Psychology Personal Strategies for Multicultural Humility and Orientation Assignment

ORIGINAL PAPER

Attitudes Toward Mental Health Services in Hispanic Older Adults: The Role of Misconceptions and Personal Beliefs

Yuri Jang • David A. Chiriboga • Julio R. Herrera •

Dinorah Martinez Tyson • Lawrence Schonfeld

Received: 17 February 2009 / Accepted: 8 December 2009 / Published online: 20 December 2009

� Springer Science+Business Media, LLC 2009

Abstract Focusing on misconceptions and personal

beliefs associated with depression, the present study

explored predictors of attitudes toward mental health ser-

vices in a sample of 297 Hispanic older adults living in

public housing (M age = 76.0 years, SD = 7.74). Results

from a hierarchical regression analysis showed that nega-

tive attitudes towards mental health services were predicted

by advanced age, belief that having depression would make

family members disappointed, and belief that counseling

brings too many bad feelings such as anger and sadness.

Findings suggest that interventions designed to promote

positive attitudes toward mental health services of older

Hispanics should address misconceptions and personal

beliefs.

Keywords Hispanics � Older adults � Attitudes toward mental health services

Introduction

Racial/ethnic minority elders often exhibit higher levels of

mental health problems than non-Hispanic Whites, but they

continue to be underrepresented among those receiving

mental health services (e.g., Alegrı́a et al. 2008; Blanco

et al. 2007; Cook et al. 2007; Smedley et al. 2002). Because

undetected and untreated mental health problems result in

poorer quality of life, higher social costs for care, attenu-

ated effectiveness of treatment, and heightened premature

mortality (U.S. Department of Health and Human Services

2001), there is a compelling need for research that may

promote access to mental health services for racial/ethnic

minority older populations.

One area of access-related research that has received

comparatively little attention has to do with attitudes toward

mental health services, and particularly the correlates of

these attitudes among racial/ethnic minority older adults.

Assessment of factors contributing to the perceptions of

mental health services will help us identify facilitators and

barriers to the service utilization. Since attitudes have

shown to be a critical determinant of actual help-seeking

behaviors (Fischer and Farina 1995; Godin and Conner

2008), research on attitudes may provide valuable infor-

mation concerning how to design and implement effective

interventions to reduce disparities in mental health care.

In the present study, we focused on misconceptions and

personal beliefs associated with depression as determinants

of the attitudes toward mental health services. Miscon-

ceptions such as attributing depression to aging (e.g.,

Sarkisian et al. 2003) and perceiving depression as a sign of

personal weakness (e.g., National Mental Health Associa-

tion 1996; Ray et al. 1992) are quite common among

minority older adults, and such misconceptions are likely to

lead to negative attitudes toward mental health services

(Givens et al. 2007; Hines-Martin et al. 2004). Members of

racial/ethnic minorities have also shown to be misinformed

about psychological and pharmacological treatment for

depression (U.S. Department of Health and Human Ser-

vices 2001). Givens et al. (2007) report that compared to

Whites, racial and ethnic minorities were less likely to

perceive that depression is biologically based and more

likely to think that antidepressants are addictive and that

Y. Jang (&) � D. A. Chiriboga � J. R. Herrera � D. Martinez Tyson � L. Schonfeld

Department of Aging and Mental Health Disparities,

Florida Mental Health Institute, University of

South Florida, 13301 Bruce B. Downs Blvd.,

MHC 1400, Tampa, FL 33612, USA

e-mail: [email protected]

123

Community Ment Health J (2011) 47:164–170

DOI 10.1007/s10597-009-9274-8

counseling brings up too many bad feelings. In some cul-

tures, one’s mental illness is not perceived as a personal

matter but as a threat to the homeostasis and harmony of

the whole family, and having a family member with mental

illness is perceived as shame (Leong and Lau 2001; Lin

and Cheung 1999). Such personal beliefs linked to family

shame and disappointment have been identified as a major

cultural barrier to the use of mental health services (e.g.,

Leong and Lau 2001).

Given the trends of population aging and growth of

Hispanics in the United States, and the critical need for

mental health research on Hispanics (U.S. Department of

Health and Human Services 2001), the present study

assessed determinants of the attitudes toward mental health

services in Hispanic older adults. Although the present

study was exploratory in nature, we expected that mis-

conceptions and negative personal beliefs would contribute

to unfavorable attitudes toward mental health services.

Examples of such misconceptions are thinking that

depression is a normal part of aging, depression is a sign of

personal weakness, antidepressant medicines are addictive,

and counseling brings up too many bad feelings; examples

of personal beliefs include believing that having a mentally

ill family member brings shame to the whole family, or

would disappoint the family. Obtaining an understanding

of cultural perceptions associated with mental health issues

may help identify areas to focus when developing public

education and mental health promotion programs for His-

panic elderly populations.

Methods

Sample

The target population for the present study consisted of

Hispanic adults aged 60 or older who were living in public

housing and who had sufficient cognitive ability to

understand and complete the survey questionnaire. To

recruit participants, we first identified senior housing

facilities in the Tampa Bay area with high rates of Hispanic

residents. The next step was to establish contact through

telephone calls or actual visits with the manager and/or the

activities coordinator of facilities in order to request

approval for a survey. Of the 15 facilities contacted, 2 were

excluded because they were rehabilitation or assisted living

facilities. Approval was obtained from 9 facilities. After

obtaining approval, we posted an invitation flyer in the

facility and also sent one out to target residents. The flyer

announced the purpose of the study; eligibility criteria; and

the date, time, and location of the survey. The survey was

conducted in a community room or cafeteria in the facility.

The survey instrument was a standardized questionnaire

designed to be self-administered in a pen and paper format.

Participants were given a choice of using a questionnaire in

English or Spanish. The Spanish version was developed

using a back-translation method, and the final product was

reviewed and reconciled by bilingual individuals who did

not participate in the initial translation process (e.g., Brislin

1970; Hambleton and de Jong 2003). Survey question-

naires were printed using a large font, and trained bilingual

interviewers were available for assistance. All participants

received $10 for their time and effort. A total of 301

individuals were surveyed between April and June 2008.

After we excluded individuals who did not meet the eli-

gibility criteria (n = 4), the final sample size was 297.

None of the participants had more than 10% missing

information on their questionnaires. Details on the

recruitment process are available elsewhere (e.g., Jang

et al. 2009).

Measures

Demographic Variables

These variables included age, gender, ethnicity, marital

status, and educational attainment.

Background Variables

Acculturation and physical and mental health status were

included as background variables. Level of acculturation

was assessed with four items related to language: self-

reported English proficiency, language used in conversa-

tions with family, preferred language for TV or video, and

preferred language for book or newspaper. The items were

drawn from two indices of acculturation widely utilized in

research on Hispanic populations (i.e., Cuellar et al. 1995;

Hazuda et al. 1988). Each response was coded from 1 to 5,

with a higher score indicating a greater level of accultur-

ation. Internal consistency based on the four items was high

(a = .92).

Three items from the Older Americans Resources and

Services Questionnaire (Fillenbaum 1988) were used to

assess subjective perception of health. The items were

‘‘How would you rate your overall health at the present

time?’’ ‘‘How is your present health compared to five years

ago?’’ and ‘‘How much do your health troubles stand in the

way of your doing the things you want to do?’’ The rating

scale ranged from 0 (positive health perception) to 7

(negative health perception). Internal consistency based on

the three items was satisfactory (a = .73).

A short form of the Center for Epidemiologic Studies–

Depression scale (CES-D; Andresen et al. 1994; see also

Radloff 1977) was used to assess depressive symptoms.

The scale includes two positive items (‘‘I felt hopeful’’ and

Community Ment Health J (2011) 47:164–170 165

123

‘‘I was happy’’) and eight negative items (e.g., ‘‘I felt

depressed’’ and ‘‘I felt lonely’’). Participants rated on a 4-

point scale how often symptoms were experienced during

the past week. The positive items were reverse-coded, and

all items were summed into total scores that ranged from 0

(no depressive symptoms) to 30 (severe depressive symp-

toms). A score of 10 or higher on the short form of the

CES-D is typically suggested as a cutoff for probable

depression (Andresen et al. 1994). The CES-D has been

translated into Spanish, and its psychometric properties

have been validated in previous studies (e.g., Grzywacz

et al. 2006; Roberts 1980). Internal consistency in the

present sample was good (a = .75).

Misconceptions and Personal Beliefs Associated with

Depression

Six questions were asked about misconceptions and per-

sonal beliefs associated with depression. The items, adop-

ted from a National Mental Health Association (1996)

survey and a study by Cooper et al. (2003), questioned

whether participants (a) thought depression is a normal part

of aging, (b) thought depression is a sign of personal

weakness, (c) thought antidepressant medicines are addic-

tive, (d) thought counseling brings up too many bad feel-

ings such as anger and sadness, (e) thought having a

mentally ill family member brings shame to the whole

family, and (f) thought if he/she had depression, his/her

family would be disappointed with him/her. Responses

were coded as 1 (yes) or 0 (no).

Attitudes Toward Mental Health Services

As a measure of mental health treatment attitudes, we used

the Attitudes Toward Seeking Professional Psychological

Help Scale—Short Form (Fischer and Farina 1995). The

scale has been frequently used in mental health services

research, and acceptable psychometric properties have

been documented (e.g., Elhai et al. 2008). The scale

includes five positive statements (e.g., ‘‘If I believed I was

having a mental breakdown, my first inclination would be

to get professional attention,’’ ‘‘A person with an emotional

problem is not likely to solve it alone; he or she is likely to

solve it with professional help’’) and five negative state-

ments (e.g., ‘‘The idea of talking about problems with a

psychologist strikes me as a poor way to get rid of emo-

tional conflicts,’’ ‘‘A person should work out his or her own

problems; getting psychological counseling would be a last

resort’’). Individuals were asked to rate each statement on a

4-point scale: disagree (0), partly disagree (1), partly agree

(2), and agree (3). Responses to the negative statements

were reverse-coded, and all responses were summed for

total scores. Total scores could range from 0 to 30, with

higher scores indicating more positive attitudes toward

mental health services. An exploratory factor analysis with

varimax rotation yielded two factors (Positive and Nega-

tive Attitudes), that together accounted for 46.3% of the

variance. Internal consistency for the scale in the present

sample was acceptable (a = .67).

Results

Descriptive Information of the Sample and Study

Variables

As shown in Table 1, the sample consisted of 297 older

adults aged 60–105, with an average age of 76 years. As is

typical in studies of older adults, a substantial proportion of

the sample (73%) was female. In terms of the ethnic

composition of the sample, the majority were from a Cuban

background (64.3%), followed by Puerto Rican (18.2%),

other (14.5%), and Mexican (3.0%). Examples of the

country of origin specified for the ‘‘other’’ response

included Spain, Venezuela, the Dominican Republic, Peru,

Columbia, and El Salvador. Due to the relatively small

numbers of participants from non-Cuban backgrounds,

ethnicity was recoded as ‘Cuban’ and ‘all others’ for

bivariate and multivariate analyses. At 20%, the proportion

of the married individuals was relatively low, as was the

proportion (20%) who had gone beyond a high school

education.

The majority (86.2%) used the Spanish version of the

questionnaire for the survey. For this reason, it was not

surprising that the average total score for acculturation,

8.18 (SD = 4.24) out of a possible maximum of 20, was

relatively low. The mean score for self-perceived health

was 6.88 (SD = 1.72). Scores for depressive symptoms

averaged 9.76 (SD = 6.12); about 43% of the sample fell

within the category of probable depression when the sug-

gested cutoff score for the short-form CES-D (C10) was

applied.

More than half (51%) thought that becoming depressed

is a normal part of aging, and 35% thought that depression

is a sign of personal weakness. More than 62% of the

sample thought that antidepressant medicines are addictive,

and about 17% thought that counseling brings up too many

bad feelings. The percentages of the sample that associated

mental illness with shame (2.7%) and with family disap-

pointment (8.2%) were relatively low.

Finally, with an average score of 21.4 (SD = 5.29) out

of a maximum of 30, the participants appeared to hold

quite positive attitudes towards mental health services. The

scores of the attitudes toward mental health services were

reasonably normal in their distribution (skewness = -.50).

166 Community Ment Health J (2011) 47:164–170

123

Predictors of the Attitudes Toward Mental Health

Services

After ensuring the absence of multicollinearity by exam-

ining bivariate correlations (rs \ .52) and variance infla-

tion factor scores (VIFs \ 1.60), we estimated a predictive

model of the attitudes toward mental health services.

Hierarchical regression models were tested with the entry

order being (a) demographic variables (age, gender, eth-

nicity, marital status, and educational attainment), (b)

background variables (acculturation, self-perceived health,

and depressive symptoms), and (c) the items assessing

misconceptions and personal beliefs associated with

depression. The results are summarized in Table 2.

At the first step, demographic variables accounted for

3% of the variance, and only age was significant. Indi-

viduals of more advanced age were more likely to have

negative attitudes toward mental health services. The entry

of acculturation and health variables explained only a small

portion of the variance, and none of these variables were

significant. The final model included the measures of

misconception and personal beliefs, which together con-

tributed an additional 12% to the explained variance. The

total explained variance was 17%. The beliefs that coun-

seling brings up too many bad feelings and that having

depression would make family members disappointed were

found to be significant predictors of negative attitudes

toward mental health services.

Discussion

The need for research on mental health among racial and

ethnic minority elders prompted the present study. The

particular focus was on the attitudes of Hispanic older

adults toward mental health services. We examined a

number of factors that might be associated with such atti-

tudes, especially those reflecting misconceptions and per-

sonal beliefs associated with depression, and tested a basic

predictive model that incorporated these factors.

Individuals’ propensity to use mental health services

was assessed with one of the most popular instruments in

mental health research, the Attitudes Toward Seeking

Professional Psychological Help Scale—Short Form

(Fischer and Farina 1995). Given that prior studies with

groups consisting primarily of college students report

average scores ranging from 15.9 to 17.4 (e.g., Elhai et al.

2008; Fischer and Farina 1995), the average in the present

sample (M = 21.4, SD = 5.29) seems to reflect a rela-

tively positive attitude. Previous studies that examined age

differences in attitudes have also reported that older adults

exhibit more positive perceptions of help seeking than their

younger counterparts (e.g., Mackenzie et al. 2006, 2008;

Robb et al. 2003; Sirey et al. 2001). Moreover, Cubans and

Cuban Americans, who constitute the bulk of the present

sample, generally are accepting of modern medical prac-

tices (e.g., Pan American Health Organization 2001).

Placing results from the present study of Hispanic older

Table 1 Descriptive

information of the sample and

study variables (n = 297)

Variable % M/SD Range

Demographic variables

Age 76.0/7.74 60–105

Gender (female) 73.1

Ethnicity (Cubans) 64.3

Marital status (married) 2.2

Educational attainment (beyond high school) 2.2

Background variables

Acculturation 8.18/4.24 4–19

Self-perception of health 3.88/1.72 0–7

Depressive symptoms 9.76/6.12 0–30

Misconceptions and personal beliefs

Think depression is a normal part of aging 51.0

Think depression is a sign of personal weakness 35.0

Think antidepressant medicines are addictive 62.3

Think counseling brings up too many bad feelings

such as anger and sadness

17.2

Think having a mentally ill family member brings

shame to the whole family

2.7

Think if I had depression, my family would be

disappointed with me

8.1

Attitudes toward mental health services 21.4/5.29 0–30

Community Ment Health J (2011) 47:164–170 167

123

adults in the context of the well-documented underutili-

zation of mental health services among minorities (e.g.,

U.S. Department of Health and Human Services 2001), the

present findings underscored the apparent paradox of

positive attitudes towards services being found in the same

group that has a long history of underutilization of these

services.

To explore the possible sources of this paradox, we

examined factors associated with attitudes towards ser-

vices. Several factors predicted. For example, those of

more advanced age were more likely to have unfavorable

attitudes toward mental health services. Such findings may

indicate cohort differences within the populations of His-

panics living in the United States. The younger cohorts

tend to be better informed of mental health issues and have

more exposure to mental health services than their older

counterparts. Such differences in experiences and expo-

sures may have led to the greater acceptance and willing-

ness to use mental health services among younger cohorts

of older adults. Considering that depressive symptoms are

more frequently experienced by older individuals with

advanced age, our findings call special attention to the

older cohorts of the elders in efforts to promote positive

attitudes toward mental health services. On the other hand,

it is also worth noting that ethnicity, in this case indicating

whether or not the respondent was of Cuban ancestry, did

not make a difference in attitudes.

The major focus of the present study was on the indi-

cators of misconceptions and personal beliefs associated

with depression. These indicators are of particular interest

because their existence has often been reported in studies

of minority populations including Hispanics (e.g., Gonz-

alez and Acevedo 2006; Leong and Lau 2001; Sirey et al.

2001). In the descriptive analysis, the sample was shown to

be quite prone to misconceptions and negative beliefs,

despite a generally positive attitude towards mental health

services. It is striking that more than half of the sample

thought that depression is a normal part of aging. More

than a third of the sample saw depression as a sign of

personal weakness, a figure that is considerably higher than

the 22% found in a recent national survey conducted by the

Mental Health America (2007). Substantial proportions of

the sample (62.3%) also showed a general apprehension

toward medications, and this finding is consistent with

those of other studies with Hispanics (e.g., Cabassa et al.

2007; Cooper et al. 2003).

More than 17% of the sample thought that counseling

brings up too many bad feelings (e.g., anger, sadness), and

such a belief was found to be significant in a multivariate

model predicting attitudes toward mental health services.

This finding underscores a need to increase public knowl-

edge and awareness about psychological treatments and

also suggests that counseling programs for Hispanic older

adults should target strength-based positive emotions rather

than problem-oriented negative emotions. A recent study

by D’Angelo et al. (2009) reports the effectiveness of

strength-based family-centered approach in treating

depression among Latinos with low income.

Although few individuals reported a concern about

family disappointment (8.1%), this concern was a signifi-

cant predictor to negative attitudes toward mental health

services in the multivariate analysis. This finding reflects

Table 2 Regression models of

attitudes toward mental health

services

Note: Gender (female = 1,

male = 0), ethnicity

(Cuban = 1, all others = 0),

marital status (married = 1,

not married = 0), educational

attainment (beyond high

school = 1, less than high

school or high school

graduate = 0)

* P \ .05, ** P \ .01,

*** P \ .001

Predictor Model 1 Model 2 Model 3

b t b t b t

Age -.19 -3.12** -.19 -3.09** -.19 -3.17**

Gender -.03 -.42 -.00 -.05 .03 .46

Ethnicity .04 .61 -.00 -.12 .03 .50

Marital status -.04 -.70 -.07 -1.08 -.05 -.93

Educational attainment -.02 -.35 .00 .07 -.01 -.27

Acculturation -.12 -1.87 -.10 -1.50

Self-perception of health .03 .43 .01 .16

Depressive symptoms -.12 -1.60 -.05 -.78

Normal part of aging .06 .98

Sign of personal weakness -.08 -1.42

Addictive .02 .32

Bad feelings -.29 -4.98***

Shame -.02 -.32

Family disappointment -.13 -2.15*

DR2 .03* .02 .12***

Overall R2 .03* .05* .17***

168 Community Ment Health J (2011) 47:164–170

123

cultural norms related to family expectations and inter-

personal communication among Hispanics that has previ-

ously been reported (e.g., Snowden 2007). Based on the

cultural values of ‘familismo,’ Hispanic older adults may

feel a greater sense of obligation and responsibility toward

their family; they may fear disappointing the family and

may not want to burden them. These cultural perceptions

associated with mental health and services should be taken

into consideration when developing intervention programs

for Hispanic older adults. For example, family involvement

in the process of mental health care seeking and treatment

is strongly encouraged.

In a supplementary analysis, the subgroup of individuals

who concerned about family disappointment (t = -2.18,

P \ .05) and the subgroup of individuals who thought

counseling would bring up too many bad feelings (t = -

2.64, P \ .01) were found to have significantly higher

levels of depressive symptoms than their counterparts. The

fact that those with a vulnerable mental health profile are

more prone to the negative beliefs about mental health care

underscores a need for intervention programs to promote

public knowledge and awareness of mental health services.

It is also possible that those individuals under distress are

more likely to have personal experiences of family disap-

pointment and negative encounters with counseling.

Some limitations of the present study should be noted.

Due to the study’s cross-sectional design and geographi-

cally defined, nonrepresentative nature of the sample,

causal inference and generalizability are not warranted.

Because the present sample was recruited from public

housing facilities, findings cannot be generalized to all

community-dwelling Hispanic older adults. The fact that

within-group variability across ethnic groups was not

addressed due to the limited sample size is also a limita-

tion. Despite these limitations, our findings identify sub-

groups and potential areas of focus for educational

interventions and campaigns to promote positive attitudes

toward mental health services in Hispanic older adults.

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