Mental Health Understanding from Culture Perspective: A Study of

Lay People Mental Health Literacy

Lina Cuwandayani and Anita

Novianty

Faculty of Psychology, Universitas Kristen Krida Wacana (UKRIDA),

Jl. Tanjung Duren Raya No.4, Jakarta Barat, Indonesia

Keywords: Chinese, Culture, Depression, Lay People, Mental Health Literacy, Schizophrenia.

Abstract: The gap between the prevalence and the access to professional treatment of mental disorder was one of the

biggest problems that acknowledged by health professionals. Low in mental health literacy was one of the

factors that contributed to prohibiting lay people to seek help. Culture has to get more attention in mental

health discussion because it is probably related to mental health literacy aspects such as mental disorder

recognition, belief about the cause of the mental disorder, stigma, even the help-seeking. In this study, we

want to explore the mental health understanding from the sample of Chinese people's perspectives in

Jakarta, Indonesia. The participants in this study were 130 people consisted of 85 women, 45 men (ranged

14-65 years old). The instruments to collect data in this study were two vignettes (depression and

schizophrenia). The method to measure data was descriptive analysis. The result showed the mental health

literacy of Chinese lay people was low, where Chinese culture mainly contributed to constructing beliefs

about the cause of the mental disorder and the decision to seek help. This study implied the study of mental

health should consider the culture to arrange a better mental health literacy program and help-seeking

system.

1 INTRODUCTION

Jorm (2000) introduced mental health literacy as

public knowledge and beliefs about mental disorder,

which consisted of recognition or labeling mental

disorder; (b) The knowledge and belief about the

cause of mental disorder; (c) The knowledge and

belief about self-help and professional help’s belief;

(d) and stigma towards mental disorder.

Some studies showed a trend that mental health

literacy in developing countries relatively low

compared to developed countries (Loo & Furnham,

2012; Kim et al., 2006; Wong et al., 2017). The

culture was one factor that related to symptoms

recognition, belief about the cause and the way to

seek help related to mental disorder. The concept of

mental health from the Western perspective

probably unacceptable in some non-western

countries because of the cultural tradition that would

be a proximal cause for the lack of ability to

recognize the symptoms (Novianty & Hadjam,

2017).

Race, ethnicity, and religion have a strong impact

on individual health and well-being. The cultural

background is important to be considered because

the concept of mental health was intertwined by

context, individual and the cause of the problem.

Mental disorders, such as depression, anxiety,

dissociative symptoms have a broader explanation

from a cultural perspective that was not seen as

health problems, instead of the challenge of

individual, morality issue, or disharmony between

family or community (Kirmayer & Swartz, 2014).

The severe mental disorder was considered a

problem in every culture, but it was addressed as

different perspectives that usually related to religion,

spirituality, and morality issue (Kirmayer &

Bhugra, 2009). Therefore, global mental health

should address the common mental disorder not

separated from diverse psychosocial context. Most

recognition or labeling of mental disorders could be

found in any kind of label, culture and diverse ways

of seeking help (Jacob & Patel, 2014).

Chinese culture in Indonesia has experienced

acculturation. Amanah, Bahari, and Fatmawati

(2014) studied the acculturation between Chinese

and Malay in Pontianak in terms of languages is

syncretistic, because of the Chinese Language in

304

Cuwandayani, L. and Novianty, A.

Mental Health Understanding from Culture Perspective: A Study of Lay People Mental Health Literacy.

DOI: 10.5220/0009594703040309

In Proceedings of the 1st International Conference on Health (ICOH 2019), pages 304-309

ISBN: 978-989-758-454-1

Indonesia was not only Mandarin but also had the

other four languages, such as Hokkien, Hakka, Teo-

Chiu, Kanton. Therefore, Chinese in Indonesia has a

significant difference between one another because

they have their own language that probably was not

understood by others. Currently, Chinese in

Indonesia was divided into two categories namely

Tionghoa Totok and Tionghoa Peranakan (Tan,

2008).

Chinese’s traditional concept about mental

health was encouraging Chinese people to

emphasize self- development to control the emotion,

to avoid interpersonal conflict and to maintain

harmony with other people. The great philosophers,

such as Confucius, were strongly influenced by

Chinese ideology and culture. Confucius taught

eight dharma virtues ”八德” (pinyin: Bā dé), such as

“孝”(pinyin: Xiào), means filial piety, “悌” (pinyin:

Tì) means humble, “忠” (pinyin: Zhōng) means

loyalty, “信” (pinyin: Xìn) means trustworthy, “禮”

(pinyin: Lǐ) means manner, “義” (pinyin: Yì) loyal

friends, “廉” (pinyin: Lián) means sincere heart, “恥

” (pinyin: Chǐ) means introspective. Chinese people

believed that people with a mental disorder was a

shame for family or having bad Fēngshuǐ. Family is

very essential in Chinese culture, not only as basic

social organization but also as a support to solve the

problem. Family is an important aspect related to

individual mental health (Tseng, Lin, & Yeh, 1995).

Traditional Chinese medicine based on the

concept of Yin and Yang, which formulated an

internal mechanism that works in the human body.

The understanding of health from traditional Chinese

medicine based on harmony between Yin and Yang

(Yip, 2003). Some Chinese people more prefer to

seek help from a traditional healer, drink herbal

medicine and tonic to cure the sickness rather than

finding psychosocial intervention and professional

help (Yip, 2003).

Most of the research about mental health literacy

currently constructed by Western perspectives,

especially according to the psychiatry field (Jorm,

2000; Kutcher, Wei, & Coniglio, 2016). Similar to

them, research about mental health literacy in

Indonesia also emphasized psychiatry definition to

measure the knowledge and belief about the

label, the cause of mental disorder and help-seeking.

The aim of this study was to measure mental health

literacy according to the mental health literacy

concept by Jorm (2000), as well as explore more the

intertwined Chinese culture perspective in each

aspect of the mental health literacy concept.

2 METHOD

The quantitative approach was applied in this study

with descriptive analysis. Two vignettes

(depression & Schizophrenia) were used as

instruments in which adapted from Jorm (2000), to

explore the recognition, belief about the cause of the

mental disorder, the way to help people with mental

disorders and stigma. Data were collected by an

online questionnaire using google form which

consisted of informed consent, personal information,

depression and schizophrenia vignettes following

eight questions of mental health literacy aspects.

2.1 Participants

Participants were Chinese adolescents (aged 14-22

years old, n=76) and Chinese adults (aged 23-65

years old, n=54) that were recruited by snowball

sampling technique. Participants who were filled

online questionnaires (n=130; 45 females; 85 males)

which consisted of Hakka/Khe (n=41), Kanton

(n=2), Hokkian (n=40), Tiochiu (n=9), dan

Peranakan (n=52).

2.2 Research Instrument

The vignettes that were used in this study was an

adapted story about the mental disorder (depression

and schizophrenia) that have been translated into the

context of Chinese people in Jakarta, Indonesia. The

questions that were following the vignettes consisted

of the aspect of mental health literacy by Jorm

(2000). The vignettes were validated with four

experts to confirm if all symptoms already fulfilled

the diagnostic criteria in DSM-V, then Aiken’s

V was applied to check the validity of all vignettes

that were used in this study.

Table 1: Aiken’s V Value for All Vignettes.

Type of Vignettes Aiken-V Conclusion

Depression Vignette for

Adolescent

0,625 Valid

Schizophrenia Vignette for

Adolescent

0,875 Valid

Depression Vignette for

Adult

0,625 Valid

Schizophrenia Vignette for

Adolescent

0,750 Valid

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2.3 Data Analysis

Data were coded into some categories according to

previous literature, then descriptive statistics in

percentage was applied in every theme.

3 RESULT

In this study, 130 data were collected in which

divided into adolescent groups and adult groups.

Data consisted of participant’s responses in each

aspect of mental health literacy.

3.1 Recognition of Mental Disorder

In the adolescent group, participants who are able to

recognize and give the psychiatric label correctly for

depression vignette (56.6%) were higher than for

schizophrenia vignette (27.6%). In the adult group,

most participants are able to recognize of psychiatric

label correctly for depression vignette (38.8%)

but are not able to recognize the schizophrenia

vignette with a psychiatric label correctly (59.2%).

Table 2: Recognition of Mental Disorder.

Themes

Adolescent Adult Group

Group

D S D S

(%) (%) (%) (%)

Correct Psychiatric Label 56.6 27.6 38.8 1.8

Incorrect Psychiatric 13.2 42.1 35.1 59.2

Label

Incorrect Label 30.2 29.0 26.1 39.0

Not know 0 1.3 0 0

Notes: D: Depression; S: Schizophrenia

3.2 The Belief about the Cause of

Mental Disorder

In explaining the cause of the mental disorder, most

participants in the adolescent group focus on

personal factors as the cause of depression (60.6%)

and schizophrenia (65.7%). It is really similar to the

adult group that most participants tend to focus on

personal factors in explaining the cause of

depression (68.5%) and schizophrenia (63%) as

well. The personal factor such as lack of doing a

ritual, lack of pray, lack of wise seems related to the

culture of participants and the paradigm of well-

being in Chinese culture, which is social support,

especially family as the main value in Chinese

culture.

Table 3: The Cause of Mental Disorder.

Themes

Adolescent

Group

Adult Group

(%)

Social 35.5 19.7 24 24.1

Personal 60.6 65.7 68.5 63

Biological 1.3 1.3 2 0

Mystical 1.3 9.2 0 9.2

Not know 1.3 0 0 0

Unidentified 0 4.1 5.5 3.7

Notes: D: Depression; S: Schizophrenia

3.3 Help-seeking

Most participants in the adolescent group try to seek

help informally for depression vignette (80.3%), and

it was higher than the schizophrenia vignette

(42.1%). Interestingly, it also similar to the adult

group in which most participants try to seek help

informally for depression vignette (88.8%) and

schizophrenia vignette (55.6%) as well.

Table 4: Help-seeking of Mental Disorder.

Themes

Adolescent

Group

Adult Group

(%)

Formal 17.1 39.5 10.1 31.5

Semi-formal 1.3 15.8 1.1 11.1

Informal 80.3 42.1 88.8 55.6

Unidentified 1.3 2.6 0 1.8

Notes: D: Depression; S: Schizophrenia

3.4 The Attitude towards People with

Mental Disorder

In this aspect, we want to explore the attitude of

laypeople towards people with depression and

schizophrenia. It was found out that most

participants are willing to be friends with people in

depression vignette (97.4%) in the adolescent group

and (100%) in the adult group with familial bonding

as the main reason. Whereas, around 42.5% of

participants in the adult group are willing to be close

with people in schizophrenia vignette. The

stigma for schizophrenic people such as dangerous,

uncontrollable, able to attack, stink, unorganized

look are the main reason for participants are not

willing to be close with them.

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3.5 Public Opinion about People with

Mental Disorder

In this aspect, we want to explore how participants

perceive what other people think and feel about the

individual with depression and schizophrenia. In the

adolescent group, most participants perceive people

will give labels toward people in depression vignette

as a common label such as stress (15.7%). They

think the other people will consider depressive

symptoms as an introvert, weird, and weak. Whereas

people with schizophrenia will be considered as

crazy (37%), mental illness (16.6%), annoying

(12.9%), weird (11.1%), possessed by the spirit

(1.8%), and feeling fear (15.1%).

3.6 Chinese’s Perspective in Mental

Health Literacy

In the recognition of the mental disorder, there is a

participant using Mandarin Language to respond to

depression vignette, such as 神情病 (pinyin:

Shénjīngbìng, which means neurotic. In the belief

about the cause of the mental disorder aspect, the

absence of social support, such as family and close

friend support was perceived as the cause of the

mental disorder. It was related to Chinese value that

prioritizes family support as one of the factors of

individual well-being. Other causes were related to

eight dharma virtues that were taught by Confucius

such as lack of worship, lack of discipline, and

untrustworthy. In a help-seeking aspect, for

depression vignette, participants tend to seek help

from a traditional healer (such as tabib, sinshe, thiau

tang, monks), drinking hu water, go to biokong,

drink herbal, praying in Vihara, or fengshui. In

Schizophrenia vignette, participants also tend to

seek informal help-seeking, such as doing kwamia,

lokthung worship, go to Biku or monks.

4 DISCUSSION

Mental health literacy of Chinese people in this

study was low in both groups (adolescent and adult).

It was indicated by the lack of recognition of the

mental disorder, the belief about the cause of mental

disorder that mostly explained by the personal

factor, informal help-seeking that was mostly

accessed, as well as the stigma that was perceived by

participants toward people with a mental disorder.

Even though participants in the adolescent group

tend to recognize depression vignette with

psychiatric labels correctly, rather than the adult

groups which tend to lack recognition of psychiatric

labels for depression and schizophrenia vignette.

Chinese in Indonesia has been assimilated with

other cultures that affect their perception and

behavior in daily life. The recognition of depression

and schizophrenia from the Chinese perspective

mostly used common labels. There are some labels

in the Chinese Language to describe people with

mental disorder such as 神經病 (pinyin:

Shénjīngbìng; translation: neurotic) which has a

negative connotation in daily life.

According to DSM-V, there are multiple causes

for depression such as genetics, childhood trauma,

medical condition, brain structure and function,

psychosocial, drugs and alcohol consumption.

However, participants in both groups of this study

tend to explain the cause of the mental disorder

(depression and schizophrenia vignette) by personal

factors. It seems related to the Confucius as a source

of guidance for Chinese people about the way of

living in daily life. Family support was the main

factor for Chinese people that indirectly having an

important role in Chinese people’s mental health

model (Tseng, Lin, & Yeh, 1995).

The lack of mental disorder recognition as a

psychiatric issue and the belief about the cause of

mental disorder by the personal factor directed

participants to seek informal help rather than

professional help. This finding is comparable with

findings of similar studies conducted by Novianty

(2017), which also found out that public stigma was

higher in schizophrenia vignette rather than

depression vignette in both groups. There was a

discrepancy between the participant’s attitude and

participant’s perceived attitude of others toward

people with a mental disorder. Participant’s attitudes

toward people with mental disorders tend to

maintain a close relationship with them, on the other

hand, the participants' perceived others have a

negative attitude toward people with a mental

disorder.

Wong et al (2017) stated that culture has

important role in shaping the belief of the cause of

mental disorder and help-seeking. This study also

found out similar findings in which culture has an

important role in the explanation of the cause of the

mental disorder, such as family issues, social

pressure, not having close friends or mystical factors

such as possessed by ancestor’s spirit, the imbalance

between yin and yang. All those responses were

related to the Chinese’s value of social and family

support as part of the individual well-being. Even

Mental Health Understanding from Culture Perspective: A Study of Lay People Mental Health Literacy

307

there is one participant which identified the cause of

the mental disorder was being a minority.

The help-seeking from the Chinese’s perspective

that was found out in this study using ritual or

traditional healing. Some participants believed

amulet paper (hu) could heal a mental disorder.

Another belief was kuamia or suanming (算命;

pinyin: Suànmìng), which able to detect our health

and well-being by analyzing the date and time of

birth using shio (Qian, 2015). This method to be

believed could predict our health condition and

prevent from scarce diseases. Another belief was by

rituals such as lokthung. Informal help-seeking that

was mostly accessed by Chinese participants in this

study probably happened because Chinese is one of

the minorities ethnic in Indonesia. according to

Gopalkrishnan and Babacan (2015), the minority

ethnic tend to seek help for mental disorder issues to

informal help-seeking rather than the majority in a

country.

The role of culture in mental health (how

laypeople recognize, understand, belief about the

cause, type of help-seeking for mental disorder

issues) was a consequence of their cultural history,

racism, and even stigma towards culture

(Gopalkrishnan & Babacan, 2015). The way of lay

people in understanding the mental health model in

different ethnicities showed similarly result that

most indigenous participant in various ethnicities

hardly recognize, identify, analyze the cause and

seek to professional help because they will tend to

try to access their cultural narrative concept in

explaining the issue and seeking traditional healer

(El-Islam, 2008; Kpanake, 2018; Rochford, 2004;

Yip, 2003).

According to Kirmayer and Swartz (2014),

culture affects how people perceive, express, explain

the symptoms and interpret the cause of the

symptoms, the pattern of help-seeking, even

social stigma. There is a construct gap between how

laypeople understand the mental disorder issue and

the psychiatry field constructing the issue. It does

not necessarily mean one against another, yet we

have to understand both constructs to find a better

solution.

We also found out the gap between adolescent

and adult groups was significantly different in their

ability to recognize the vignette using the

psychiatric label. The adolescent group is able

recognizing the vignette using a psychiatric label

correctly than the adult group. Another point we

have to focus on the term “your family/close friend”

in vignette seems to affect the participant’s attitude

toward a person in depression and schizophrenia

vignette. Most participants are willing to maintain a

close relationship with him, because of familial

bonding.

This study implies that culture affects how lay

people, specifically in this study was Chinese

participants, addressing, interpreting the cause,

the way to seek help and stigma towards symptoms

expressed by people with a mental disorder.

Therefore, culture should be considered in

promoting the awareness of mental health issues,

even in diagnosing the mental disorder.

5 CONCLUSIONS

There is a discrepancy of knowledge and belief

about representative symptoms of depression and

schizophrenia between the psychiatric field and lay

people’s understanding of the mental health issue.

The way Chinese lay people construct the label, the

interpretation of cause, the way to seek help and the

attitude towards people with a mental disorder were

affected by their culture. Specifically, culture mainly

affects the beliefs about the cause of the mental

disorder and the way people try to seek help.

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