What stops Korean immigrants from accessing child and adolescent mental health services?

Background Access to child and adolescent mental health services by ethnic minorities has been poorly studied. Despite rapid growth of the immigrant Korean population, evidence indicates that few Korean families utilise these services in New Zealand. Those that do tend to present late and with significant morbidity. We sought to understand barriers to service access from Korean parents’ perspectives. Method Seven focus groups were undertaken with 31 Korean parents of children aged 18 and under. The focus groups were semi-structured, held in the Korean language and utilised two case scenarios of common childhood/adolescent mental illnesses around which a set of broad, open-ended questions were posed. All conversations were audiorecorded, transcribed and translated into English. Thematic analysis was conducted using NVivo software. Results Both attitudinal and structural barriers were identified. Attitudinal barriers included attribution of mental illness to external stressors or parenting problems, social stigma, denial or normalization of children’s behaviour, fear of family disempowerment, and mistrust of public mental health services. Structural barriers included parents’ lack of information regarding available services, logistical difficulties in access, communication difficulties, concerns over the quality of translators, and cultural competence of service providers. Conclusion Significant barriers prevent Korean immigrant families from accessing child and adolescent mental health services in New Zealand. Measures to improve access, for example by countering stigma, are urgently required. Supplementary Information The online version contains supplementary material available at 10.1186/s13034-022-00455-0.


Introduction
Korean immigration to both Australia and New Zealand (NZ) is relatively recent compared with other Asian ethnic groups. Since 1990, immigration has increased markedly and Koreans now constitute the 4th largest Asian ethnicity in NZ [1]. Taken together, Asians comprise more than 12% of population and are now the second largest ethnic minority, after Maori [2]. In the United States and Canada, low access of mental health services by Asian immigrants led to an assumption that prevalence rates of mental illness were low, but this has not been borne out by epidemiological studies which show rates similar to the mainstream population [3]. Asian patients tend to present with more severe and chronic mental illness than those of patients from other cultural backgrounds and consequently require more intensive treatment and longer hospitalization [4].
There is little epidemiologic data specifically focused on Asian children in NZ, Australia or the United States, but some evidence indicates that Asians, like other youth in NZ, report relatively high levels of depression, suicidal

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Child and Adolescent Psychiatry and Mental Health  16:19 thoughts and suicide attempts [5]. Similarly, Korean epidemiological studies indicate that rates of adolescent depression and ADHD in that country are similar to those in the West [6]. Suicide rates among adolescent Koreans are the highest among countries of the Organisation for Economic Cooperation and Development (OECD) and the 2nd highest cause of adolescent mortality [7]. Utilisation of child and adolescent mental health services in NZ is even lower for Asians than for Maori or Pacific, other ethnic minorities known to have reduced access [8]. This trend is particularly notable in the North Island of NZ where the rate of attendance of Asian youth to child and adolescent mental health services outpatient clinics is one tenth that of Maori. However, inpatient admission rates during the same period were high, suggesting late presentation and comparable rates of serious disorder [8].
In light of obvious unmet need, and the evidence that early intervention is associated with improved outcome, failure of minority groups to access mental health services is a serious concern. In this study we explore reasons for the low rates of access to child and adolescent mental health services by the Korean community in NZ.

Method
Focus groups were used to examine Korean parents' attitudes and knowledge. Women are mainly responsible for child rearing and therefore it is common to find families where the father lives in Korea and the remainder of the family lives in New Zealand. Hence, our focus was on the experiences and beliefs of Korean women. However, the opportunity arose to also undertake one focus group of Korean fathers living in NZ. We decided not to mix male and female participants because Korean females tend to defer to males and this would be expected to affect group dynamics and the quality of the discussion. Two common clinical scenarios, childhood attention deficit hyperactivity disorder (ADHD) and adolescent depression, were chosen and presented to each group, followed by a set of semi-structured questions for the participants to discuss, all in the Korean language. The semi-structured interview format in Korean and English is presented in Additional files 1 and 2.
Potential participants were contacted through the Korean community via notices in churches, schools, and Korean community groups in Hamilton, NZ. A total of 31 participants were recruited of which 4 were male. All participants were parents with children aged between 4 and 18 years, all but one had a university qualification, and most were between 35 and 55 years. Written informed consent was obtained from all participants; no remuneration was offered. Seven focus groups of 4-6 participants were facilitated by the first author, conducted during the evening in an informal setting (the home of one of the participants), each lasting between 2 and 3 h. Each session was audiorecorded, transcribed and translated by the first author.
Thematic analysis [9] was used to identify, analyse and report themes in the data. A coding system was developed through discussion of the transcripts by all four authors. The thematic analysis used text segments identified and coded into assigned categories. These were grouped into possible themes and, with re-reading and refinement, major themes developed; results from male (n = 1) and female (n = 6) focus groups were similar and pooled for analysis. The software package NVivo 8 (QSR International) was used to organise and structure transcript analysis. Results from all authors were integrated to increase coding reliability.

Results
We identified several, partly overlapping, factors that prevented access to child and adolescent mental health services; two major themes emerged: attitudinal and structural.

Attitudinal barriers
1. Attribution of children's emotional or behaviour problems to external stressors and/or parenting deficits Focus group participants tended to attribute problems to absent parents, parenting deficits, or alternatively as the consequence of external stress, such as school difficulties, racism, migration stresses, or puberty. External attribution of the child's emotional and behavioural problems also led to Korean parents feeling guilty.

Stigma
With a scenario indicating an illness requiring mental health service involvement, social stigma and a sense of shame was a major concern.
"Going to the mental health service is a huge stigma.

Denial/normalization of children and young person's behavioural and emotional problem
Participants tended to normalise the behavioural and emotional problems presented in the scenarios.
"Well at that age, I thought about suicide many times, I think it is normal to feel like that at least once at this age. They will usually grow out of this" "This boy sounds just like any other boy I know, boys have to be active and curious.. " 4. Fear of family disempowerment leading to service avoidance and attempting to manage by themselves Korean parents expressed fear of unknown services and were concerned over losing control of their child's care. The strong emotional response to the idea of referral to child and adolescent mental health services seemed to be related to concern over the unknown as well as fear that their parental rights and opinions would not be respected.

Discussion
The relevant literature is limited, even with regard to difficulties faced by Koreans in accessing child and adolescent mental health services in their own country. One survey identified a lack of information about available services, prejudice about mental illness, and misconceptions regarding severity being the main obstacles to accessing services [11]. Our results show similar problems as well as additional difficulties related to immigration from a traditional Asian culture to a Western, English-speaking country. Our analysis identified two groups of barriers, attitudinal and structural/systemic. The most prominent attitudinal barriers included perceived shame, embarrassment and guilt in having children with emotional and/or behavioural problems. These were generally considered a parental responsibility and helps explain why parents avoid service referral and attempt to solve problems by themselves or within their own immigrant community.
Shame plays a key role in social control and underlies the enforcement of rules in Confucius philosophy-influenced Asian countries, including Korea [12]. The shame of losing face for the individual is shared by the wider family and community itself. Accordingly, the disturbed behaviour that accompanies mental illness tends to cause shame and embarrassment in the family and wider community. As a result, mental illness is often kept hidden and secret.
Despite being given the explanation that our two scenarios reflected treatable mental illness, instead of experiencing relief from what might be seen as a face-saving alternative, most parents objected to this explanation and actively disputed the illness model. This attitude appears related to both mental health literacy and stigma. Thus, when stigma is perceived as too high a price to pay, parents disregard illness as a model for explaining children's behavioural and emotional problems.
In Korea, both mental and physical illnesses were traditionally attributed to superstitious belief systems until contact with Western concepts following the Korean War in 1950. After this, and subsequent rapid industrialisation, belief systems regarding mental illness have evolved. Koreans have been integrating Western models of both physical and mental illness. Child and adolescent mental health is no longer a taboo subject in Korea and is now commonly discussed in the media, including television programs such as "Live Good Morning" that include discussion of common cases by mental health professionals.
In our focus group discussions, there was very little attribution of mental illness to superstitious or ancestral curses, unlike findings among Chinese immigrants to Australia [13]. This difference may relate, in part, to the high educational attainment of the Korean parents in our sample.
There has been a misconception based on cultural stereotypes that Asians are model citizens and therefore experience lower rates of mental illness. However this hypothesis has been challenged, and it pointed out that Asians with mental illness often suffer in silence until the family and community are unable to cope, leading to delayed and ambivalent engagement with mainstream service providers [14].
Korean immigrants who have been less integrated into their host culture tend to adhere to beliefs in attitudes prevalent at the time they left Korea. Such individuals, as parents, appear to avoid contact with mental health services for their children. It was evident in focus groups that those with experience of child mental health services in Korea were more positive toward such services in NZ. Additionally, recent immigrants or parents of international students appeared to show better levels of mental health literacy compared to Korean immigrants who had lived in NZ for longer.
Structural barriers included lack of information about service providers and how to access them, and concerns regarding service providers' cultural competency, specifically regarding non-Koreans' ability to understand the nuances and underlying meaning of the family problems. Remarkably, none of our participants was aware regional child and adolescent mental health services or how to access these. Likewise, they were unaware of the Health and Disability Code of Patient Rights and the free provision of translators.
In addition to language barriers, differences in mental health service organisation may add to difficulties in access. For example, Korea has universal mandatory public health insurance, and citizens can seek the opinion of any doctor of their choice. Specialist or hospital based services do not require formal referral, and healthcare access and choice are thus very much consumer based. Our findings suggest that this systemic difference added to Korean immigrant parents' fear of losing control in managing mental disorder in their children.
The majority of our participants preferred opting out of public mental health services in favour of alternatives, such as seeking help through family networks and community organisations, notably Korean churches. Most agreed that they would, if necessary, go back to Korea to seek an opinion from a Korean child psychiatrist or mental health service. Our findings thus emphasise the importance of culture and language barriers and also the perceived lack of accessible information regarding mental health services.  16:19 In 2002 the NZ Mental Health Commission recommended promoting mental health in Asian communities by increasing public support for cultural diversity, providing information, English language education, developing community support programmes and increasing service providers' awareness of Asian cultural issues [8]. Unfortunately, after 15 years there is little evidence to indicate effective nationwide implementation of these recommendations or indeed changes in the way Asian populations tend to view and access mental health services. Thus, although these results were derived from one region (Waikato), they are likely to reflect more general barriers to clinical service access in NZ.
On the other hand, some regional initiatives are relevant, including a Korean mental health and addiction awareness group (Like Minds, Like Mine, 2016). Asian mental health support groups have also developed in Auckland (Independent Living Services, 2013), New Zealand's largest city and one with a proportionately higher Asian population than elsewhere in the country. Similarly, the Mental Health Foundation, a charitable trust, has developed Kai Xin Xing Dong, a public education program to reduce stigma for Asian youth experiencing mental illness (Mental Health Foundation, 2017). The impact of these initiatives is as yet uncertain.

Limitations
Our study explored parental attitudes regarding helpseeking on behalf of children; it did not address attitudes of either parents or children regarding their own mental health. Despite overlaps with other Asian populations, Korean culture has many distinctive features, potentially limiting the generalisability of our results. Similarly, our sample of Korean parents in NZ had notably high educational attainment, likely related to NZ immigration criteria, and so our results may also have been affected by this factor.
Participating parents were recruited largely through the first author's Korean school and church involvement. Most participated with an expressed willingness to help Korean families in NZ, but their knowledge of the first author may have influenced responses. At the time of interview, no parents were involved with child and adolescent mental health services. However, after one focus group, a mother approached the first author regarding her teenaged daughter's disordered eating, later seeking help from Korea.

Conclusion
Both attitudinal and structural barriers prevent adequate mental health service delivery to the Korean community in NZ. To overcome these barriers, a more concerted effort is required beyond provision of translators for clinical encounters. The importance of education and information dissemination among minority communities is essential, as is developing the appropriate cultural sensitivity and competency of mental health staff. The concept of cultural competency in mental health service providers has gained traction with evidence of improved access and better engagement in treatment [15,16].
Shortly after conclusion of the project, the first author presented a summary of results to an evening meeting of the local Korean community. Based on these findings, the local child and adolescent mental health service has made several changes, including more proactive provision of translators, added emphasis on confidentiality, closer links to high school guidance counsellors, and education of staff regarding Korean and other minority cultures and their implications for service access.