J Immigrant Minority Health DOI 10.1007/s10903-014-0018-7
BRIEF COMMUNICATION
Perceptions of Mental Illness and Related Stigma Among Vietnamese Populations: Findings from a Mixed Method Study Mai Do • Nhu Ngoc K. Pham • Stacy Wallick Bonnie Kaul Nastasi
•
Springer Science+Business Media New York 2014
Abstract Mental-illness-related (MIR) stigma is recognized as a major barrier to health care. Yet very little is known about mental illness and stigma among Vietnamese populations, or how emigration and acculturation processes might affect traditional views. Focus group discussions were conducted with Vietnamese Americans in New Orleans (Louisiana) and Vietnamese nationals in Bui Chu (Vietnam), who shared historical and cultural backgrounds, in 2010 to assess differences in their perceptions of mental illness and stigma. Results show several significant differences in mental illness perceptions between Vietnamese Americans and Vietnamese nationals, while MIR stigma seemed prevalent and understanding of mental illness was low among both groups. Keywords Mental illness Stigma Vietnamese Vietnamese Americans
Introduction Vietnamese Americans, like other Asian immigrants, reportedly underutilize mental health services. Discussions with Vietnamese immigrants in the United States and elsewhere and with health professionals have pointed to stigma as a major impediment to care [1–3]. Yet, little M. Do N. N. K. Pham (&) S. Wallick Department of Global Health Systems and Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA e-mail: [email protected] B. K. Nastasi Department of Psychology, Tulane University, New Orleans, LA, USA
research has investigated mental-illness-related (MIR) stigma among this population. This study explored perceptions of mental illness and stigma among Vietnamese in New Orleans and Vietnamese nationals in Bui Chu (Ninh Binh province), who never left the country. The two groups share a socio-cultural heritage—a significant proportion of Vietnamese in New Orleans came from Bui Chu—but differ in recent cultural environment. Many Vietnamese in New Orleans first moved from Bui Chu in the north to South of Vietnam at the end of the First Indochina War (1954). Twenty years later, the Vietnam War ended, they made the second move to the United States. Yet, the hardship did not end there. Vietnamese in New Orleans once again experienced the traumas of Hurricane Katrina (2005) and the Deepwater Horizon (BP) oil spill (2010), reigniting similar traumas of the past. Surprisingly, previous studies did not find long-lasting impacts of disasters on the mental health status of Vietnamese in New Orleans [4]. One of the questions raised was whether living in a different culture has shifted the perceptions of mental health and stigma, which may have affected how mental illness was reported. This study attempts to address this question by comparing mental illness perceptions among Vietnamese Americans and Vietnamese nationals, through a mixed-method approach.
Methods Approved by the Internal Review Board of Tulane University, in 2010, eight focus group discussions (FGDs) were conducted among Vietnamese in eastern New Orleans and Vietnamese nationals from Bui Chu (Vietnam). On average, ten individuals participated in each FGD; a total of 81 participants aged 25–70 took part in the FGDs in both
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locations (41 in New Orleans, 40 in Bui Chu), participants were equally divided between genders. In each FGD, participants were first asked to complete a short questionnaire indicating their opinions towards MIR statements, and then the discussion was conducted.
Results Through FGD coding based on thematic responses coupled with surveys’ guideline questions and issues discussed, important similarities and differences between the two sample groups were noticed. Similarities Everyone agreed that mental illness was a departure from the norms, as people with MIR problems did ‘‘weird stuff,’’ or that they were ‘‘anti-social.’’ Many participants in New Orleans used the word ‘‘crazy’’ to describe mental illness. Both groups clearly distinguished the mentally ill, ‘‘them,’’ from ‘‘normal people like us,’’ referring to the mentally ill in third person while keeping both physical and social distance, in fear of violent behaviors. I am scared of it. If I see someone with mental illness, I do not want to come near them. (Man, 50-70, New Orleans) Worries were a commonly cited cause of mental illness among all participants, where one would become mentally ill if he/she spent too much time thinking about his/her problems, not sharing them with family members and friends. Both groups distinguished long-term mental health issues caused by major stressors from problems due to daily stress. Sudden mental or emotional shocks, especially from the wars, had long-lasting impacts in both locations. I had 7 siblings and I was the only one who joined the military. I almost lost my leg. My older brother died in the North. Later on another brother died. Altogether I lost 5 siblings… After fighting in the North, my siblings and I evacuated from the war zone, we lost contact with each other… Without a family, no wife, no children, I feel depressed. (Man, 50-70, New Orleans) In New Orleans, recent disasters were among leading stressors. Not many communities suffered from repeat traumas as did this community—first the wars, then Hurricane Katrina, and more recently the BP Oil Spill. Many Vietnamese Americans had barely recovered from Hurricane Katrina, only to be worried again about their financial situation as a result of the oil spill. The long-term impacts are palpable:
123
In my case, it was after Hurricane Katrina. I felt that my body and my health changed after that incident. I have not confirmed that I have mental illness. But psychologically, my life changed tremendously. Now my life is not happy, healthy, exciting, and hopeful… It [Katrina] was the worst experience I have gone through since I came to the U.S. I suspect that someday I may have mental illness if I do not find a way out. (Man, 50-70, New Orleans) As hinted above and apparent from the quote below, repeat traumas may have caused many participants to shy away from talking about their mental distress—a possible reason for the low prevalence of mental health issues found in recent surveys [4]. I have much sadness… I very much want to speak out. But I still keep it to myself; I still endure and do not share it with other… That is why when the doctors investigate; they find that very few Vietnamese have mental illness. For example, I am depressed, but it takes many people to come to find that out. (Man, 50-70, New Orleans)
Differences Important differences were observed between the two groups. Vietnamese Americans were less likely than Vietnamese nationals to attach mental illness to a specific physical health problem, but had a harder time describing it. They made clear distinctions between mental and physical health, in which mental health dealt with ‘‘the state of mind.’’ In contrast, Vietnamese nationals often equated mental illness with physical problems, where causes of mental illness were physical health and behaviors, including not being able to eat or sleep. Table 1 shows significant differences between the two groups regarding to MIR stigma, based on data from the quantitative measure of stigma. First, Vietnamese Americans were much more likely than Vietnamese nationals to report ‘‘no opinion’’ to statements relating to MIR stigma, which may indicate their reluctance to discuss stigma. Second, for many statements indicating a stigmatizing attitude toward the mentally ill, a significantly greater proportion of Vietnamese Americans reported agreement or no opinion than Vietnamese nationals. For example, Vietnamese Americans were more likely than Vietnamese nationals to not have an opinion or agree that families and individuals with mental disorders should hide their illness (67.6% compared to 22.5%), indicating stigmatizing attitudes towards those with MIR issues. Consistent with data collected from the FGDs, quantitative data point to the public’s not-so-friendly perceptions towards those with mental illness.
J Immigrant Minority Health Table 1 MIR stigma among FGD participants in New Orleans and Bui Chu
Statement
New Orleans (%)
Bui Chu (%)
People with mental illness are fearful Strongly disagree
.000 2.8
27.5
Disagree
27.8
50.0
No opinion
36.1
2.5
Agree
22.2
15.0
Strongly agree
11.1
5.0
5.3
12.5
People with mental illness are often pitied Strongly disagree Disagree
.000 2.6
30.0
No opinion
42.1
0.0
Agree
31.6
50.0
Strongly agree
18.4
7.5
2.6
17.5
Disagree No opinion
31.6 42.1
50.0 2.5
Agree
15.8
25.0
7.9
5.0
People with mental health problems are dangerous Strongly disagree
Strongly agree
.000
Families of people with mental health problems should be embarrassed of themselves
.000
Strongly disagree
44.4
17.5
Disagree
16.7
62.5
No opinion
30.6
2.5
Agree
8.3
10.0
Strongly agree
0.0
7.5
People are not understanding of those with mental health problems
.001
Strongly disagree
2.6
30.0
Disagree
7.9
17.5
No opinion
42.1
7.5
Agree
26.3
25.0
Strongly agree
21.1
20.0
People with mental illness are usually talked down to because of their mental health problems Strongly disagree
.000 2.7
15.0
Disagree
13.5
52.5
No opinion Agree
43.2 27.1
5.0 20.0
Strongly agree
13.5
7.5
2.6
17.5
Disagree
10.3
52.5
No opinion
41.0
7.5
Agree
35.9
15.0
Strongly agree
10.3
7.5
People usually avoid those with mental health problems Strongly disagree
p-value
.000
.000
It is a sign of personal weakness to receive treatment for emotional or mental problems Strongly disagree
35.2
12.5
Disagree No opinion
24.3 29.7
47.5 5.0
123
J Immigrant Minority Health Table 1 continued
Statement Agree Strongly agree
New Orleans (%)
Bui Chu (%)
10.8
15.0
0.0
20.0
People tend not to like those who seek help for emotional or mental problems 32.4
15.0
Disagree
18.9
55.0
No opinion
37.9
10.0
Agree
8.1
5.0
Strongly agree
2.7
15.0
Discussion This study highlights varying levels of understanding and perceptions toward mental illness among Vietnamese populations. None of the participants seemed to have a good understanding of mental illness. ‘‘Worries’’ and sudden traumatic experiences were cited as common causes for mental illness by both groups. In both locations, participants indicated that sudden mental or emotional shocks, such as wars or natural disasters, could result in mental illness, not only among those directly involved but possibly among the next generations as well. However, there are also critical differences between the two groups. Vietnamese nationals were more likely than Vietnamese Americans to maintain the traditional view and see the body and the mind as two parts of a unitary model [5]; they were also more able to describe mental illness and person(s) with such illness. Many participants also emphasized the tendency of Vietnamese to keep problems inside rather than talking about them, not wanting to be reminded of the many repeat traumas that they have endured. This finding is consistent with an earlier report on the post-Katrina resilience of Vietnamese in New Orleans [6]. Another possible explanation for reluctance to talk about mental illness could be stigmatizing attitudes towards those with mental issues. Living in the United States, where privacy and the capacity for independent living are highly valued, may have also contributed to Vietnamese Americans’ view of mental illness as a personal matter, creating unwillingness to admit to or share emotional troubles. The study did not provide strong evidence that Vietnamese in New Orleans had less stigmatizing attitudes toward mental illness than their counterparts in Bui Chu. Life in a second culture did not substantially change the Vietnamese Americans’ ideas about mental health; instead it seemed to encourage them to hold back their opinions in discussing MIR issues.
123
.001
Strongly disagree
N
p-value
41
40
This early investigation opens opportunities for further research on other issues surrounding mental illness and MIR stigma among Vietnamese populations, such as cultural effects on MIR stigma—how they may vary between sites and between generations. While disasters were reported as major causes of mental disorders, their long-term impacts on mental illness, particularly among the offspring of those directly involved, and related stigma are not clear. To our knowledge, this is the only study that has compared Vietnamese nationals with Vietnamese Americans on perceptions of mental illness and stigma. Its strengths include the use of mixed methods to gain insight to a highly sensitive topic. The study highlights a lack of understanding of mental illness and a potentially high level of stigma in both groups. Much work is needed to reduce the stigma and negative perceptions of mental illness among the overall Vietnamese population. Acknowledgments This study is supported by the Gulf Coast Transdisciplinary Research Recover Center for Community Health (NIH 1RC2MD004783-01; Principal Investigator: Maureen Litchveld). We also thank Mark VanLandingham for his inputs and comments on earlier drafts of the report.
References 1. Sadavoy J, Meier R, Ong AY. Barriers to access to mental health services for ethnic seniors: the Toronto study. [Research Support, Non-U.S. Gov’t]. Can J Psychiatry. 2004;49(3):192–9. 2. Wynaden D, Chapman R, Orb A, McGowan S, Zeeman Z, Yeak S. Factors that influence Asian communities’ access to mental health care. [Research Support, Non-U.S. Gov’t]. Int J Ment Health Nurs. 2005;14(2):88–95. doi:10.1111/j.1440-0979.2005.00364.x. 3. Leong FT, Lau AS. Barriers to providing effective mental health services to Asian Americans. Ment Health Serv Res. 2001;3(4): 201–14. 4. Vu L, VanLandingham MJ. Physical and mental health consequences of Katrina on Vietnamese immigrants in New Orleans: a pre- and post-disaster assessment. J Immigr Minor Health. 2012; 14(3):386–94. 5. Obeyesekere G. Depression, Buddhism and the work of culture in Sri Lanka. In: Culture and depression: studies in the anthropology
J Immigrant Minority Health and cross-cultural psychiatry of affect and disorder. 1985. pp. 134–152. 6. Carlin K, Preibe A, Do M, Bankston C, VanLandingham M. Culture and Resiliency within a Vietnamese-American Enclave
post-Katrina. Global Horizons. Center for Policy and Resilience, University of Southern Mississippi Gulf Coast, Long Beach, MS. 2011.
123
BRIEF COMMUNICATION
Perceptions of Mental Illness and Related Stigma Among Vietnamese Populations: Findings from a Mixed Method Study Mai Do • Nhu Ngoc K. Pham • Stacy Wallick Bonnie Kaul Nastasi
•
Springer Science+Business Media New York 2014
Abstract Mental-illness-related (MIR) stigma is recognized as a major barrier to health care. Yet very little is known about mental illness and stigma among Vietnamese populations, or how emigration and acculturation processes might affect traditional views. Focus group discussions were conducted with Vietnamese Americans in New Orleans (Louisiana) and Vietnamese nationals in Bui Chu (Vietnam), who shared historical and cultural backgrounds, in 2010 to assess differences in their perceptions of mental illness and stigma. Results show several significant differences in mental illness perceptions between Vietnamese Americans and Vietnamese nationals, while MIR stigma seemed prevalent and understanding of mental illness was low among both groups. Keywords Mental illness Stigma Vietnamese Vietnamese Americans
Introduction Vietnamese Americans, like other Asian immigrants, reportedly underutilize mental health services. Discussions with Vietnamese immigrants in the United States and elsewhere and with health professionals have pointed to stigma as a major impediment to care [1–3]. Yet, little M. Do N. N. K. Pham (&) S. Wallick Department of Global Health Systems and Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA e-mail: [email protected] B. K. Nastasi Department of Psychology, Tulane University, New Orleans, LA, USA
research has investigated mental-illness-related (MIR) stigma among this population. This study explored perceptions of mental illness and stigma among Vietnamese in New Orleans and Vietnamese nationals in Bui Chu (Ninh Binh province), who never left the country. The two groups share a socio-cultural heritage—a significant proportion of Vietnamese in New Orleans came from Bui Chu—but differ in recent cultural environment. Many Vietnamese in New Orleans first moved from Bui Chu in the north to South of Vietnam at the end of the First Indochina War (1954). Twenty years later, the Vietnam War ended, they made the second move to the United States. Yet, the hardship did not end there. Vietnamese in New Orleans once again experienced the traumas of Hurricane Katrina (2005) and the Deepwater Horizon (BP) oil spill (2010), reigniting similar traumas of the past. Surprisingly, previous studies did not find long-lasting impacts of disasters on the mental health status of Vietnamese in New Orleans [4]. One of the questions raised was whether living in a different culture has shifted the perceptions of mental health and stigma, which may have affected how mental illness was reported. This study attempts to address this question by comparing mental illness perceptions among Vietnamese Americans and Vietnamese nationals, through a mixed-method approach.
Methods Approved by the Internal Review Board of Tulane University, in 2010, eight focus group discussions (FGDs) were conducted among Vietnamese in eastern New Orleans and Vietnamese nationals from Bui Chu (Vietnam). On average, ten individuals participated in each FGD; a total of 81 participants aged 25–70 took part in the FGDs in both
123
J Immigrant Minority Health
locations (41 in New Orleans, 40 in Bui Chu), participants were equally divided between genders. In each FGD, participants were first asked to complete a short questionnaire indicating their opinions towards MIR statements, and then the discussion was conducted.
Results Through FGD coding based on thematic responses coupled with surveys’ guideline questions and issues discussed, important similarities and differences between the two sample groups were noticed. Similarities Everyone agreed that mental illness was a departure from the norms, as people with MIR problems did ‘‘weird stuff,’’ or that they were ‘‘anti-social.’’ Many participants in New Orleans used the word ‘‘crazy’’ to describe mental illness. Both groups clearly distinguished the mentally ill, ‘‘them,’’ from ‘‘normal people like us,’’ referring to the mentally ill in third person while keeping both physical and social distance, in fear of violent behaviors. I am scared of it. If I see someone with mental illness, I do not want to come near them. (Man, 50-70, New Orleans) Worries were a commonly cited cause of mental illness among all participants, where one would become mentally ill if he/she spent too much time thinking about his/her problems, not sharing them with family members and friends. Both groups distinguished long-term mental health issues caused by major stressors from problems due to daily stress. Sudden mental or emotional shocks, especially from the wars, had long-lasting impacts in both locations. I had 7 siblings and I was the only one who joined the military. I almost lost my leg. My older brother died in the North. Later on another brother died. Altogether I lost 5 siblings… After fighting in the North, my siblings and I evacuated from the war zone, we lost contact with each other… Without a family, no wife, no children, I feel depressed. (Man, 50-70, New Orleans) In New Orleans, recent disasters were among leading stressors. Not many communities suffered from repeat traumas as did this community—first the wars, then Hurricane Katrina, and more recently the BP Oil Spill. Many Vietnamese Americans had barely recovered from Hurricane Katrina, only to be worried again about their financial situation as a result of the oil spill. The long-term impacts are palpable:
123
In my case, it was after Hurricane Katrina. I felt that my body and my health changed after that incident. I have not confirmed that I have mental illness. But psychologically, my life changed tremendously. Now my life is not happy, healthy, exciting, and hopeful… It [Katrina] was the worst experience I have gone through since I came to the U.S. I suspect that someday I may have mental illness if I do not find a way out. (Man, 50-70, New Orleans) As hinted above and apparent from the quote below, repeat traumas may have caused many participants to shy away from talking about their mental distress—a possible reason for the low prevalence of mental health issues found in recent surveys [4]. I have much sadness… I very much want to speak out. But I still keep it to myself; I still endure and do not share it with other… That is why when the doctors investigate; they find that very few Vietnamese have mental illness. For example, I am depressed, but it takes many people to come to find that out. (Man, 50-70, New Orleans)
Differences Important differences were observed between the two groups. Vietnamese Americans were less likely than Vietnamese nationals to attach mental illness to a specific physical health problem, but had a harder time describing it. They made clear distinctions between mental and physical health, in which mental health dealt with ‘‘the state of mind.’’ In contrast, Vietnamese nationals often equated mental illness with physical problems, where causes of mental illness were physical health and behaviors, including not being able to eat or sleep. Table 1 shows significant differences between the two groups regarding to MIR stigma, based on data from the quantitative measure of stigma. First, Vietnamese Americans were much more likely than Vietnamese nationals to report ‘‘no opinion’’ to statements relating to MIR stigma, which may indicate their reluctance to discuss stigma. Second, for many statements indicating a stigmatizing attitude toward the mentally ill, a significantly greater proportion of Vietnamese Americans reported agreement or no opinion than Vietnamese nationals. For example, Vietnamese Americans were more likely than Vietnamese nationals to not have an opinion or agree that families and individuals with mental disorders should hide their illness (67.6% compared to 22.5%), indicating stigmatizing attitudes towards those with MIR issues. Consistent with data collected from the FGDs, quantitative data point to the public’s not-so-friendly perceptions towards those with mental illness.
J Immigrant Minority Health Table 1 MIR stigma among FGD participants in New Orleans and Bui Chu
Statement
New Orleans (%)
Bui Chu (%)
People with mental illness are fearful Strongly disagree
.000 2.8
27.5
Disagree
27.8
50.0
No opinion
36.1
2.5
Agree
22.2
15.0
Strongly agree
11.1
5.0
5.3
12.5
People with mental illness are often pitied Strongly disagree Disagree
.000 2.6
30.0
No opinion
42.1
0.0
Agree
31.6
50.0
Strongly agree
18.4
7.5
2.6
17.5
Disagree No opinion
31.6 42.1
50.0 2.5
Agree
15.8
25.0
7.9
5.0
People with mental health problems are dangerous Strongly disagree
Strongly agree
.000
Families of people with mental health problems should be embarrassed of themselves
.000
Strongly disagree
44.4
17.5
Disagree
16.7
62.5
No opinion
30.6
2.5
Agree
8.3
10.0
Strongly agree
0.0
7.5
People are not understanding of those with mental health problems
.001
Strongly disagree
2.6
30.0
Disagree
7.9
17.5
No opinion
42.1
7.5
Agree
26.3
25.0
Strongly agree
21.1
20.0
People with mental illness are usually talked down to because of their mental health problems Strongly disagree
.000 2.7
15.0
Disagree
13.5
52.5
No opinion Agree
43.2 27.1
5.0 20.0
Strongly agree
13.5
7.5
2.6
17.5
Disagree
10.3
52.5
No opinion
41.0
7.5
Agree
35.9
15.0
Strongly agree
10.3
7.5
People usually avoid those with mental health problems Strongly disagree
p-value
.000
.000
It is a sign of personal weakness to receive treatment for emotional or mental problems Strongly disagree
35.2
12.5
Disagree No opinion
24.3 29.7
47.5 5.0
123
J Immigrant Minority Health Table 1 continued
Statement Agree Strongly agree
New Orleans (%)
Bui Chu (%)
10.8
15.0
0.0
20.0
People tend not to like those who seek help for emotional or mental problems 32.4
15.0
Disagree
18.9
55.0
No opinion
37.9
10.0
Agree
8.1
5.0
Strongly agree
2.7
15.0
Discussion This study highlights varying levels of understanding and perceptions toward mental illness among Vietnamese populations. None of the participants seemed to have a good understanding of mental illness. ‘‘Worries’’ and sudden traumatic experiences were cited as common causes for mental illness by both groups. In both locations, participants indicated that sudden mental or emotional shocks, such as wars or natural disasters, could result in mental illness, not only among those directly involved but possibly among the next generations as well. However, there are also critical differences between the two groups. Vietnamese nationals were more likely than Vietnamese Americans to maintain the traditional view and see the body and the mind as two parts of a unitary model [5]; they were also more able to describe mental illness and person(s) with such illness. Many participants also emphasized the tendency of Vietnamese to keep problems inside rather than talking about them, not wanting to be reminded of the many repeat traumas that they have endured. This finding is consistent with an earlier report on the post-Katrina resilience of Vietnamese in New Orleans [6]. Another possible explanation for reluctance to talk about mental illness could be stigmatizing attitudes towards those with mental issues. Living in the United States, where privacy and the capacity for independent living are highly valued, may have also contributed to Vietnamese Americans’ view of mental illness as a personal matter, creating unwillingness to admit to or share emotional troubles. The study did not provide strong evidence that Vietnamese in New Orleans had less stigmatizing attitudes toward mental illness than their counterparts in Bui Chu. Life in a second culture did not substantially change the Vietnamese Americans’ ideas about mental health; instead it seemed to encourage them to hold back their opinions in discussing MIR issues.
123
.001
Strongly disagree
N
p-value
41
40
This early investigation opens opportunities for further research on other issues surrounding mental illness and MIR stigma among Vietnamese populations, such as cultural effects on MIR stigma—how they may vary between sites and between generations. While disasters were reported as major causes of mental disorders, their long-term impacts on mental illness, particularly among the offspring of those directly involved, and related stigma are not clear. To our knowledge, this is the only study that has compared Vietnamese nationals with Vietnamese Americans on perceptions of mental illness and stigma. Its strengths include the use of mixed methods to gain insight to a highly sensitive topic. The study highlights a lack of understanding of mental illness and a potentially high level of stigma in both groups. Much work is needed to reduce the stigma and negative perceptions of mental illness among the overall Vietnamese population. Acknowledgments This study is supported by the Gulf Coast Transdisciplinary Research Recover Center for Community Health (NIH 1RC2MD004783-01; Principal Investigator: Maureen Litchveld). We also thank Mark VanLandingham for his inputs and comments on earlier drafts of the report.
References 1. Sadavoy J, Meier R, Ong AY. Barriers to access to mental health services for ethnic seniors: the Toronto study. [Research Support, Non-U.S. Gov’t]. Can J Psychiatry. 2004;49(3):192–9. 2. Wynaden D, Chapman R, Orb A, McGowan S, Zeeman Z, Yeak S. Factors that influence Asian communities’ access to mental health care. [Research Support, Non-U.S. Gov’t]. Int J Ment Health Nurs. 2005;14(2):88–95. doi:10.1111/j.1440-0979.2005.00364.x. 3. Leong FT, Lau AS. Barriers to providing effective mental health services to Asian Americans. Ment Health Serv Res. 2001;3(4): 201–14. 4. Vu L, VanLandingham MJ. Physical and mental health consequences of Katrina on Vietnamese immigrants in New Orleans: a pre- and post-disaster assessment. J Immigr Minor Health. 2012; 14(3):386–94. 5. Obeyesekere G. Depression, Buddhism and the work of culture in Sri Lanka. In: Culture and depression: studies in the anthropology
J Immigrant Minority Health and cross-cultural psychiatry of affect and disorder. 1985. pp. 134–152. 6. Carlin K, Preibe A, Do M, Bankston C, VanLandingham M. Culture and Resiliency within a Vietnamese-American Enclave
post-Katrina. Global Horizons. Center for Policy and Resilience, University of Southern Mississippi Gulf Coast, Long Beach, MS. 2011.
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