 115).

Variable	Attmental	SSFF	Stigma	Attrib	Psydistress
Marital status	.04	.01	.01	−.08	.00
Education	−.27**	−.23*	.03	.16	−.05
Income	−.23*	−.09	.05	.29**	.02
Occupation	.14	.15	.09	−.19*	−.01
Religion as support	.03	−.26**	−.03	.09	.05
Documentation status	.16	.07	−.12	−.20*	−.06
Length in the US
	−.11	−.19	.07	.09	.05

Attmental: attitudes towards seeking mental health services.

SSFF: social support from family and friends.

Stigma: stigma about mental health.

Attrib: attributions about mental illness.

Psydistress: psychological distress.

p < .05; ** p < .01.

Hypothesis testing

Our first hypothesis was that, controlling for socio-demographics variables participants with higher levels of psychological distress would have less favorable attitudes towards seeking professional mental health services. In the hierarchical regression analyses to test this hypothesis, we controlled for our specified potential confounding variables. Next, the psychological distress variable was entered into the model and this variable was significant (β = −.13; p < .05).

Next, we hypothesized that a combination of negative stigma and attributions towards mental illness would be negatively related to positive attitudes towards seeking professional mental health services. To test this hypothesis, we controlled for socio-demographic variables that were potential confounding variables. Next, we added the combined variable which accounted for negative stigma and attributions towards mental illness. This variable was significant (β = −.15; p < .05).

Our third hypothesis was that social support from family and friends would be related to less favorable attitudes towards seeking professional mental health services. We controlled for potential cofounding demographic variables. Next, we added the social support variables to the model, and only social support from family was significant (β = −.05; p < .05).

Discussion

This is one of the first studies to examine factors related to Jamaican immigrants’ attitudes towards seeking professional mental health services. Specifically, we examined how the levels of psychological distress, stigma and attributions about mental illness and perceptions of social support from family and friends, were associated with attitudes towards seeking professional mental health services among a sample of first-generation Jamaican immigrants in NYC. Major findings indicated that perceptions of social support from family, but not from friends, was related to less favorable attitudes towards seeking professional mental health services. Given that perceptions of social support from friends had no significant relationship on attitudes towards seeking professional mental health services, this finding might suggest that issues of mental health are still strongly held as a family issue, not to be discussed with persons outside the immediate family, not even with friends. These results support other empirical findings among Caribbean immigrant groups that positive or strong social support from relatives is negatively correlated with seeking professional healthcare (Linns and Graham, 1989). For example, Thrasher and Anderson (1988) found that Caribbean immigrant groups tend not to use mental health services because of their reliance on family to deal with problems. As to why Caribbean immigrants may look first within the family for help, these authors suggest that Caribbean immigrants appear to hold the belief that the family shares the responsibility for an individual’s problems and that mental illness is best treated within the family. This cultural viewpoint persists in many parts of the Caribbean, including Jamaica, and may still be present as immigrants restructure social and family relations in the US (Foner, 1997).

Persons reporting psychological distress also had less favorable attitudes towards seeking professional mental health care services and these results are somewhat consistent with past studies of Caribbean immigrants mostly in Britain. Studies on British Caribbean immigrants suggest that these immigrants endure distressing symptoms, delay seeking help, view mental illness as a stigma and present somatic rather than psychological symptoms (Pipe et al., 1991; Shaw et al., 1999). Other studies have found that Caribbean immigrants tend to turn to local pastors or folk practitioners with mental health concerns (Schwartz, 1985). Related to this, there is consistent evidence that a substantial proportion of racial/ethnic minority groups with mental disorders or emotional problems are treated in the physical health sector (Leaf and Bruce, 1987). Thus, health practitioners should assess ways in which Jamaican immigrants may express psychological symptoms somatically, how the tolerance of somatic symptoms may influence the diagnostic process when consulting professional mental practitioners, and what types of support systems (e.g. family, extended kin, religious affiliation and involvement, etc.) are used to deal with psychological distress.

In our view, professional mental health practitioners should not discourage immigrants from relying on non-professionals for mental health support. Rather, the goal should be to develop an effective and culturally responsive treatment plan that incorporates empirically validated treatments and best practices for mental health support (e.g. medications and cognitive behavioral therapy) along with culturally responsive approaches (e.g. seeking support of religious practitioner). A combination of professional and nonprofessional support may well be a useful formula for Jamaican immigrants.

A combination of mental illness attributions and mental health stigmas were related to attitudes towards seeking professional mental health services in this Jamaican immigrant sample, and this is noteworthy. Guze (1992) argues that stigma against the mentally ill is a harmful force and prevents people from seeking and receiving the care they need, while Kusher and Sher (1991) maintain that both positive and negative attitudes towards mental illness have important influences on peoples’ attitudes towards seeking psychological help. The ways in which stigma and attributions about mental illness influence Caribbean immigrants’ attitudes towards seeking psychological help warrant more detailed examination. The results of this study indicate that mental health practitioners must explore the belief systems of Jamaican clients as it pertains to the causes of mental distress in general and the stigma it holds towards seeking professional mental health services. Both belief systems may influence help seeking and also mental health progress and outcomes (Chung et al., 2008, 2011).

A few limitations of this study warrant consideration. Convenience sampling of NYC Jamaicans, though appropriate for a preliminary study of this nature, does limit the generalizability of these findings to Jamaican immigrants in the US at large. Self-reported data, although a commonly used method in the social sciences, does have limitations related to social desirability and underreporting, especially given the sensitive nature of some survey questions. Additionally, we assessed attitudes towards seeking professional mental health services and not actual help-seeking behavior themselves. Therefore, future studies should evaluate the extent to which attitudinal constructs (e.g. stigma) actually determines actual help-seeking behaviors. Finally, given the cross-sectional design, these findings document relationships and not causal inferences.

We undertook this study with the aim of providing information that might be useful to mental health practitioners that encounter Jamaicans in professional practice treatment. Our study suggests that practitioners should be prepared to explore the impact of migration and assimilation experiences; thoughts and feelings related to getting professional help; how social and emotional symptoms may be expressed somatically; culturally derived values and beliefs about mental distress and about mental health help-seeking; and also how family and friendship support systems may be incorporated into treatment for better outcomes. As with any group, assumptions cannot be made about Jamaicans as a cultural group in the US without recognition of intra-group variability. As our data suggest, Jamaican immigrants’ attitudes towards seeking professional health services might also be affected by their gender, documentation status, level of education and length of time since these immigrants left their home island.

We also endorse a need for further study on the mental health needs and mental health service utilization attitudes and patterns among the Jamaican immigrants. Jamaicans have a long history of migration to the US and are the largest group from the English-speaking Caribbean (Camarota, 2007). Their migration and assimilation experiences may contribute to psychological distress which can be alleviated by evidenced-informed mental health services. However, the existing knowledge base on Jamaicans in the US is quite sparse and their ethnic cultural distinctions may be buried in the tendency to view native-born and immigrant persons of African ancestry as basically the same group. Our study attempts to depart from this mold by providing information on the help-seeking attitudes of Jamaicans that we hope will inform interventions and resources to address their mental health needs.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author biographies

Cordelle York is Chief of Inpatient Services of the New York State Office of Mental Health at Kingsboro Psychiatric Center. Her research interests include culture and mental health.

Dexter R Voisin is a Professor at the University of Chicago, School of Social Service Administration. His research interests are in the field of mental health service delivery, culture and the impact of community violence exposures on adolescent developmental outcomes.

Donna Baptiste is a faculty member at Northwestern University, the Family Institute. She provides therapy to individuals, families and groups and conducts research on the impact of family interventions on adolescent problem behaviors.

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