Association of refugees’ knowledge of mental illness and their attitudes towards mental illness

doi:10.21203/rs.3.rs-48966/v1

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Association of refugees’ knowledge of mental illness and their attitudes towards mental illness

https://doi.org/10.21203/rs.3.rs-48966/v1

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The purpose of this study is to identify the level of mental health knowledge of defectors and to investigate the effect of sociodemographic characteristics and mental health knowledge level on mental health attitudes. We conducted a questionnaire survey of 150 people, and analyzed the data of 138 people. The t-test and one-way ANOVA were used to analyze differences according to demographic characteristics. Hierarchical regression analysis was performed to measure the effect of mental illness knowledge on attitudes toward mental illness. The positive correlations between the mental health attitudes of North Korean defectors and the knowledge level were significant, and the knowledge level between final academic achievement in South Korea and the entry year into South Korea was also significant. The higher the knowledge of mental health, the more generous the minds of the mentally illness because they know better about it, and they have negative thoughts about regulating their lives.

Psychiatry

Psychology

Health Policy

refugee

mental illness

knowledge

attitude

The number of North Korean refugees who come to South Korea has increased rapidly since the mid-1990s when the food situation started to deteriorate in North Korea (this period is known as the Arduous March). The total number of newly arrived North Korean refugees in South Korea exceeded 2,803 in 2008; it decreased to around 1,418 in 2016, reaching a total of 32,476 refugees for 20 years(1998–2018).¹ Since 2018, the number of refugees has decreased because North Korean–Chinese border surveillance has been tightened; however, the number of escaping upper class has increased.^1–4 As the number of North Korean refugees has gradually increased in South Korea, the social interest in their adaptation to South Korean society has increased accordingly.

Diverse factors such as their socio-economic environment and personal capacities affect North Korean refugees' adaptation to South Korean society; among these factors, mental health plays an important role. A large proportion of North Korean refugees have both physical and psychological trauma caused by the environmental factors associated with the threat to their survival in the process of immigrating to South Korea through a third country.² In many cases, these refugees experience post-traumatic stress disorder due to, for example, witnessing the public executions of others, hearing about starvation from family or relatives, being beaten, being punished for their political mistakes, and illnesses among their family members or relatives² They also experience mental stress caused by their need for economic independence, cultural differences, separation from their families, the language barrier, and discrimination in the settlement process. ^3–4 As a result, many refugees experience mental health problems such as clinical anxiety and depression.^5–9

Studies on the mental health problems among North Korean refugees have been conducted in order to identify the current situation of them and the factors influencing their situation. According to one study, which analyzed the prevalence and factors associated with mental health problems among 500 North Korean refugees, about 5% of the survey respondents showed post-traumatic stress disorder while 48% exhibited depression and anxiety. The study revealed that the experience of trauma caused by severe violence, threat to life, sexual violence, and the loss of intimate relationships was a major factor affecting their mental health.² Another study compared the traumatic experience, stress, hopelessness, and depression among North Korean refugees to low-income earners and other groups of residents in South Korea, revealing that the mental health of North Korean refugees was generally worse than that of low-income earners in South Korea.⁵ Likewise, previous studies have mostly analyzed the impact of personal characteristics and social and economic factors on the mental health of North Korean refugees.^2,10−11 However, there are few studies on the actual status of mental health knowledge among refugees from North Korea.

Mental health problems arising from the resettlement of immigrants, including North Korean refugees, are likely to stem from their negative experience before migration. These mental health issues have been linked to traumatic events, such as violence, harassment, and the lack of basic needs. In addition, the mental health of refugees is believed to be distinct from that of other traumatized populations, such as war veterans and sexual assault victims, due to their unique traumatic experiences.⁵ However, psychosocial factors, such as the lack of a sense of belonging, financial difficulties, discrimination, and the lack of information related to mental health, also play an important role. ⁵ In fact, some North Korean defector-residents lack mental health knowledge and do not have appropriate access to medical care. While it is not easy to cope with the mental health problems caused by social and economic factors, the problems arising from a lack of mental health knowledge can be resolved through institutional support and individual efforts to obtain such knowledge.

Since knowledge and attitude are meaningful factors in understanding and changing human behavior, social psychology argues that there is nothing as important in human behavior as knowledge and attitude. In fact, several studies have shown that a lower rate of psychiatric clinical visits is attributable to a lower level of knowledge regarding mental health disorders⁸, including information about mental illnesses, their symptoms, and their treatments. ^8–9 In addition, studies have shown that greater knowledge leads to less stigma^10–11. Moreover, acceptance and tolerance-based attitudes can reduce fear¹³. For instance, supportive and open-minded people may hire a person suffering from mental illness(es)¹⁴. That is, the level of knowledge could effects on the level of understanding mental illness. Therefore, many researchers have conducted studies on how knowledge and attitude affect human behavior.¹² In line with this trend, this study aims to identify the level of mental health knowledge among North Korean refugees and to investigate the effect of sociodemographic characteristics and level of mental health.

1. Study population

Given the fact that North Korean refugees are averse to exposing their identities and are generally not willing to respond to a questionnaire, we secured our targets through a snowball sampling method with the help of professional counselors at a regional center for refugees in the Seoul–Incheon area. Snowball sampling is a method that allows targets to introduce acquaintances as subsequent targets. This is a convenient sampling method. We interviewed adult refugees (over 19 years of age) who visited the regional center, explained our questionnaire during regular meetings at the center, and asked those who agreed to participate in the study to respond to our questionnaire. We sought participants who the refugees’ year of entry into South Korea, their gender, and their age to the greatest degree possible in order to account for any changes in their mental health awareness and attitudes. In terms of gender, 70% of our sample was female, and 30% was male, which is similar to the gender composition among all North Korean refugees. After describing the purpose of our study and explaining the instructions for our questionnaire to the professional counselors, we passed out preliminary questionnaires to five subjects with the aim of estimating the level of difficulty and the target’s understanding of our questionnaire for test. From August 1 to August 30, 2013, we conducted a questionnaire survey of 150 subjects and analyzed the data obtained from 138 respondents, excluding answers from 12 people who did not complete the questionnaire.

2. Variables

In our study, we adopted the knowledge measurement tools used in various research studies.^13–15 The knowledge measurement tools consisted of 30 items in total; seven items were used to measure knowledge about the causes of schizophrenia, five items judged knowledge about symptoms, eight items judged knowledge about medication, five items judged the knowledge about treatments, and five items judged knowledge about relapse. ¹⁵ Each question in our questionnaire was to be answered with 'yes', 'no', or 'I do not know'; if the answer was wrong, we gave a score of 0, and when the answer was right, we gave 1 point. In a previous study, to increase the validity of these measurement tools, the questions were pre-investigated among four schizophrenic patients' families, and two items that were not understood by the target were eliminated. As a result of this elimination, the study’s main analysis showed high validity and reliability.¹⁵ We also eliminated two items after finishing survey. Ultimately, a total of 28 items were used. The instrument used in this study was shown to reliable (Cronbach's alpha = .81).

In our study, a community attitude survey developed by Taylor and Dear (1981) was used with the CAMI (Community Attitudes toward the Mental Ill inventory)¹⁶, translated into Korean.¹⁷ This tool was composed of 10 sub-items, each of which consisted of four sub-domains: non-authority consciousness (e.g., “Mental hospitals are an outdated means of treating the mentally ill”), compassion (e.g., “The mentally ill have for too long been the subjects of ridicule”), social regulation (e.g., “A women would be foolish to merry a man who has suffered from mental illness, even though he seems fully recovered”), and community mental health concepts (e.g., “Residents should accept the location of mental health facilities in their neighborhood to serve the needs of the local community”). All 40 items were measured on a 5-point scale. The values from the questions on negative attitudes were totaled as-is, while those from the questions on positive attitudes were totaled inversely; thus, the higher the total score, the more positive the respondents’ attitudes were. The validity and reliability of this tool was verified in previous studies^16–17, and the reliability of this tool was a Cronbach's alpha score of .81.

Among the general characteristics of our subjects, we classified marital status into single, married, or unmarried. Final North Korean educational background was classified as follows: In-Min school (elementary school), senior-middle school, college, or university and above. Educational attainment in South Korea was classified as follows: no formal education, elementary and middle school, high school, or college and above. Religion was classified as yes or no. Economic activity (e.g., a job) was also classified as yes or no. Monthly income was classified as less than KRW 1 million, more than KRW 1 million but less than 2 million, or KRW 2 million or more. The entry year to South Korea and the final defection year were measured using continuous variables. This study was conducted by the IRB (IIT-2013-287, Inje University) after our subjects received a preliminary explanation about our research and provided consent to participate in the study.

3. Statistical analysis

The demographic characteristics of the subjects are presented as a constant and as a percentage. Mental health knowledge and attitudes toward mental illness were calculated as the mean and standard deviation. A t-test and one-way ANOVA were used to analyze the differences between mental health knowledge and attitudes towards people with mental illnesses according to demographic and social characteristics. A hierarchical regression analysis was performed in three stages to measure the effects of mental illness knowledge on attitudes towards mentally ill patients. In the first model, the impact of the demographic and social characteristics of North Korean refugees on mental health attitudes was measured. In the second model, the variables related to North Korean refugees' entry into North Korea were added. Then, in the third model, the effect of mental health knowledge on mental health attitudes was measured by adding the variables. The data were analyzed using SPSS Win 18 (SPSS Inc., Chicago, IL, USA).

Of the 138 subjects, 39.1% were male, and 60.9% were female, and the average age of the subjects was 44.62. In terms of the subjects’ education level in North Korea, 59.4% graduated from In-Min school (elementary school). We examined the refugees’ level of education in South Korea after defection and found that 24.6% of them had entered a university in North Korea to continue their education. However, 58.7% of the subjects did not answer the question on education. About 67.4% of the respondents followed a religion, and 63.0% experienced economic activity. The refugees’ monthly average personal income was less than KRW 2 million. The average year of entry into South Korea was 2006, while the last year of defection was 2003, with an average of 3 years of overseas stay (Table 1).

Table 1

General characteristics of the subjects.
Variables		n(%) or M ± SD (Min, Max)
Age		44.62 ± 15.7 (19, 87)
Gender	male	54 (39.1%)
Gender	female	84 (60.9%)
Marital Status	single	38 (27.5%)
	married	64 (46.4%)
	unmarried (divorced/widowed/separated)	28 (20.3%)
Education in North Korea	No school	10 (7.2%)
	In-Min school	82 (59.4%)
	Middle and high school	26 (18.8%)
	University graduation	20 (14.5%)
Education in South Korea	No answer	81 (58.7%)
	Elementary / middle school	7 (5.1%)
	high school	15 (10.9%)
	University graduation	34 (24.6%)
Religiously affiliated	Yes	93 (67.4%)
Religiously affiliated	No	45 (32.6%)
Economic activity	Yes	80 (63.0%)
Economic activity	No	35 (37.0%)
Monthly income (KRW)	less than 1 million	52 (37.7%)
	1 million ~ 2 million	52 (37.7%)
	more than 2 million	15 (10.9%)
South Korea entry year		2006 (1998, 2013)
Final defection year		2003 (1998. 2013)

In analyzing the differences in the scores on mental health attitudes resulting from social demographic characteristics, we found that the year of entry into South Korea was a significant factor. For compassion, the differences between the groups in terms of gender and monthly average income were shown to be significant, and the difference in terms of final academic achievement in North Korea was also significant between the groups. The difference between the groups in terms of their year of entry into South Korea was, likewise, significant. In the case of attitudes towards social life regulation, there were no significant general characteristics at a 95% level, excluding the gender factor, but the differences between the groups in terms of final educational achievement in South Korea and year of entry into South Korea were significant at a 95% level. For community mental health attitudes, a difference between the groups with different marital statuses was confirmed, and there were also differences between the final education levels in South Korea and North Korea (Table 2).

Table 2

Mental health attitudes by the socio-demographic characteristics of the subjects.
Variables	T(F)
	CAMI
	Non-authority consciousness	Compassion	Social life regulation	Community mental health attitude
Gender	0.286	3.077*	1.972*	0.959
Monthly income	2.123	3.589*	1.919	2.197
Religion	0.702	0.607	0.257	0.512
Marital status	0.600	2.339	2.008	3.861*
Economic activity	0.102	1.391	0.174	0.114
Final education in North Korea	0.613	6.362*	0.854	4.195*
Final education in South Korea	8.103*	1.560	5.353*	2.475
South Korea entry year	1.547*	0.750	2.626*	1.300
Final defection year	0.845	1.065	1.229	0.534
*<.05.

In order to understand the impact of knowledge about mental health on the refugees’ mental health attitudes, it is necessary to examine the effects of knowledge on mental health, including non-authority consciousness, compassion, social life regulation, community mental health, total points, and knowledge points. The results of our hierarchical regression analysis are shown in Table 3 and Table 4. The positive correlations between the mental health attitudes of North Korean refugees and the level of their knowledge were significant.

Table 3

The correlations between mental health attitudes and individual characteristics.
		Age	Knowledge level
CAMI	Non-authority consciousness	− .073	.286^**
	Compassion	.043	.212^**
	Social life regulation	− .115	.250^**
	Community mental health attitude	.029	.215^**
*<.05.

Table 4

The effect of mental health knowledge and individual characteristics on mental health attitudes.
	CAMI
	Non-authority consciousness			Compassion			Social life regulation			Community mental health attitude
	Model 1(ß)	Model 2(ß)	Model 3(ß)	Model 1(ß)	Model 2(ß)	Model 3(ß)	Model 1(ß)	Model 2(ß)	Model 3(ß)	Model 1(ß)	Model 2(ß)	Model 3(ß)
Age	.120	.110	.123	.277*	.279*	.304*	.038	.022	.046	.125	.117	.133
Gender	− .019	− .011	− .024	− .093	− .092	− .114	− .051	− .057	− .074	− .083	− .086	− .098
Monthly income	.192*	.158	.142	.205*	.210*	.169	.108	.062	.035	.152	.128	.107
Religion	.147	.155	.149	.024	.018	− .003	.073	.091	.084	.045	.052	.047
Marital status	− .072	− .074	− .085	− .219	− .219	− .242*	− .082	− .094	− .110	− .116	− .123	− .137
Economic activity	− .005	-0.48	− .044	.072	.083	.090	− .052	− .120	− .113	− .052	− .087	− .085
Final education in North Korea	.100	.092	.076	.082	.086	.077	.049	.045	.022	.170	.167	.151
Final education in South Korea	.344*	.331*	.286*	.165	.168	.097	.282*	.270*	.204*	.104	.093	.045
South Korea entry year		− .450*	− .454*		.081	.090		− .489*	− .494		− .280	− .287
Final defection year		.232	.244		− .027	− .011		.173	.187		.113	.128
Knowledge level			.123			.236*			.197*			.150
R square	.180	.266	.278	.154	.158	.203	.114	.240	.271	.094	.135	.154
F for R square	2.311*	4.781*	1.359	1.844*	.165	4.484*	1.344	6.794*	3.530*	1.092	1.780	1.762
*<.05.

The purpose of this study was to better understand North Korean refugees’ socio-demographic characteristics and their levels of mental health knowledge, as well as to investigate how these factors affect their mental health attitudes. According to our findings on North Korean refugees’ knowledge of mental health, the correct answer rate was 12.8 points (out of 28), which was below 50 points when converted to 100 points.

Once North Korean refugees arrive in South Korea and the South Korean government decides to grant them protection, they are first placed in a settlement support center known as the Hanawon. At the Hanawon, an adaptive education program is provided to the refugees through a 392 hour program that lasts 12 weeks. Regular educational programs include emotional stability and health promotion programs, such as psychological tests, group counseling, and health screening. There are also other programs that help refugees understand South Korean society, such as sessions on democracy, the market economy, and Korean history. The center also provides career guidance programs, such as aptitude tests and a job description session. When refugees complete their training at Hanawon and are settled in their new residences, they continue to receive training at the Regional Adaptation Center (Hana Center). The types and methods of education programs operated by each Regional Adaptation Center differ from center to center, but, in essence, they include daily life improvement programs, career exploration programs, and vocational preparation programs necessary for understanding life within the community. Although the Hanawon serves as a training facility to help refugees maintain emotional stability and nurture cultural heterogeneity, most refugees are not provided with knowledge about mental health. According to a previous study on North Korean women who escaped from North Korea, many North Korean women were found to be suffering from chronic diseases due to a lack of health awareness.¹⁸

Our findings on the effects of socio-economic characteristics and mental health knowledge on mental health attitudes are as follows: The higher refugees’ education level in South Korea, the more negative their perceptions are of social regulation. Also, the earlier their entry into South Korea (i.e., the longer they have resided in South Korea), the more negative their perceptions of social regulation. We discovered that the refugees tend to focus more on free will over regulation. Also, the higher the percentage of their knowledge accuracy, the greater their compassion and the more negative their views on social regulation. Final educational achievement in South Korea and the year of entry into South Korea can be seen as surrogate variables to measure socialization in South Korea. Therefore, we can assume that a higher level of socialization in South Korea and a higher level of knowledge of mental health result in a more negative perception of regulations on mental illness. This socialization into South Korea was an important determinant of North Korean refugees' positive perceptions of mental illness. This can be interpreted as a positive change, as refugees become more socially integrated and acquire more education and knowledge.¹⁹ In terms of such education and knowledge, knowledge of mental health among North Korean refugees was significant only when it comes to compassion and social life regulations. The higher their knowledge of mental health, the more positive their attitudes became towards mental illnesses because they better understood them and held negative views on how they regulated their lives. This is consistent with previous studies showing that mental health workers with a high level of knowledge about mental health have a higher level of compassion and negative views toward social life regulations than those with a low level of knowledge.²⁰ Otherwise, the higher their knowledge of mental illnesses, the more positive the respondents’ perceptions of them.

Based on the results of this study, we make the following suggestions to improve the mental health of refugees from North Korea. First, there is a need to run regular education programs to enhance mental health knowledge among North Korean refugees. Because refugees’ knowledge of mental health affects their attitudes, which in turn affects their behavior, mental health knowledge education must come first. Second, it is necessary to provide policy support for North Korean refugees so they can receive high-quality higher education in South Korea. Considering that the proportion of North Korean refugees who graduated from college in South Korea is less than half that of South Koreans, it is necessary to expand the window of opportunity for higher education so that North Korean refugees can settle more effectively into South Korean society.

While previous studies related to the mental health of refugees measured the socioeconomic factors affecting depression, stress, and anxiety, our study is significant because it examines the level of mental health knowledge, as well as the socio-economic factors, of North Korean refugees and analyzes the effects of these factors on their mental health attitudes. Nevertheless, this study has certain limitations. First, this study was conducted on 138 North Korean refugees living in the Seoul–Incheon area. Therefore, it may not be appropriate to generalize our findings to all North Korean refugees living in different regions of South Korea. Second, there is a representation problem inherent in our sampling. Since our study used the snowball sampling method, it is possible that the bias within the sample may have affected the results of the study. The use of the snowball sampling method was an inevitable choice due to the closed nature of North Korean refugees. However, since one of the limitations raised in the previous studies is the problem of the representativeness of the sample, future studies should develop a method that will secure a more representative sample. Third, this study did not include mental health promotion behaviors. In this study, only the mental health knowledge and mental health attitudes of refugees from North Korea were examined. If behaviors that promote mental health are considered in the future, not only the influence of mental health knowledge on mental health attitudes but also the effect of mental health attitudes on actual mental health promotion behaviors can be understood more systematically. This knowledge will provide useful foundational data to help develop mental health promotion and intervention programs for North Korean refugees.

CAMI (Community Attitudes toward the Mental Ill Inventory)

Ethics approval and consent to participate

This study was conducted by the IRB (IIT-2013-287, Inje University) after our subjects received a preliminary explanation about our research and provided consent to participate in the study.

Consent for publication

Not applicable

Availability of data and materials

The datasets used during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable

Authors' contributions

EJ analyzed and interpreted the refugees’ data regarding psychological knowledge and mental status. SW was a major contributor in writing the manuscript. All authors read and approved the final manuscript."

Acknowledgements

Not applicable

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Association of refugees’ knowledge of mental illness and their attitudes towards mental illness

Status:

Journal Publication

Version 1

Abstract

Introduction

Methods

1. Study population

3. Statistical analysis

Results

Discussion

Abbreviations

Declarations

Competing interests

Funding

Authors' contributions

Acknowledgements

References

Status:

Journal Publication

Version 1