The purpose of this study was to examine the specific likely reasons for increased stress levels among ethnic minorities in Hong Kong. By using the means of a survey and focus group, this study used reasons for elevated stress levels that have been identified somewhere through the use of the literature. The reasons that were identified through the review of the literature including the following: (a) discrimination, (b) struggling to adapt to the local culture and language, (c) low socioeconomic status, (d) lower social position and impaired family functioning. Before conducting the survey, the author distributed a validated scale to measure stress levels among ethnic minorities. Those whose stress levels were more than 150 points using the scale measurement were included in this study. The survey was then sent to them which had seven questions, and four of them were touching on the four reasons listed above. Eighty-Nine (N=89) ethnic minorities responded to the survey without skipping any question. The survey responses were analysed using SPSS 20.0 whereby it was determined that the elevated stress levels among ethnic minorities were significantly contributed by the struggle to adapt to the local culture and learn Cantonese. A focus group of ten members was conducted to reinforce the survey findings where it was discovered that struggling to speak Cantonese and adapt to the local language and discrimination are significant contributors. Therefore, it was concluded that struggling to adjust to the local culture and language contributed majorly to the increased stress levels among ethnic minorities and that discrimination also played a role even if it is insignificant. Therefore, strategies focusing on how to reduce stress levels among ethnic minorities should be specific and focused on the particular reasons identified.
CHAPTER ONE: INTRODUCTION
1.1 Background
According to the World Health Organisation (WHO, 2018), mental health is an essential aspect of a high-quality life in the modern world. Life has become more complicated than before in the recent times, and people require a functional ability to stay well and be able to successfully cope up with the normal stresses of life as well as complete daily tasks productively. Therefore, countries should be able to detect mental illness like high stress levels promptly, promote mental health in public, prevent mental health illnesses as well as offer timely treatment and rehabilitation for those in need. However, building a mental-health friendly environment is extremely challenging because the seriousness of mental health problem might differ from one geographical location to another and from one social group to another.
According to a 2017 mental health review report that was published by the Food and Health Bureau of Hong Kong Special Administrative Region, despite a well organised and well equipped public health system in Hong Kong, mental health problems are not uncommon. As WHO (2018) maintained, mental health is always beyond typical medical attention. It is also all over the news that Hong Kong is currently facing a mental health crisis because of its high population (more than 7 million inhabitants) hence immense day-to-day challenges that most people fail to cope up with (Heifetz, 2016). More particularly, a survey that was conducted between 2010 and 2013 revealed that the typical mental illnesses in this city that are affecting about 13% of Chinese adults aged between 16 and 75 years are anxiety and depressive disorders that express in different ways such as a mix of both or individual occurrences (Lam et al., 2015). Moreover, according to a report by the Department of Health (2015), about 4.8% of residents aged between 16 and 64 years were suffering from a diagnosable severe mental health problem in 2014. The number of mental health patients has also been on the rise; for example, between 2011 and 2016 alone, there was an increase of around 30,000 patients demanding for the services of the Hospital Authority (HA) (Hong Kong Special Administrative Region, 2017) which shows that mental health is a significant concern in this city.
Conversely, studies (e.g., Leung et al., 2008) have shown that the seriousness of mental health problems in this region depends on ethnicity, age, and social class. For instance, among children and adolescents, the problem is of more concern because they suffer from a wide range of mental health illnesses such as conduct disorders, attention deficit hyperactive disorder, depressive disorders, oppositional defiant disorder, etc. (Leung et al., 2008). In 2005, Kessler and his colleagues released an article that established that promotion of mental health and prevention of mental health illnesses before the age of 14 years reduces psychological health problems like elevated stress levels in adulthood by more than 50%. Therefore, the current mental health crisis for children and adolescents in Hong Kong suggests that this problem will persist for a longer duration than expected despite the ongoing efforts of the Government.
Several American and UK studies (e.g., Corrigan & Watson, 2007; Jimenez et al., 2013; McGuire & Miranda, 2008) have also confirmed that mental health and ethnicity are intimately connected. In a study that utilised evidence from South Asia, it was also discovered that psychiatric disorders vary significantly between ethnic groups among rural Asian population (Hawes, Axinn & Ghimire, 2016). More particularly, the main reason behind mental health differences among different ethnic groups (in most countries such as America and Europe) is the issue of disparity of mental health services. Hawes et al. (2016), however, did not identify the main reasons for mental health ethnic variations in rural Asia hence one can tentatively claim that the reasons might differ from one geographical region to another which is why it is essential to investigate different reasons for each specific area.
1.2 Statement of the Problem
Mental health such as high stress levels can result in stigma (Knaak, Mantler & Szeto, 2017). Studies (e.g., Clement et al., 2014) have confirmed that this stigma can impede mental health illness patients from seeking professional help. This can worsen mental health cases hence the need for timely intervention and treatment of those in need. Stigmatisation in healthcare is closely related to discrimination (Henderson et al., 2014) which implies that ethnic minorities who are at risk of bias in the society are more likely to have less access to high-quality healthcare than their majority counterparts. In Hong Kong, discrimination against ethnic minorities (immigrants from Mainland China and South and Southeast Asia) is prevalent today and is becoming even more severe because of racial and cultural differences (Ye, 2016). Ethnic minorities are discriminated almost in every sector ranging from banking to healthcare (Lee & Chung, 2018), which shows that they are the most affected by mental health problems besides the fact that high levels of stigmatisation prevent most of them from seeking professional help. From a psychiatric perspective, the evidence base for mental health problems among the minorities is rigorous. However, from a sociological perspective, little is known about the stress levels of ethnic minorities in Hong Kong. Instead, surveys have only established the severity of mental health illness at a regional level, e.g., the number (or proportion) of Hong Kong residents suffering from mental health problems (Moon, 2017).
It is parallel with the natural law that an ethnic group of the few in the society is prone to discrimination, but it is against the tenets of human rights that everybody in the community is equal. Therefore, it is unacceptable for ethnic minorities to be discriminated and stigmatised as they are barriers to access to quality healthcare. As this is problematic, it is the responsibility of policymakers to ensure ethnic minorities in Hong Kong receive the same level of quality of mental health care to their majority counterparts. Furthermore, it is typical that finding a solution to a problem starts with investigating the causes of the problem. A new approach to doing this is to look into the factors causing stressful life among ethnic minorities in Hong Kong. Therefore, based on the best level of knowledge of the author, no study has investigated the proposed problem in Hong Kong hence this will be the first research study to examine the problem.
1.3 Aims and Objectives
The main aim of this study is to determine factors contributing to stressful life among ethnic minorities in Hong Kong. In order to fulfil this aim, this research study focused on the following objectives:
i. Determine if discrimination on ethnic grounds is a contributing factor to stress levels among ethnic minorities in Hong Kong.
ii. Determine if socioeconomic status is a contributing factor to stress levels among ethnic minorities in Hong Kong.
iii. Determine if struggling to adopt to the local culture is a contributing factor to stress levels among ethnic minorities.
iv. Determine if lower social position and poor family functioning are contributing factors to stress levels among ethic minorities in Hong Kong.
1.4 Hypotheses
In the place of research questions, this study adopted null hypotheses based on the findings of previous research studies. They are as follows…
H0 (1): Discrimination on ethnic grounds reduces stress levels among ethnic minorities.
H0 (2): Low socioeconomic status among ethnic minorities in Hong Kong reduces stress levels among ethnic minorities.
H0 (3): Struggling to adopt to the local culture in Hong Kong reduces stress levels among ethnic minorities.
H0 (4): Lower socioeconomic status and poor family functioning among ethnic minorities in Hong Kong reduces their stress levels.
CHAPTER TWO: LITERATURE REVIEW
2.1 The Importance of Mental Health
Based on the WHO definition of mental health, it is evident that it is an important aspect not only to the life of an individual but also the whole community. Individuals are the basic units of a community, and if a large proportion of individuals in a given community are unable to realize their potential and unable to work productively, the whole community is more likely to be affected profoundly in many ways. The main importance of good mental health is the fact that it improves the quality of life. It promotes peace of mind hence enabling people to live their lives to the fullest. Examples of mental health problems that reduce the quality of life significantly include depression, anxiety, and addiction, etc (Connell, O'Cathain & Brazier, 2014). Depression, anxiety, and addiction among other common mental health illness can result in high stress levels.
Quality of life can be measured in many ways, and depending on how one defines it, it benefits individuals in many ways. For example, people with a high quality of life are more likely to have healthy relationships with others in the community which promotes togetherness among people (Rakhshani et al., 2010). It has also been established that people with good mental health, due to their high quality of life, can make good life choices such as keeping fit through physical exercise which also grants them the ability to handle the stresses of daily living (Ohrnberger, Fichera & Sutton, 2017). Nonetheless, a person who can effectively deal with the ups and downs of everyday life is also able to grow and discover his or her potential.
Conversely, good mental health reduces medical costs because people can make sound decisions in their lives that can protect their physical health. For example, people suffering from anxiety disorders are likely to reduce the number of their medical visits after attending psychotherapeutic sessions hence leading to reduced treatment and lab costs (Marciniak et al., 2005). People who have an untreated mental health problem are more likely to visit a doctor more frequently than an individual with sound mental health (Fogarty et al., 2008). The main reason for this is that mental health problems have been implicated in many physical health problems such as heart attack and poor dental health (Ohrnberger et al., 2017). Mental health problems impair judgmental functioning leading to individuals making poor behavioural choices like smoking and excessive alcohol intake that affect their physical health which is the reason for the increased medical costs among mental health patients.
Therefore, mental health is good for enterprises. Many studies (e.g., Behera, 2012) have confirmed that mental health problems can result in reduced productivity in the workplace, frequent absenteeism, reduced work attendance, and increased accidents at the place of work. This means that businesses or organisations must be careful when choosing mental health benefit plans for their employees. This will lead to increased organisational performance and efficacy hence improving both the local and national economies. Thus, the mental health crisis in Hong Kong suggests that the local economy has been affected profoundly calling for the urgency to address the problem through appropriate policymaking. Before defining the meaning of seriousness of mental health among ethnic minorities in Hong Kong, it is essential to highlight the various ethnic minorities in this region.
2.2 Ethnic Minorities of Hong Kong
Ethnic minorities are one of the two central themes of this study. They refer to a group of people whose culture and tradition deviate from the main society. According to a thematic report on the 2016 population by-census that was conducted in Hong Kong in 2016, ethnic minorities in Hong Kong refer to any person who belongs to a non-Chinese ethnic group (Census and Statistics Department, 2016). The population by-census that was conducted between June and August 2016 confirmed that about 584 383 ethnic minorities resided in Hong Kong in 2016 which comprised 8.0% of the whole population of the city (Census and Statistics Department, 2016). However, during this by-census, foreign helpers were also classified as ethnic minorities, but when they are excluded, the number of ethnic minorities was around 260 000 in 2016 or approximately 3.5% of the total population (Census and Statistics Department, 2016). The ethnic minorities primarily comprise of Asians other than Chinese, e.g., Indians, Japanese, Filipinos, Nepalese, etc. (Census and Statistics Department, 2016). The proportion of each ethnic minority group like the Japanese was documented in the 2016 population by-census where it was discovered that Filipinos comprised the most significant portion of Asians residing in Hong Kong. Apart from the non-Chinese Asian ethnic minorities that contain about 78% of ethnic minorities in Hong Kong, others include Mixed, Whites, and Others that comprise of about 11%, 10%, and 0.6% of the total number of ethnic minorities respectively (Census and Statistics Department, 2016).
2.3 Current Situation in Hong Kong
Hong Kong is currently facing a public mental health burden. People of all age groups in this city are increasingly seeking mental health services in public facilities. For example, between 2010 and 2015 alone, the number of young residents (below 15 years old) seeking mental health help from the psychiatric department of the Hospital Authority (HA) increased by 78% (Chiu, 2016). Around one of six residents of Hong Kong suffered from a diagnosable mental health problem in 2017 (Moon, 2017). However, this ratio is likely to be even bigger among the ethnic minorities because they suffer from various forms of discrimination like being condemned to menial jobs that cannot afford a decent living. More particularly, they have unequal access to social services, highly discriminated, cannot communicate properly because of language barriers, and they lack job security compared to the ethnic majorities (Amoah, 2018).
These everyday life pressures can result in mental health problems or even worsen existing mental health problems. Moreover, Amoah (2018) who is a research assistant professor at the Lingnan University maintained that the Government of Hong Kong Special Administrative Region is currently overlooking mental challenges facing ethnic minorities who seem to be marginalised in this context. This is very true because presently the seriousness of mental health problems among ethnic minorities of Hong Kong is not known and yet other marginalised groups such as homeless people are given adequate attention. The role of the Department of Health is to promote mental health among the public, and it has established various agencies that help to help it in establishing its responsibilities. It has formed the following agencies and programmes for specific groups of residents: they include, Maternal and Child Health Centres (MCHCs), Student Health Service Centres, Adolescent Health Programme (AHP), Men's Health Programme, and Elderly Health Service (EHS) (Department of Health, 2015). Despite the worrying mental health crisis among ethnic minorities, the government has not considered a specific approach to dealing with it which suggests that the government overlooks them. The government can promote the mental well-being of all its people by giving them equal opportunities hence improving societal inclusivity of the ethnic minorities.
2.4 What Can be Done
Increasing societal inclusivity by giving people equal opportunities can help in reducing the mental health crisis among ethnic minorities in Hong Kong (Amoah, 2018). The mental health problem in Hong Kong has been persistent for a long time. A report that was issued in 2005 and published in 2006 indicated that there is high mortality related to severe mental illness in this region; the report suggested some policy changes that can be made to address the issue (Chiu & Lam, 2006). The authors of the report, first of all, maintained that severe mental disorders are medical conditions with behavioural disturbances. This is not scientifically true but the authors wanted to put across that medical treatment should be coupled with a comprehensive review of mental health. Furthermore, they also maintained that this could not be met with the current health resource investment in Hong Kong (Chiu & Lam, 2006). Amoah (2018) also mentioned the increment of the government budget to offer the two services concurrently. However, seemingly, the government has not considered this policy recommendation to its fullest potential because mental health services are provided differently from physical health services.
However, since 2005, or at least since the time the policy recommendation came into existence, the government has gone beyond ad-hoc measures in response to tragic incidents such as suicide and violence due to stressful life. Today, the government has clearer policy definitions of how to promote mental health among the public but still much need to be done regarding Mental Health Policy. Despite the renowned fact that Mental Health Policy should be long-term and evidence-based (Chiu & Lam, 2006), today, the government has outlined a policy that violates some of the findings of previous research findings. An effective policy is the one that ensures destigmatisation so that more people seek professional help in the time of need, accessibility, and quality care (Chiu & Lam, 2006). The current system is very overloaded based on the recent findings that the number of people seeking mental health treatment has doubled and tripled over the years (Chiu & Lam, 2006).
Secondly, the current mental health policy overlooks some crucial findings of previous studies. For example, it is well known that mental illness aggravates physical illness hence increasing the cost of medical treatment. The increased medical costs are costly to the local economy. Nonetheless, it is also well established that various factors such as age, gender, and ethnicity contribute to mental illness (Chiu & Lam, 2006) but currently, the policy does not cover up how ethnic minorities can have increased access to mental health care. The likely reason why the government is reluctant to implement these policy changes is the fact that there is limited evidence in the context of Hong Kong. It has been discovered that territory-wide epidemiological studies are conducted once after several decades which is exceptionally worrying provided with the current rapid demographic changes (Chiu & Lam, 2006). More people from Mainland China and other parts of Asia are moving to Hong Kong to look for greener pastures every day. Therefore, epidemiological studies that consider ethnic differences should regularly be conducted to update the evidence-base in order to address the mental health needs of the community.
2.5 Stress Levels Among Ethnic Minorities in Hong Kong
Stress is defined as a person’s response to an external stimulus like change in environment or circumstance (Fink, 2009). The human body is an extensive system that adapts into a new environment or circumstance with time but sometimes it might fail to because of harsh circumstances. Examples of circumstances include writing an exam or worrying about an exam; this means that stress is sourced both externally and internally. In most cases, stress is viewed as a negative concept but in some situations, it can help people to achieve their goals because of its resultant pressure (Fink, 2009). A classic example of how stress can be a positive concept is the pressure and stress athletes undergo to break world records. It is stress that compels students to read for exams and prepare for term papers. This level of stress is considered moderate. Therefore, moderate stress is considered the best level of stress that people should undergo in their daily lives in order to achieve their goals and dreams (Fink, 2009). However, sometimes, too much stress can be detrimental to wellbeing (Fink, 2009).
Acculturation can result in stress among immigrants in Hong Kong. As mentioned above, a majority of the ethnic minorities originate from Asian countries and a few of them from other parts of the world. First and foremost, the commonly spoken language in Hong Kong is Cantonese. Ethnic minorities from countries like India and Japan might experience a lot of trouble to learn the language. As psychologists argue, human development is demarcated by critical periods in which critical developmental achievements take place (Snow & Hoefnagel-Hohle, 1978). Adults have already passed the critical stage of language learning which usually takes place during childhood (Snow & Hoefnagel-Hohle, 1978). Thus, they find a hard time to learn a new language, and this can probably lead to heightened pressure due to inability to cope up with demand as a result of lack of communication.
Therefore, some of the factors that affect the stress levels of ethnic minorities include language barrier and difficulties with acculturation. In addition to them, it was also highlighted in the review of the literature above that ethnic minorities are subject to discrimination which can be new since most of them migrated from their parent countries where there was no discrimination. This change of environment and social pressure can elevate stress levels. Furthermore, these stress levels can be worsened by the fact that ethnic minorities of Hong Kong experience a wide range of forms of discrimination including at the workplace. This affects them economically hence causing frustration and increased stress levels especially for those who came to search for greener pastures. Therefore, there is a high likelihood that ethnic minorities are experiencing elevated levels of stress, but there is no study that has investigated the exact cause neither is there a study that has studied the seriousness of this matter. Therefore, this will be the first study to examine the various reasons for elevated stress levels among ethnic minorities in Hong Kong. Additionally, ethnic minorities with high-stress levels were identified first then a questionnaire inquiring for the specific reasons was administered to the designated individuals. This study does not give even a slight insight into the seriousness of mental health among ethnic minorities hence it should be substituted with future research. The findings of this study plus those of the proposed prospective study will lay the groundwork to develop strategies and policies for reducing stress levels among ethnic minorities.
CHAPTER THREE: METHODOLOGY
3.1 Introduction
Many factors affect the selection of a research design among them technical factors, practical factors, and ethical factors. In order to ensure all the elements have been put into consideration, the researcher must adopt an appropriate research process. The importance of considering all the necessary factors is to increase the rigour of the study by improving reliability, validity, and representativeness. The researcher must consider factors like time, funding, access to participants, etc. before deciding the study design and methodological approach. Moreover, sometimes all these factors can be considered, e.g., the respondents are available, but ethical considerations such as informed consent impede the researcher from collecting data. In this light, therefore, it is essential to follow a logical research process and address all these factors adequately. The author adopted the research process onion that was developed by Saunders and his colleagues in 2009 (See Figure 1).
Figure 1: The Research Process Onion (Adopted from Saunders et al., 2009)
According to Saunders et al. (2009), an excellent research study should have a well-defined research philosophy. There are three types of research philosophies namely positivism, interpretivism, and realism. Positivism is mostly used in quantitative research because it involves the tenets of a natural scientist such as hypothesis testing through quantifiable means (Saunders et al., 2009). Realism, as the name suggests, is also another branch of science that deals with exposing the truth of reality (Saunders et al., 2009). It has been used in both quantitative and qualitative research appropriately. Interpretivism deals with differences between human beings as occupants of the social space (Saunders et al., 2009). Since this study intends to investigate the seriousness of mental health problems among ethnic minorities in Hong Kong, it adopted the research philosophy of realism. More particularly, this study intends to expose the reality of the current situation in Hong Kong regarding the mental health of ethnic minorities.
Conversely, there are two types of reasoning when conducting a research study namely deductive and inductive. Inductive reasoning entails making generalisations out of specific observations whereas deductive reasoning involves arriving at a particular conclusion from a broad range of observations (Saunders et al., 2009). Each of them has a weakness(es). For example, inductive reasoning often results in “false” facts because the discoveries can be challenged later. A classic example of inductive reasoning is when once in history scientists thought that Europe was made up of only whites, but later blacks were discovered. Because of this weakness, the author considered deductive reasoning. The main weakness of deductive reasoning is that it is a process whose stages are highly dependent on one another, for example, if step 1 is untrue, step 2 will also be false. Therefore, it requires high levels of carefulness when performing it which might be very challenging to novice researchers especially undergraduate students (Saunders et al., 2009). Based on this weakness, the author opted to combine the two types of reasoning in order to address their weaknesses most effectively (Saunders et al., 2009).
Additionally, the remaining steps of the onion research process will be explained in the next section of the methodological approach. This section will logically explain the research strategy, time horizon, and data collection method that was employed in this study and why.
3.2 Methodological Approach
This study employed both quantitative and qualitative research methods. Mixed methods are a new approach to research in social sciences that systematically integrates quantitative and qualitative data in a single inquiry. The principal part of this methodological approach is a questionnaire that was distributed to ethnic minorities in Hong Kong. The questionnaire was distributed in the form of a survey to the eligible subjects. First and foremost, the purpose of this study was twofold: identify eligible participants then collect data from the selected participants. The research required to identify ethnic minorities high stress levels then collect data regarding the seriousness of mental health problems among them. In order to determine those who have a mental illness, a survey was conducted. Therefore, the structure of the survey was to identify those who have mental illness among ethnic minorities in Hong Kong.
The main reason why this approach of data collection was adopted is that of time constraints. The author had limited time to conduct this study, therefore, took a cross-sectional time horizon. Other reasons are: (a) high levels of representativeness which means the findings can be generalised to all ethnic minorities residing in Hong Kong; (b) they are less costly hence easy to conduct especially for undergraduate students; (c) they can produce a large sample size thus enhancing statistical significance during data
