Adaptational Problems Vietnamese Refugees
of
I. Health and Mental Health Status Keh-Ming Lin, MD; Laurie Tazuma, MD; Minoru Masuda, PhD
\s=b\ The forced migratory influx of Vietnamese to the United States has raised questions regarding the resettlement process, the effect of culture shock, the refugees' coping behavior and adaptabilities, and their health and mental health status. We report the two-year results of ongoing research on the Vietnamese refugees based on the use of the Cornell Medical Index (CMI). The responses on the CMI on the first (1975) and second (1976) administrations indicate a high and continuing level of physical and mental dysfunction. The second administration also revealed significant shifts in dysfunctions as well as exposing factors that related to these dysfunctions, ie, age/sex interactions, marital status, family groupings, and public assistance. The follow-up CMI also showed an increase in anger and hostility with concomitant reductions in feelings of inadequacy. (Arch Gen Psychiatry 36:955-961, 1979)
difficulties adapting environment have long Extreme recognized.18 Psychiat¬ problems prevalent in
to a new sociocultural been ric have been observed to be more in immigrants,3 and especially in refugees or displaced persons, as evidenced by numerous case reports and several clinical studies among various refugee groups since the end of World War II.10'9 Paranoid reaction, depression, anxie¬ ty, reactive psychosis, and conversion reaction have been observed as particularly prevalent. A marked tendency toward somatic over-concern and increased incidence of somatic complaints were also found to be present in several refugee groups.1"" Increase in incidence of physical health problems has been reported in Chinese expatriates and Hungarian refugees by Hinkle et al.-" However, most of these studies were based on retrospective clinical material. Questions about the extent of influence of the adaptational difficulties on health and mental health status of the refugees, factors that contribute to adaptation and health, and the characteristics of high-risk subgroups among the refugees have not been explored. These seem to be highly relevant issues. The importance of the refugee problems can readily be appreciated by the fact that, according to a United Nations report, an estimated 45 million persons have been denied residency in their homeland from 1945 to 1967, and in 1968 alone, 7 million people were considered to be international refugees.21 According to the same report, today there are about 15 million refugees in the world. This kind of forced
Accepted for publication March 7, 1979. From the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Reprint requests to Department of Psychiatry and Behavioral Sciences, RP-10, University of Washington, Seattle, WA 98195 (Dr Masuda).
immigration has been a recurrent theme all through history. People with refugee experiences are scattered in every corner of today's America, forming conspicuous segments in metropolitan areas and requiring special
consideration.22-23 The collapse of the South Vietnam regime in April 1975 brought another surge of refugees into the United States. In subsequent months, more than 140,000 Vietnamese fled their homeland and entered the United States. They started to arrive in the greater Seattle area as early as May 1975. In early June, two local community service agencies, the Employment Opportunity Center (EOC)24 and the Asian Counselling and Referral Service (ACRS),25 proposed a multifaceted program called "Project Pioneer." This program was promptly funded through federal, state, and private sources and started offering courses and counsel¬ ling to the Vietnamese with the purpose of easing transi¬ tion of the Vietnamese into American life and helping them find employment. In the following six months it
processed 426 refugees. Perceiving the need for health service and research, the University of Washington Department of Psychiatry and
Behavioral Sciences formed a team on a volunteer basis. A health clinic was set up within the context of "Project Pioneer" and operated six months, from July through December 1975.26 The project was designed from its incep¬ tion to be a longitudinal yearly follow-up, using observa¬ tion and questionnaire administration to document the health and mental health status of the refugees in differ¬ ent stages of adaptation. Phase 1 (data collection in 1975) of this study was conducted in combination with health service in such a setting.2" Phase 2 (data collection in 1976) of this study, completed one year later, was conducted by home visits. In the two-year period, the authors have had extensive contact with the Vietnamese community as well as with many helping agencies in the greater Seattle area, and frequently served as consultants for the psychosocial problems of the refugees. Based on the nature of different testing instruments, there will be two parts to this report: part 1 deals with the most clinically relevant material; part 2 concerns the relationship of life events and health status. METHODS Phase 1 of the
study
was
conducted in the context of
"Project
Pioneer," which recruited clients nonselectively from sponsoring agencies in the community as well as from state-sponsored agencies. Questionnaires were administered to the clients while
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of California - San Diego User on 01/22/2016
providing basic hygienic and everyday medical knowledge classes, with the help of Vietnamese interpreters. Phase 2 was conducted through home visits by the same research team, consisting of a male Chinese psychiatrist, a female Japa¬ nese-American medical student, and an experienced Vietnamese community worker. Interviews, observations, and administrations of questionnaires were done in an atmosphere of concern for the health and welfare of the refugees, usually with maximal cooper¬ ation elicited. Among the 152 subjects of phase 1, 54 were seen again in phase 2. The remainder of phase 2 subjects came from two sources: 39 subjects who did not participate in the phase 1 study were randomly sampled from the "Project Pioneer" group; and 48 were newly recruited from the Vietnamese community. Total subjects for phase 2 numbered 141. Due to the voluntary nature of participation and the high mobility of the refugees in the first year of resettlement, the sample was not entirely selected at random; furthermore, not all phase 1 subjects nor a preselected portion of them was included in the phase 2 follow-up. However, the characteristics of the subjects were very similar to each other for both phases (Table 1). The instruments used included the Cornell Medical Index (CMI), the Social Readjustment Rating Questionnaire (SRRQ), the Sched¬ ule of Recent Experience (SRE), and a questionnaire for health and social history especially designed for this study. They were all translated into Vietnamese by a group of Vietnamese overseas students and double-checked by a competent Vietnamese doctor. The data derived from the SRRQ and the SRE will not be described herein; these results will be reported as part 2. The CMI is a widely used health status questionnaire consisting of 18 sections totaling 195 questions. The first 12 sections (A to L) deal mainly with symptoms in discrete physiological systems, while the last six sections (M to R) are mainly concerned with psychological symptoms. Since the appearance of the CMI in 1949, many studies conducted in various cultures have found this instrument to be a valid screening tool for neurotic tendencies and a sensitive indicator of a person's physical and mental health.27'3" Hence, the instrument was chosen as an indicator of physical, psychological, and psychophysiological problems of refugees. The health and social history questionnaire was newly designed Table 1— Sample Characteristics: Phase 1 and Phase 2
Phase 1
Characteristic Sex M
(N
=
152)
Phase 2
(N
=
141)
_
66 34
68 32
23 40 23 15
17 53 22
42
44
Age
Below 21 21-30 31-45 46 and above Marital status Married
52
48
14 53
50
College/graduate school_33_45 Religion Buddhist Catholic Protestant No preference
57 19
13"
needs, personal and family medical history, family constellation, habits, attitudes, and perceptions about the refugee experience, employment status, training and employment history, social activities, contacts with Vietnamese, contacts with Americans, agency utilization, and English proficiency. Based on the questions on family constellations and supple¬ mented by personal interview findings, four family types were identified in 132 of the phase 2 subjects and in 54 of the phase 1 subjects. The four family types consisted of the following: type 1, young single men, living alone, who have no relatives in this country (phase 1,17%; phase 2,18%); type 2, individuals who live in nuclear family units (phase 1, 56%; phase 2, 57%); type 3, individ¬ uals who have extended family networks in this country (phase 1, 22%; phase 2, 21%); and type 4, women, divorced or separated, who are also heads of households (phase 1, 6%; phase 2, 4%). The percentages of families in each category were similar in phase 1 and phase 2. Three social contact indices were constructed from the health and social history questionnaires: Vietnamese community contact index (scale 0 to 17); American social contact index (scale 0 to 21); and helping agency contact index (scale 0 to 7). Data obtained were transcribed into computer coding and subjected to analysis. The statistical methods used are indicated in the text or in the tables.
RESULTS
The Vietnamese sample characteristics for phases 1 and presented in Table 1. In general, this is a fairly young sample. About half of them were still unmarried, and most of them had had at least high school education. Religious preference was, in order, Buddhism, Catholicism, then Protestantism, the last representing more recent Western influence. A comparison of the employment classifications and status of the Vietnamese in phase 2 and in Vietnam (Table 2) shows not only the high rate of unemployment (46%) among this group of refugees, but also the fact of under¬ employment based on comparison of work categories. For example, of the 18% who had had prestigious jobs such as managers, professionals, and businessmen in Vietnam, none were able to work in the same line of work in phase 2, while one third were in the clerical or service categories, and one fourth were employed as skilled workers. This was true also for the 25% who served in the Armed Forces, some 2 are
of them of high found in service phase 2.
military rank. One third jobs such as dishwashers
Table 2— Employment Status: Phase 2
vs
of them or
were
janitors
in Vietnam
10
Widowed, divorced/separated Never married Education level Grade school High school, technical school
to obtain information about current health
50 27 14
Categories Service Clerical Skilled worker Fisherman
Phase 2 28
In Vietnam
19
10 12 20
4
25 12
4
Managerial Sales Small business Professional Armed forces Student
Unemployed
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of California - San Diego User on 01/22/2016
...
46
in
Table 3—Mean CMI Scores and Percentages With High Scores According tO'Sections* Sections M to R
Phase 1 Phase 2
152 141
%
Mean 12 13
a
10
=
Total A to R Mean
53 55
34 35
%
distributions were drastically different according to sex and age (age-sex interaction: F 4.97, < .005). Younger (less than 21) and older (more than 45) men, as well as women in their reproductive years between the ages of 21 and 45, were found to have higher scores than their counterparts. These differences between age and sex were found to be similarly significant in the M to R categories as well (age-sex interaction: F 4.94, < .005). Using the criteria of cutoff points of > 10 points for sections M to R and > 30 for total CMI scores (A to R) as indicators of dysfunction, marital status was shown to be a factor influencing CMI scores ( 2 test: A to R: 2 3.4, < .05; M to R: 2 5.0, < .025). "Not married" individ¬ uals included the never married singles as well as those divorced, separated, and widowed. This difference in distribution was seen only in phase 2 and not in phase 1. Thus, being married carried the probability of higher CMI
>
30
48 56
=
"CMI indicates Cornell Medical Index.
The total (A to R) and psychological (M to R) mean CMI for both phases are shown in Table 3. The phase 1 and phase 2 scores in all categories are high and remarka¬ bly similar. As will be discussed later, these scores are high compared with the previously established norms. One year after their arrival and start of resettlement, the magni¬ tude of the CMI scores continued to remain high. A previous study2" had suggested cutoff points of total CMI scores (A to R) of > 30 or category M to R scores of > 10 to be indicative of serious dysfunction. In Table 3, the Vietnamese CMI scores in both phases in these two categories showed that close to 50% or more displayed scores of dysfunction. Of the 49 subjects who were administered the CMI in both phases, their scores showed a statistically significant correlation (r .70, < .0001) for both the total CMI scores (A to R) as well as the M to R scores. The mean scores of this continuous subgroup in both phases are the same as those of the whole sample. The CMI scores in both phases were tested against various demographic variables. In phase 1, significant differences were only observed in the M to R section scores scores
=
in terms of the age and sex. Women and older people tended to respond with higher M to R scores but not the total scores. In phase 2, the influence of several variables on the CMI scores became more evident: scores for male and female subjects were significantly different in all categories for all age groups. Age-sex interaction as they affect CMI scores in phase 2 but not in phase 1 are shown in Fig 1. While, overall, women displayed higher scores in all categories, the score
=
=
(dysfunctional) scores. In phase 2, but not in phase 1, total CMI scores differed significantly among the four family types (Fig 2): the widowed or separated female heads of households had the highest scores, and the single young men had the lowest. Figure 2 illustrates this difference in terms of the total CMI scores (F 3.10; < .05). Findings for the M to R scores parallel the results for the total scores (F 2.96; =
=
of
I. Health and Mental Health Status Keh-Ming Lin, MD; Laurie Tazuma, MD; Minoru Masuda, PhD
\s=b\ The forced migratory influx of Vietnamese to the United States has raised questions regarding the resettlement process, the effect of culture shock, the refugees' coping behavior and adaptabilities, and their health and mental health status. We report the two-year results of ongoing research on the Vietnamese refugees based on the use of the Cornell Medical Index (CMI). The responses on the CMI on the first (1975) and second (1976) administrations indicate a high and continuing level of physical and mental dysfunction. The second administration also revealed significant shifts in dysfunctions as well as exposing factors that related to these dysfunctions, ie, age/sex interactions, marital status, family groupings, and public assistance. The follow-up CMI also showed an increase in anger and hostility with concomitant reductions in feelings of inadequacy. (Arch Gen Psychiatry 36:955-961, 1979)
difficulties adapting environment have long Extreme recognized.18 Psychiat¬ problems prevalent in
to a new sociocultural been ric have been observed to be more in immigrants,3 and especially in refugees or displaced persons, as evidenced by numerous case reports and several clinical studies among various refugee groups since the end of World War II.10'9 Paranoid reaction, depression, anxie¬ ty, reactive psychosis, and conversion reaction have been observed as particularly prevalent. A marked tendency toward somatic over-concern and increased incidence of somatic complaints were also found to be present in several refugee groups.1"" Increase in incidence of physical health problems has been reported in Chinese expatriates and Hungarian refugees by Hinkle et al.-" However, most of these studies were based on retrospective clinical material. Questions about the extent of influence of the adaptational difficulties on health and mental health status of the refugees, factors that contribute to adaptation and health, and the characteristics of high-risk subgroups among the refugees have not been explored. These seem to be highly relevant issues. The importance of the refugee problems can readily be appreciated by the fact that, according to a United Nations report, an estimated 45 million persons have been denied residency in their homeland from 1945 to 1967, and in 1968 alone, 7 million people were considered to be international refugees.21 According to the same report, today there are about 15 million refugees in the world. This kind of forced
Accepted for publication March 7, 1979. From the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Reprint requests to Department of Psychiatry and Behavioral Sciences, RP-10, University of Washington, Seattle, WA 98195 (Dr Masuda).
immigration has been a recurrent theme all through history. People with refugee experiences are scattered in every corner of today's America, forming conspicuous segments in metropolitan areas and requiring special
consideration.22-23 The collapse of the South Vietnam regime in April 1975 brought another surge of refugees into the United States. In subsequent months, more than 140,000 Vietnamese fled their homeland and entered the United States. They started to arrive in the greater Seattle area as early as May 1975. In early June, two local community service agencies, the Employment Opportunity Center (EOC)24 and the Asian Counselling and Referral Service (ACRS),25 proposed a multifaceted program called "Project Pioneer." This program was promptly funded through federal, state, and private sources and started offering courses and counsel¬ ling to the Vietnamese with the purpose of easing transi¬ tion of the Vietnamese into American life and helping them find employment. In the following six months it
processed 426 refugees. Perceiving the need for health service and research, the University of Washington Department of Psychiatry and
Behavioral Sciences formed a team on a volunteer basis. A health clinic was set up within the context of "Project Pioneer" and operated six months, from July through December 1975.26 The project was designed from its incep¬ tion to be a longitudinal yearly follow-up, using observa¬ tion and questionnaire administration to document the health and mental health status of the refugees in differ¬ ent stages of adaptation. Phase 1 (data collection in 1975) of this study was conducted in combination with health service in such a setting.2" Phase 2 (data collection in 1976) of this study, completed one year later, was conducted by home visits. In the two-year period, the authors have had extensive contact with the Vietnamese community as well as with many helping agencies in the greater Seattle area, and frequently served as consultants for the psychosocial problems of the refugees. Based on the nature of different testing instruments, there will be two parts to this report: part 1 deals with the most clinically relevant material; part 2 concerns the relationship of life events and health status. METHODS Phase 1 of the
study
was
conducted in the context of
"Project
Pioneer," which recruited clients nonselectively from sponsoring agencies in the community as well as from state-sponsored agencies. Questionnaires were administered to the clients while
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of California - San Diego User on 01/22/2016
providing basic hygienic and everyday medical knowledge classes, with the help of Vietnamese interpreters. Phase 2 was conducted through home visits by the same research team, consisting of a male Chinese psychiatrist, a female Japa¬ nese-American medical student, and an experienced Vietnamese community worker. Interviews, observations, and administrations of questionnaires were done in an atmosphere of concern for the health and welfare of the refugees, usually with maximal cooper¬ ation elicited. Among the 152 subjects of phase 1, 54 were seen again in phase 2. The remainder of phase 2 subjects came from two sources: 39 subjects who did not participate in the phase 1 study were randomly sampled from the "Project Pioneer" group; and 48 were newly recruited from the Vietnamese community. Total subjects for phase 2 numbered 141. Due to the voluntary nature of participation and the high mobility of the refugees in the first year of resettlement, the sample was not entirely selected at random; furthermore, not all phase 1 subjects nor a preselected portion of them was included in the phase 2 follow-up. However, the characteristics of the subjects were very similar to each other for both phases (Table 1). The instruments used included the Cornell Medical Index (CMI), the Social Readjustment Rating Questionnaire (SRRQ), the Sched¬ ule of Recent Experience (SRE), and a questionnaire for health and social history especially designed for this study. They were all translated into Vietnamese by a group of Vietnamese overseas students and double-checked by a competent Vietnamese doctor. The data derived from the SRRQ and the SRE will not be described herein; these results will be reported as part 2. The CMI is a widely used health status questionnaire consisting of 18 sections totaling 195 questions. The first 12 sections (A to L) deal mainly with symptoms in discrete physiological systems, while the last six sections (M to R) are mainly concerned with psychological symptoms. Since the appearance of the CMI in 1949, many studies conducted in various cultures have found this instrument to be a valid screening tool for neurotic tendencies and a sensitive indicator of a person's physical and mental health.27'3" Hence, the instrument was chosen as an indicator of physical, psychological, and psychophysiological problems of refugees. The health and social history questionnaire was newly designed Table 1— Sample Characteristics: Phase 1 and Phase 2
Phase 1
Characteristic Sex M
(N
=
152)
Phase 2
(N
=
141)
_
66 34
68 32
23 40 23 15
17 53 22
42
44
Age
Below 21 21-30 31-45 46 and above Marital status Married
52
48
14 53
50
College/graduate school_33_45 Religion Buddhist Catholic Protestant No preference
57 19
13"
needs, personal and family medical history, family constellation, habits, attitudes, and perceptions about the refugee experience, employment status, training and employment history, social activities, contacts with Vietnamese, contacts with Americans, agency utilization, and English proficiency. Based on the questions on family constellations and supple¬ mented by personal interview findings, four family types were identified in 132 of the phase 2 subjects and in 54 of the phase 1 subjects. The four family types consisted of the following: type 1, young single men, living alone, who have no relatives in this country (phase 1,17%; phase 2,18%); type 2, individuals who live in nuclear family units (phase 1, 56%; phase 2, 57%); type 3, individ¬ uals who have extended family networks in this country (phase 1, 22%; phase 2, 21%); and type 4, women, divorced or separated, who are also heads of households (phase 1, 6%; phase 2, 4%). The percentages of families in each category were similar in phase 1 and phase 2. Three social contact indices were constructed from the health and social history questionnaires: Vietnamese community contact index (scale 0 to 17); American social contact index (scale 0 to 21); and helping agency contact index (scale 0 to 7). Data obtained were transcribed into computer coding and subjected to analysis. The statistical methods used are indicated in the text or in the tables.
RESULTS
The Vietnamese sample characteristics for phases 1 and presented in Table 1. In general, this is a fairly young sample. About half of them were still unmarried, and most of them had had at least high school education. Religious preference was, in order, Buddhism, Catholicism, then Protestantism, the last representing more recent Western influence. A comparison of the employment classifications and status of the Vietnamese in phase 2 and in Vietnam (Table 2) shows not only the high rate of unemployment (46%) among this group of refugees, but also the fact of under¬ employment based on comparison of work categories. For example, of the 18% who had had prestigious jobs such as managers, professionals, and businessmen in Vietnam, none were able to work in the same line of work in phase 2, while one third were in the clerical or service categories, and one fourth were employed as skilled workers. This was true also for the 25% who served in the Armed Forces, some 2 are
of them of high found in service phase 2.
military rank. One third jobs such as dishwashers
Table 2— Employment Status: Phase 2
vs
of them or
were
janitors
in Vietnam
10
Widowed, divorced/separated Never married Education level Grade school High school, technical school
to obtain information about current health
50 27 14
Categories Service Clerical Skilled worker Fisherman
Phase 2 28
In Vietnam
19
10 12 20
4
25 12
4
Managerial Sales Small business Professional Armed forces Student
Unemployed
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of California - San Diego User on 01/22/2016
...
46
in
Table 3—Mean CMI Scores and Percentages With High Scores According tO'Sections* Sections M to R
Phase 1 Phase 2
152 141
%
Mean 12 13
a
10
=
Total A to R Mean
53 55
34 35
%
distributions were drastically different according to sex and age (age-sex interaction: F 4.97, < .005). Younger (less than 21) and older (more than 45) men, as well as women in their reproductive years between the ages of 21 and 45, were found to have higher scores than their counterparts. These differences between age and sex were found to be similarly significant in the M to R categories as well (age-sex interaction: F 4.94, < .005). Using the criteria of cutoff points of > 10 points for sections M to R and > 30 for total CMI scores (A to R) as indicators of dysfunction, marital status was shown to be a factor influencing CMI scores ( 2 test: A to R: 2 3.4, < .05; M to R: 2 5.0, < .025). "Not married" individ¬ uals included the never married singles as well as those divorced, separated, and widowed. This difference in distribution was seen only in phase 2 and not in phase 1. Thus, being married carried the probability of higher CMI
>
30
48 56
=
"CMI indicates Cornell Medical Index.
The total (A to R) and psychological (M to R) mean CMI for both phases are shown in Table 3. The phase 1 and phase 2 scores in all categories are high and remarka¬ bly similar. As will be discussed later, these scores are high compared with the previously established norms. One year after their arrival and start of resettlement, the magni¬ tude of the CMI scores continued to remain high. A previous study2" had suggested cutoff points of total CMI scores (A to R) of > 30 or category M to R scores of > 10 to be indicative of serious dysfunction. In Table 3, the Vietnamese CMI scores in both phases in these two categories showed that close to 50% or more displayed scores of dysfunction. Of the 49 subjects who were administered the CMI in both phases, their scores showed a statistically significant correlation (r .70, < .0001) for both the total CMI scores (A to R) as well as the M to R scores. The mean scores of this continuous subgroup in both phases are the same as those of the whole sample. The CMI scores in both phases were tested against various demographic variables. In phase 1, significant differences were only observed in the M to R section scores scores
=
in terms of the age and sex. Women and older people tended to respond with higher M to R scores but not the total scores. In phase 2, the influence of several variables on the CMI scores became more evident: scores for male and female subjects were significantly different in all categories for all age groups. Age-sex interaction as they affect CMI scores in phase 2 but not in phase 1 are shown in Fig 1. While, overall, women displayed higher scores in all categories, the score
=
=
(dysfunctional) scores. In phase 2, but not in phase 1, total CMI scores differed significantly among the four family types (Fig 2): the widowed or separated female heads of households had the highest scores, and the single young men had the lowest. Figure 2 illustrates this difference in terms of the total CMI scores (F 3.10; < .05). Findings for the M to R scores parallel the results for the total scores (F 2.96; =
=
