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Soc Sci Med. 2014 Feb;103:84-93. doi: 10.1016/j.socscimed.2013.09.009.

"What matters most:" a cultural mechanism moderating structural vulnerability and moral experience of mental illness stigma.

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Department of Epidemiology, School of Public Health, Columbia University, United States. Electronic address:
Department of Social Work, Columbia University, United States.
Department of Epidemiology, School of Public Health, Columbia University, United States.
Department of Psychology, Fordham University, United States.
Department of Psychiatry, Chinese University of Hong Kong, Hong Kong.
Department of Anthropology, Harvard University, United States; Department of Social Medicine, Harvard University, United States.


To understand Chinese immigrants' experiences with mental illness stigma and mental health disparities, we integrate frameworks of 'structural vulnerability' and 'moral experience' to identify how interaction between structural discrimination and cultural engagements might shape stigma. Fifty Chinese immigrants, including 64% Fuzhounese immigrants who experienced particularly harsh socio-economical deprivation, from two Chinese bilingual psychiatric inpatient units in New York City were interviewed from 2006 to 2010 about their experiences of mental illness stigma. Interview questions were derived from 4 stigma measures, covering various life domains. Participants were asked to elaborate their rating of measure items, and thus provided open-ended, narrative data. Analysis of the narrative data followed a deductive approach, guided by frameworks of structural discrimination and "what matters most" - a cultural mechanism signifying meaningful participation in the community. After identifying initial coding classifications, analysis focused on the interface between the two main concepts. Results indicated that experiences with mental illness stigma were contingent on the degree to which immigrants were able to participate in work to achieve "what mattered most" in their cultural context, i.e., accumulation of financial resources. Structural vulnerability - being situated in an inferior position when facing structural discrimination - made access to affordable mental health services challenging. As such, structural discrimination increased healthcare spending and interfered with financial accumulation, often resulting in future treatment nonadherence and enforcing mental health disparities. Study participants' internalizing their structurally-vulnerable position further led to a depreciated sense of self, resulting in a reduced capacity to advocate for healthcare system changes. Paradoxically, the multi-layered structural marginalization experienced by Chinese immigrants with mental illness allowed those who maintained capacity to work to retain social status even while holding a mental illness status. Mental health providers may prioritize work participation to shift service users' positions within the hierarchy of structural vulnerability.


Chinese; Culture; Health disparities; Immigrants; Psychosis; Stigma; Structural; United States

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