AWA: Academic Writing at Auckland

Introduction

Asian immigrants may encounter many difficulties when moving to the new country; difficulties such as language barriers, unemployment and family separation may impact negatively on their mental health. However, many Asian people avoid using mental health services due to stigma associated with mental illness in their culture. This essay will provide an overview of how the mental illness stigma stops Asian people from asking for help and review how social marketing campaigns have attempted to reduce stigma, followed by the proposal of a social marketing campaigned aimed at Chinese immigrants in particular.

 

Immigration and Mental Illness

Although the immigration process in itself does not necessarily affect mental health in a negative way, research has shown that if the circumstances associated with the migration and resettlement events are stressful, then the immigrants are at an increased risk of developing mental health issues in the first 24 months after their arrival to the new country (Canadian Task Force, 1988; Hyman, 2007). Such stressful experiences include, but are not only limited to discrimination and prejudice, isolation, separation from friends and family, being unable to speak the new language and low socio-economic status (Agic, 2003).

Research has shown that immigrants usually have limited knowledge about mental health and mental illness. Despite this, only a few interventions that promote mental health appear to be effective in reaching ethno-cultural/racial groups such as ethnic and racial minorities and immigrants (Agic, 2003). Health promotion programs designed for the general population often do not reach the ethno-cultural and racial communities. More than this, the lack of linguistically and culturally appropriate health promotion interventions and mental health services often contribute further to marginalize and stigmatize the ethno-cultural/racial groups (Riddick, 1998).

A distinctive characteristic of New Zealand is the racial and cultural diversity of its population. The 2006 Census found that after European and Maori, the Asian ethnic group was New Zealand’s third largest major ethnic group, making up 9.2 percent of the New Zealand population (Statistics New Zealand, 2006). Auckland was identified as the most ethnically diverse region, with the Asian population making up the second largest ethnic group. “Asian” is a broad ethnic category, made up of many distinct ethnic groups. In New Zealand, the most common Asian ethnic group is Chinese, followed by Indian, Korean and Filipino (Statistics New Zealand, 2006).

A significant number of studies have focused on the adaptation difficulties and problems that Asian immigrants face when coming to New Zealand, and the mental health implications that are related to these issues. Such problems include language difficulties, employment issues, traumatic experiences prior to immigration, separation from family and disruption of social support networks (Ho, Au, Bedford, & Cooper, 2002). For example, language barriers may result in isolation, while unemployment and underemployment have been linked to increased risk of depression and anxiety levels. (Aycan & Berry, 1996).

As a result, immigrants are likely to experience a wide range of mental health issues, however, many Asians avoid using mental health services due to stigma associated with mental illness.

Stigma

The word ‘stigma’ has a Greek origin and was used to describe a scar or mark left as a result of branding animals (McDaid, 2008). Despite variations in conceptualising the definition of ‘stigma’, in general terms, stigma can be described as a tool or an attribute used to discriminate and separate certain individuals from the social norm due to actual or believed individual characteristics, behaviours or beliefs (Li, Stanton, Fang, & Lin, 2006).

Phelan and Link (2001) have developed a conceptual framework of stigma, which states that in order for stigma to occur, differences between people are identified and labelled, then linked to undesirable or negative stereotypes. Stigmatisation causes labelled individuals to feel ashamed and devaluated, while making other feel that they are better or superior. Stigma often results in discrimination, which involves the systematic exclusion, disapproval of and rejection of the labelled person (Li, et al., 2006).

More than this, people often also come to posses a self-stigma through which they come to believe the common and current stereotypes, thus internalising the society’s beliefs and attitudes regarding those stereotypes (Fortney et al., 2004). Self-stigma often results in reduced feelings of self worth and low self-efficacy and self-esteem.

Despite centuries of research and education on the topic, people with mental illness have long been viewed with suspicion and fear, and mental disorders are still perceived as signs of weakness (Byrne, 2000). Stigmatisation of those with mental illness occurs in every society. The roots and reasons for the continued stigmatisation of people with mental illness are complex and strongly linked to individual cultures. The extent or degree of the stigma varies according to the social and cultural context of a community (Byrne, 2000).

Stigmatisation of people with mental illness results in creation of additional barriers to recovery or ling a fulfilling life. People with mental disorders are often being treated unfairly and denied access to services and goods: they are often subjected to stigmatising attitudes of employers, health care providers, family, friends and the wider social circle (Guzofski, 2007). More than this, the fear of being stigmatised often discourages people from seeking help and using mental health services. Therefore, addressing the issue of stigma is important not only to help people with mental illness face less hardships, but also in order to encourage people to use mental health services, without being afraid that they will be stigmatised and discriminated against.

In Asian cultures, mental disorders are often viewed as supernatural punishments for sinning or wrong-doings (Nguyen, 1982). Mental disorders reflect badly on a person’s family: for example, if a young man comes from a family in which a family member had a mental illness, than people’s opinion may be influenced regarding how suitable the young man is for marriage (Ho, et al., 2002). Therefore, it has often been reported that Asian people express psychological distress as a physical experience, rather than a psychological one (e.g. complaining of body pains and headaches).

As a result, because mental illness is highly stigmatizing in Asian cultures, many people are reluctant to use mental health services and delay seeking help. Many afflicted people avoid telling others about their conditions and are sometimes kept hidden by their families (Ho, et al., 2002). This is supported by research investigating help seeking behavior for psychological and emotional issues that has shown that Asian people are more likely than other ethnic groups not to seek outside help for their problems, thus leading to under-utilization of mental health services (Lin, Inui, Kleinman, & Womack, 1982).

For Asian immigrants, additional barriers to the possibility of being stigmatized if one is found to have a mental illness, include appropriateness of the service, mistrust in the service and the health professional, accessibility, persisting language barriers, and lack of knowledge regarding what services are available (Agic, 2003). In New Zealand, many interventions throughout the years have been aimed at reducing many of these barriers for the Asian immigrants, some more successful than others (Ho, et al., 2002; Myers et al., 2009). However, despite the existence of these interventions which help make the mental health services more appropriate for the Asian population, no significant attempt has been made to address the issue of ‘stigma’ aimed at Asian people in particular.

Research has indicated that education of mental illness and mental health can result in positive changes in the negative beliefs and attitudes people hold toward mental illness, thus becoming an essential step in the reduction of stigma (Agic, 2003). For example,  people who have a better understanding of mental illness are less likely to avoid and discriminate against people with mental illness and more likely to engage in interpersonal health support (Smith, 2007). As it is impossible to attempt to educate each individual, a broader approach must be taken, such as using a social marketing campaign to educate Asian immigrants about mental illness and stigma.

 

Efforts to reduce stigma

Social marketing

Social marketing is one of the most effective ways of changing the public attitudes and reducing stigma towards people with mental illness. Social marketing began to be used as a health promotion tool in the 1970s, and involves using persuasive measures used by commercial marketers, with the aim of communicating a health message (Lavack, 2007). Social marketing aims to influence social behaviours with the scope of benefiting the target population and society in general. It involves carrying out research (in order to understand the opinions, attitudes and needs of the target population) and relies on evaluation measures in order to assess its effectiveness (Kotler & Zaltman, 1971). The planing of a social marketing campaign focuses on adapting four key elements to the scope of the campaign and the needs of the target population. These four key elements of any marketing strategy are known as the four Ps: Product, Price, Place and Promotion (Lavack, 2007).

In social marketing, the first ‘P’, the ‘Product’, refers to concrete physical products, ideas, services or practices (Bloom & Novelli, 1981). The target population must first believe that there is an issue which would benefit from the ‘product’ being offered (Lavack, 2007). ‘Price’ refers to the actions that an individual of the target population must take in order to attain the ‘Product’. This can involve a monetary cost, effort, time or something else that the individual must give up (Weinreich, 1999).  For example, in a campaign that promotes the importance of getting a cervical smear, the ‘Price’ includes elements such as time, traveling costs or transport issues, possible pain and discomfort from the procedure. If an individual perceives the cost or the price as outweighing the potential benefits of the product, then it is less likely that he or she will adopt the product (Lavack, 2007). On the other hand, if the potential benefits are believed to be greater than the costs, than trial and adoption of the product is more likely to occur. ‘Place’, refers to the location or methods used through which the product reaches the target population. This can include locations such as public spaces (libraries, shopping malls, churches), medical and health centers, or using mass media (newspapers, radio, television) as a means of promoting the product (Weinreich, 1999). The last ‘P’, ‘Promotion’, involves a range of communication tools such as public relations and advertising. It involves research that is often used to identify the most efficient and effective way of reaching the target population, as well as tailoring the message that is being promoted or delivered, in order to appeal to the target audience (Lavack, 2007). These 4 Ps can be tailored to fit the aim of the campaign and the target audience.

 

Social marketing campaigns to reduce stigma

Numerous efforts to de-stigmatize mental illness have been made in the last several years, by using social marketing as a tool.

Penn and Corrigan believed that a potential good strategy for reducing stigma associated with mental illness is a campaign in which the last of the four Ps, ‘promotion’ focused on public relations, by promoting personal contact (Smith, 2007). The advantage of this strategy was believed to be the opportunity for educating the public, combined with the opportunity to interact with a person with mental illness. This approach was based on the research done on prejudice reduction, in which prejudice towards people of different ethnicities was shown to diminish as a result of promotion of personal contact (Hamburger, 1994; Smith, 2007).

However, adopting this strategy in order to reduce stigma against people mental illness may not be entirely practical, due to the feasibility of direct contact with people with mental illness. It may be difficult to find people with mental illness who are willing to have direct contact with the general public. For example, in an Asian population, this would prove particularly difficult given that people with mental illness usually keep their condition a secret. A second limitation is that this intervention would have to happen on a small scale, therefore being less efficient than other forms of education or promotion. Therefore, in order to maximize efficiency, social marketing campaigns occur on larger scale.

Evans-Lacko et al (2010) have evaluated an anti-stigma marketing campaign in Cambridge, UK. The campaign evaluated was short term (4 weeks long) and localized only to the Cambridge area. The campaign involved advertising in the local newspaper, on the radio and at bus stops, and used postcards, posters and fliers in public spaces such as city centre and shopping malls. The effect of the campaign was evaluated by carrying out face-to-face interviews prior, during and post campaign, measuring attitudes, mental health/illness-related knowledge and campaign awareness. The results showed that moderate levels of campaign awareness were achieved; however, a noteworthy finding is that the campaign awareness had increased gradually over the 4-week period.

One might expect social marketing campaigns of longer duration to be more successful and more likely to maximize their impact. However, Evans-Lacko and her colleagues have emphasized the fact that there is no concrete proof for this. For example, some studies in smoking-cessation marketing campaigns have identified that improved behavioural outcomes are linked to longer duration campaigns while a literature review of such campaigns found no significant relationship between effectiveness and duration (Evans-Lacko, et al., 2010).

Due to mixed results regarding the relationship between campaign length and success of the campaign, it is important to consider if it is possible to have an impact on reducing stigma via a short term campaign, considering the high costs involved in producing and sustaining a longer term social marketing campaign. For example, the anti-stigma campaign from Cambridge evaluated by Evans-Lacko showed some positive results, despite it’s short duration of only 4 weeks. However, the results also showed that campaign awareness increased gradually over the 4-week period, so it may be that the levels of awareness would have kept increasing if the campaign was to run longer.

A similar marketing campaign was launched in Scotland, in October 2002, with the aim of addressing discrimination and stigma of people with mental illness. The campaign included publicity campaigns at a national level for the general population as well as targeted publicity campaigns intended for specific groups (e.g. young people). The campaign ran for 4 years and made use of billboards, posters, television, cinema and radio ads (Myers, et al., 2009).

For evaluation and research purposes, several attitude surveys were run prior and after the campaign, on a range of topics. The findings showed positive changes in attitudes such as a decrease in the number of people who believed that people with mental illness are dangerous and who would not want others to know if they had a mental disorder. Despite these positive findings, the campaign had been criticized for it’s lack of diversity (Myers, et al., 2009). The campaign messages and materials were developed for the general and majority of the population which meant that the materials were not always appropriate to or promoted within different communities, such as ethnic minorities.

The lack of diversity has proven to be a limitation for other campaigns as well. For example, Ganguly (1995) has identified that many of the health campaigns in Australia which involved television or posters advertisements often portrayed images of blond, blue-eye Australians, thus making it difficult for people of different ethnicities or races to relate to them. Research has shown that designing interventions and campaigns that target specific ethno-cultural groups improves the acceptance of the message, thus reducing stigma of people with mental illness (Agic, 2003).

In New Zealand, a large scale social marketing campaign ‘Like Minds Like Mine’ was launched in 1996 with the aim of reducing stigma and discrimination associated with mental illness (Vaughan & Hansen, 2004). The campaign functions at a variety of levels: nationwide advertising (e.g. television ads, billboards, etc), regional training and promotional activities and community projects. A noteworthy aspect of the campaign is that considerable efforts have been made to make the campaign more appealing to specific groups. For example, research has shown that males are less likely to use mental health services, therefore the campaign began using males in television ads so that the male viewers identify with the person delivering the message (Vaughan & Hansen, 2004). Similarly, Maori people have also been used in the campaign in order to appeal to the Maori population. Some of the printed materials were translated in several other languages (Vaughan and Hansen, 2004). The ‘Like Minds Like Mine’ campaign proved to be very successful, often being referred to as the ‘Gold Standard’ of anti-stigma campaigns (Queensland Alliance, 2009). The campaign has achieved high rates of campaign awareness, significant improvement in the general public’s attitudes, and a noteworthy improvement in the experiences of people with mental illness (Vaughan and Hansen, 2004).

Most of the anti-stigma social marketing campaigns have been either at a national level or aimed at the general population. Some (like the one evaluated by Evans-Lacko and her colleagues) have been localized to only one area; however they were still aimed at the general public. Because the majority of the campaigns are aimed at the general population, they are less likely to reach certain population subgroups such as different ethnic groups. The ‘Like Minds Like Mine’ campaign in New Zealand has taken some measures to address this issue, however, certain groups are still likely to be hard to reach. For example, the campaign is not likely to be as successful in the Asian community, as the only measure that Like Minds campaign has taken to so far to address the Asian population was the translation of materials in several Asian languages. As a result, it would be beneficial for an anti-stigma campaign aimed at the Asian immigrant community to be developed in New Zealand.

Proposed campaign

Population

The proposed campaign will be aimed at Chinese immigrants. The reason for this is that as mentioned previously, the Asian ethnic group is third largest in New Zealand. Asian immigrants have numerous mental health issues as a result of their immigration to New Zealand. More than this, mental illness is highly stigmatised in Asian cultures. Because the Asian ethnic group is a broad category, it would be hard to develop a campaign that addressed all the ethnicities which comprise the Asian population, especially since nothing of this sort has been done in New Zealand before. As a result, the campaign will focus on Chinese immigrants, since Chinese it is the largest ethnicity of the Asian population in New Zealand. The campaign will target the Chinese population in general terms, but will focus in particular on the Chinese immigrants as many of the mental issues of the Chinese population are due to the immigration process.

Furthermore, in order to reduce cost and to make the evaluation process easier, this campaign will take place in the Auckland region. If the campaign shows success, it may then be adopted to the entire country, or applied to other ethnic subgroups of the Asian population.

The scope of the campaign:

The overall, general scope of the campaign is to educate the Chinese population about mental illness and the issue of stigma.

The first scope of the campaign is to explain mental illness, different disorders and the importance of seeking help in a way that appeals and is culturally appropriate to the Chinese population. Emphasis will be put on the idea that mental illness has a significant direct and indirect impact on the society, hence why it is important to use mental health services.

Second scope of the campaign is to explain how stigma is a crucial reason why people with mental illness are reluctant to use mental health services and therefore how stigma impacts negatively on our society.

A noteworthy point that the campaign will put forward is that mental illness is not necessarily a supernatural punishment for wrong-doing, but that it often is a result of the immigration. The reason why the focus is put on what effects immigration may have on one’s mental health is because this takes the focus of the individual: the individual is not blamed for his condition or believed to have done something wrong. More than this, everyone has gone through the process of immigration or knows someone who did, and they know that moving to a different country is not easy, so they may sympathise with someone who is finding it hard to cope with the change.

The campaign will run for 4 months.

The four Ps:

The ‘product’ offered by the campaign is the “understanding that stigma associated with mental illness hurts us all”.

The ‘price’ is to abandon the pre-conceived ideas about mental illness and stigmatising people with mental illness. The potential benefit of discarding these ideas and attitudes is a society where people with mental illness can seek help without being embarrassed or afraid of being stigmatised.

The target population will be reached via a range of means. Mass media tools will include the Chinese television channel (CTV8), the Chinese radio station (ChinaClick) and the Chinese newspaper (Chinese Express). The Chinese newspaper will run an article related to the campaign every week for the duration of the campaign. The articles will cover subjects related to the two scopes of the campaign: explain mental illness and the link between mental illness and immigration and explain the negative implications of stigmatising people with mental illness. Posters will be placed in the Auckland areas where large numbers of Chinese population reside, Asian markets, Chinese shops, health clinics, schools and universities. Fliers and brochures would also be placed in health clinics and handed out at community meetings. An internet website for the campaign will also be created. This will be a particularly useful tool for the younger segment of the population as they will have access to a wide range of information and resources, discussion forum, non-stop access, etc.

A key aspect of this campaign is that the ‘promotion’ of the message will be in Chinese, in order to eliminate the language barrier that many other campaigns have faced: all the printed media (posters, fliers, brochures) as well as the newspaper articles will be written in Chinese. The television and radio advertisements will also be in Chinese. However, a literal translation from English to Chinese may not be adequate in portraying the message accurately or may not be culturally appropriate. Therefore, careful consideration must be given to how the information will be developed. In order to achieve this, translation specialists and Chinese linguistics specialists will work together with health promoters in order to develop the most adequate and culturally appropriate slogans and messages.

Stakeholders

Developing a social marketing campaign that is specific to and culturally appropriate to the Chinese population will require the support, expertise and knowledge of a multi-disciplinary team: mental health promoters, media agencies, Ministry of Health, translational services, Chinese community leaders and mental health service providers.

 

Evaluation

The effectiveness of the campaign will be evaluated via pre/post and follow up surveys.

The pre-campaign survey will assess the public’s knowledge about mental illness, opinions and attitudes towards people with mental illness. Post-campaign survey will investigate the same topics as the pre-campaign survey, in addition to awareness and opinions about the campaign. Follow up questionnaire will be carried out 6 months after the end of the campaign, in order to assess the long term success of the campaign.

The samples for the surveys will be comprised of Chinese people in the Auckland region, who have immigrated to New Zealand over 1 year ago. The participants must have been in Auckland for at least 1 year in order to make sure that they had the chance to be exposed to the campaign. Advertisements will be placed in the newspaper, on websites, on the television channel and radio, asking people to participate in the surveys.

The evaluation process will not only offer insight in the success of the campaign, but also reveal ineffective components of the campaign. Being able to identify the positive as well as the negative aspects of the campaign will be beneficial in case the campaign is repeated.

Limitations and future directions

A limitation is that this campaign will be introduced at a specific point in time, with the aim of changing beliefs and attitudes associated with mental illness and stigma among immigrants. However, people continue to immigrate into New Zealand: new immigrants with the same sort of preconceived ideas regarding mental illness will arrive after the campaign has finished, thus making the campaign seem futile at first glance. However, this is true of any marketing campaign: if a campaign is run only once at a specific point in time with no follow up or ongoing measures to sustain it, in time, its effects will diminish and disappear (Myers, et al., 2009).

However, if the evaluation process reveals that this campaign was successful in changing attitudes towards mental illness among the Chinese immigrant population at this point in time, perhaps this may serve as a motivating factor to introduce a long-term, on-going campaign. If an on-going campaign is not possible to be achieved, then perhaps a periodic one (repeating the campaign every year for example) may be affective as well.

A flaw in design is that the television channel, the radio station and the news paper are not Auckland specific, so is likely that Chinese people from all over the country will be exposed to the campaign as a result of these mass media tools. However, as mentioned previously, in order to simplify the evaluation process and reduce cost, the campaign will focus on Auckland.

As mentioned previously, if the campaign proves to be successful in changing beliefs about and attitudes towards people with mental illness, it can perhaps develop further. For example, it can be carried out long-term, it can be introduced all over the country, or adapted to other Asian ethnicities. If repeated, a potential improvement may be to explore the most effective ways in which to appeal to different age groups. For example, developing messages which are more likely to appeal to the younger population.

Conclusion

Asian immigrants are at increased risk of developing mental health issues yet they are reluctant to use health services as mental illness is highly stigmatised in their culture. Social marketing campaigns have proven to be effective tools in addressing stigma and improving attitudes towards people with mental illness, however, many campaigns do not reach ethnic minorities, or are often culturally inappropriate. Culture specific social marketing campaigns may prove to be more effective in reaching ethnic minorities than nationwide campaigns as the information can be tailored in order to make sure that language is not a barrier anymore and that the message is appropriate.

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