Stigma is a barrier to mental health care access, especially among older immigrants, say experts
By JULIE MINDA
Starting about a decade ago, mental health began percolating up as a pressing public health concern on the community health needs assessments of Providence Mission Hospital Mission Viejo in California. Even after the Providence St. Joseph Health facility added mental health professionals to increase access to care in the community, mental health issues remained among top concerns on needs assessments.
Amy Guerra, then an employee of the Westbound Communications marketing firm, staffs a Promise to Talk campaign booth at a community event in Orange County, California, in 2019. The campaign from three Providence St. Joseph Health hospitals encourages people to talk openly about mental health challenges.
Probing deeper through research, hospital leadership keyed in on a significant access barrier: There was pervasive stigma — particularly among vulnerable immigrant populations — when it came to mental health care. To tackle the problem, Mission Hospital embarked on an extensive public health campaign around 2016 to combat stigma and to encourage people to talk openly about their mental health challenges. Two other Providence St. Joseph Health hospitals in the greater Los Angeles area — Providence St. Joseph Hospital Orange and Providence St. Jude Medical Center in Fullerton — since have joined the campaign.
The primary audience is economically and socially disadvantaged groups within Orange County, skewing toward women and including English, Spanish, Vietnamese and bilingual speakers. The secondary target audience is the general public living in Orange County.
The initiative is having a positive and measurable impact on attitudes about mental health treatment.
"If you don't deal with the stigma, it doesn't matter how much access you offer," says Barry Ross, regional director of community health investment for Providence St. Joseph's Southern California region. "The challenge we faced was that we really wanted to reach people who are hard to reach. Finding trusted platforms to reach them is important. It's all about trust."
Lost in translation
Research conducted over the past decade or so found that low-income Hispanic and Vietnamese-American populations in Orange County have worse mental health stressors and greater prevalence of mental health conditions than higher-income whites and are less likely to seek mental health treatment.
Christy Cornwall directs community benefit for Mission Hospital. She says research by the three hospitals has shown that, in general, the older and less acculturated that Hispanic and Vietnamese Americans are, the less willing they are to talk about mental health. There was — and still is — a perception that mental illness is associated with shame and weakness.
Ross says that low-income immigrants who overcome cultural taboos and are open to accessing mental health services may encounter significant barriers to care. Barriers may include difficulty finding bilingual, bicultural psychiatrists, and a lack of insurance or money to pay out-of-pocket for care.
People without legal immigration status may fear accessing care will bring the attention of immigration authorities. Immigrants who are covered by Medi-Cal, California's Medicaid plan, may worry that using the benefit will harm their applications for permanent legal status even though the federal government stopped applying the Trump administration's public charge rule in March.
Talk about it
Mission Hospital hired Westbound Communications, a marketing and communications firm in Southern California, to help develop and implement a campaign to destigmatize mental health treatment. Mission Hospital and Westbound studied social science research around stigma reduction and evaluated more than 60 preexisting mental health campaigns before determining that the Each Mind Matters campaign from the California Division of Mental Health aligned well with Mission Hospital's campaign objectives. The campaign is a state program funded through the Mental Health Services Act, Prop 63.
Pattie Cordova is among nearly a dozen Hispanic or Vietnamese-American social media influencers in Orange County whom the Promise to Talk campaign engaged to post about mental health topics during Mental Health Awareness Month in May.
Mission Hospital and Westbound used Each Mind Matters resources created by the division, co-branding materials with both the hospital and health division's names. The hospital and its agency translated all materials into Spanish and Vietnamese for outreach to low-income immigrant populations, with a focus on young mothers. These women make health care decisions for their children and can influence their parents' health care decision-making as well.
The Providence iteration of the Each Mind Matters campaign is called Promise to Talk. It has morphed over the years, including with the addition of the two other hospitals. It has remained centered on the message that it is not just OK, but essential to talk about mental health because mental health is just as important as bodily health.
Part of the campaign includes asking people to "Promise to Talk." Cornwall explains, "If you're struggling or a loved one is struggling, keeping it inside is not helping you or anyone else, so we're asking people to make a promise to talk to a friend, someone in their faith community," and/or to a mental health professional.
Lime green benches
Prior to the pandemic's onset, Westbound's bilingual, bicultural staff crewed booths at events, parks, churches, food pantries and other sites in medically underserved communities to talk about mental health and to share mental health education sheets and information on how to access bilingual, bicultural mental health treatment.
The team partnered with schools, churches and county health departments to extend the campaign.
The hospitals and agency commissioned several lime green benches — lime green is a color used to promote mental health awareness — and moved them around to locations where they would be readily noticeable. Signs explain the importance of talking about mental health and invite passersby to sit on the benches with someone to begin the conversation.
When COVID-19 ended this experiential outreach, staff beefed up hospital and campaign websites emphasizing the Promise to Talk call to action. They increased mental health messaging on the hospitals' social media feeds. And they recruited social media influencers — mainly Hispanic and Vietnamese mothers with followings in those demographics — and paid them to post about mental health and the Promise to Talk campaign.
Traditional media relations and paid advertising are another part of the communications strategy.
Each Providence hospital pays about $100,000 from its community benefit funds to Westbound each year for the campaign.
Westbound says in the 2020 calendar year, 1,176 people made the promise to talk about mental health with a friend or family member; 38,695 encountered the campaign through social and digital media and there have been more than 7.3 million impressions of online content. This includes viewings of social and digital media, website content, influencer posts and earned and paid media.
Cornwall and Ross see the greatest evidence of campaign impact in changing perceptions.
Each fall, Westbound conducts impact surveys in the Orange County communities where the campaign has been most active, asking community members whether they would be willing to talk about mental health with someone in their social circle and whether they feel their local community is "caring and sympathetic" to people with mental health conditions. Generally, there have been improvements in these measures over time, with more people saying they are willing to talk about mental health and more people saying that they believe that their community is compassionate.
Ross says the immigrant communities that are the primary audience for the mental health messaging have been hit especially hard by pandemic impacts, and are reeling from resulting mental health concerns.
He says, "I think what we've been able to do is to raise awareness in these vulnerable communities that this is something that can be talked about."
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