Kim N, Rabe M, Ding P, Li D, Shah I. Mental health of intracontinental Asian migrant communities: underrstanding the role of non-governmental organizations through a case study of ASSIST in South Korea. HPHR. 2021;37.
In many Asian countries such as Japan, China, the Republic of Korea, Nepal, Philippines, and Indonesia, governments lack the funding to address mental health, giving rise to scarcities in mental health services and large inequities in resource allocation amongst the socially disadvantaged, which include migrants and those living in rural areas. This study aims to understand the role of non-governmental organizations in addressing the mental health of intracontinental Asian migrant communities in various host Asian countries.
The first part of the study outlines and categorizes different types of intra-Asian migrant mental health NGOs that provide different forms of support through treatment, community care, research, training and capacity development, and education. The second part of the study presents a qualitative case study of two South Korean NGOs, ASSIST and Asian-Maeul: Migrant Community Center. The two NGOs have partnered to provide mental health support for intracontinental Asian migrant communities in South Korea. The study discusses results from semi-structured interviews of 3 migrants and 2 NGO personnel that have engaged with the NGOs.
Our research demonstrated that an integration of the treatment care, rehabilitation model and community-based prevention programs would provide a sustainable, community-centric model for mental health support in the long-term. Lack of funding and targeted information towards migrants were key limitations to this approach.
Further research needs to be conducted to better understand and analyze the role of NGOs in providing mental health support and services for migrants. With improved awareness of migrant community needs, communication with migrant communities, and implementation of new directions and programs, opportunities for mutual collaboration and improvement will arise between NGO providers, local migrant communities, and hospital service providers.
From marriage migrants to temporary foreign workers, the number of intracontinental Asian migrants in South Korea continues to grow rapidly, increasing from 1.1 million in 2012 to 1.4 million in 2016.1 In many Asian countries such as Japan, China, the Republic of Korea, Nepal, Philippines, and Indonesia, governments lack the funding to address mental health, giving rise to scarcities in mental health services and large inequities in resource allocation amongst the socially disadvantaged, which include migrants and those living in rural areas.2, 3 Migrants in Asia are often exposed to mental health risks such as depression, alcohol abuse, and PTSD due to strenous working conditions, experiences of displacement and discrimination, and limited access to mental health services.4 Additionally, cultural attitudes in Asian migrant communities downplay mental health issues, resulting in significant barriers to accessing mental health services.5
Asian migrants and returnees face unique mental health risks because of the complex ways in which they are isolated and marginalized. Different groups can have very specific mental health risk factors, reasons for migrating, and cultural aspects that play a role in how migrating or returning affects their mental health.
Female migrants often experience sexual assault as well as other forms of sexual exploitation that manifest through isolation and economic insecurity. A study of Nepalese female migrant factory workers between the ages of 14-19 found that not only had 12% of them experienced sexual harassment, but also that this harassment came from their employers, male coworkers, and partners.6 1 in 3 of the women reported being pressured into consuming alcohol with their harassers while 1 in 20 reported being pressured into watching pornographic films.
Migrant workers also find themselves particularly susceptible to workplace injuries because of the unsafe working conditions. The Korean-Chinese (commonly called Chosun-Jok) are currently the largest group of migrant workers in Korea, and accounted for approximately 45% of migrant workers in 2012.7 While Korean-Chinese experience relatively better conditions compared to other migrant worker groups as a result of their partly Korean ethnicity, they still experience numerous mental health risks such as anxiety and PTSD as a result of exposure to physical and chemical hazards.
Migrants with socioeconomic disadvantages are also vulnerable to exploitation through forced labor. According to the Global Slavery Index’s 2018, the Asia and Pacific regions have an estimated 24.9 million individuals in modern slavery, accounting for more than half of the approximately 40.3 million people in forced labor globally.8 Studies aiming to prevent and document migrant journeys reveal the contexts for migrant and returnee exploitation. One such study was the South Asia Work in Freedom Transnational Evaluation (SWiFT), a five year research program that aimed to evaluate trafficking interventions on migrants and returnees in Nepal, India, and Bangladesh.9 Beyond developing poignant insights into the lives and stories of migrants, the program also compiled data on the often neglected conditions of returnee women. Of the participating returnee women in Nepal, 91.2% reported having suffered forced labor.10 Similarly in India, 53.5% of the returnee female migrants reported they had limited input in the decision concerning their migration. The study concluded that pre-migration interventions focusing on education about trafficking risks did very little to help migrants overcome or avoid these types of situations.11
Migrants are also susceptible to alienation and consequently have higher risks for mental health. An ethnographic analysis of urban migrants in Shanghai found that migrants had difficulty expressing these sentiments. The study also concluded that survey results did not accurately reflect the mental state of Chinese migrant communities given the broader Chinese cultural values of endurance, limitations in the Mandarin vocabulary to express mental health concerns, and societal stigmatization of mental health. The results indicated that environmental factors did not accurately reflect Chinese migrants’ mental state because of both the broader Chinese cultural values of endurance and shame as well the fact that Mandarin lacks easy-to-use mental health vocabulary.12 A combination of stigma surrounding mental health and a feeling of cultural alienation presents a significant barrier for migrants to access the mental health care they need.
Due to the significant cultural and societal barriers, access to mental health resources is limited in Asian populations and for the migrant community in particular. Economic conditions and the lack of mental health services and providers have led to limited access to care in countries such as the Philippines, South Korea, Bangladesh, Nepal, China, and Thailand.13 Some countries have cultural and historical attitudes that present barriers to recognizing the need for mental health services. Japanese culture has historically stigmatized mental health, something that continues to affect citizens and especially migrants today. Individuals are deterred from seeking professional treatment and are instead expected to rely on their community, including their family and other relatives.14 In many cases, migrants do not have these strong tight-knit communities that would be expected to support them and suffer greatly from the lack of both governmental and social safety nets.15 In Nepal, suffering from any sort of mental illness is perceived as a “spiritual dysfunction” leading to individuals with mental disorders, and their families being discriminated against due to the stigma.16 Mental health literacy is extremely low, resulting in avoidance of treatment.
Where government or public health sector services fall short, non-governmental organizations have the potential to step in and deliver the type and quality of care that is needed for vulnerable populations. NGOs are driven by compassion and are recognized as welfare oriented nonprofits dedicated to promoting health and social development.17 Mental health NGOs (MHNGO) play a significant role in closing the mental health treatment gap, especially for persons that face discrimination and stigma because of their mental health.
There are four primary models in which MHNGOs provide comprehensive mental health support. The first model provides treatment-based care and rehabilitation. Facilitators to this care include providing psychosocial rehabilitation via community based service delivery models, engaging community members to assist efforts by training them in psychosocial and mental health issues, and creating multidisciplinary teams of service providers.18 The second model offers community-based activities and prevention programs.19 This model establishes trust of local communities through programs of primary prevention and through involvement with community partners such as centers and clinics. The third model focuses on research and training-based services.20 This type of MHNGOs are actively involved in research initiatives, and often collaborate with national and international agencies to investigate underlying mechanisms of mental disorders. Research may also assess the efficacy of programs and interventions and use client-interviews/evaluations to supplement the assessments. Finally, the fourth model centers around advocacy and empowerment.21 This category of MHNGOs advocate for the needs and rights of underprivileged and underserved populations, especially those with mental illnesses. It is also important to note that MNHGOs may engage and provide multiple models identified above.
The first model of MHNGOs provide treatment-based care and rehabilitation. The MHNGO identifies unmet needs of the populations they wish to serve, and develops treatment and rehabilitation programs accordingly. The range of treatment services depends on the conditions of focus and available resources, including government-partnership and donor models.22 Some examples of services include “in-patient care, out-patient clinics, day care programs, and residential care for individuals with chronic conditions”.13, 23 MHNGOs within this category prioritize in-person interactions with clients. An example of this model is the MS Chellamuthu Trust and Research Foundation located in Tamil Nadu, India.24 This MHNGO has institution-based rehabilitation programs in which people with mental illnesses are admitted into centers and receive therapeutic interventions under supervised care. MSCTRF provides both residential and non-residential rehabilitation facilities. For example, their Centres for Psychiatric Rehabilitation have five locations, and admission and determination of appropriate intervention is conducted by a committee of mental health professionals.
The second model of MHNGOs are based on community-based activities and prevention programs. NGOs have initiated community-based mental health programs, focused on establishing trust of local communities through programs ranging from primary prevention (e.g. suicide prevention) to involvement with community clinics.25 An example of this MHNGO is Basic Needs, an NGO based in Nepal.26 Through a mental health and development model, Basic Needs focuses on user empowerment, fosters community development, and strengthens the health system to integrate mental health into pre-existing community-based interventions.
The third model of MHNGOs are research and training-based. Some MHNGOs include research programs in which they investigate health areas ranging from infectious diseases to mental illnesses. MHNGOs may also work to develop the skills of their staff-members through workshops, conferences, and seminars to provide opportunities to train professionals and health workers in counseling skills.13 An example of this model of MHNGO is the Schizophrenia Research Foundation, also known as SCARF, located in Chennai, India. Affiliated with the WHO Collaborating Centre for Mental Health Research, SCARF initiates and supports research programs investigating the biological, social, and psychological aspects of schizophrenia in underprivileged communities.27
The fourth model of MHNGOs focus on advocacy for the needs and rights of underprivileged and underserved populations, especially those with mental illnesses. This could take the forms of documenting and distributing facts and information about mental health to reduce stigma, lobbying for policy change in mental healthcare, and publishing newsletters or an MHNGO website to encourage understanding of the challenges of mental illnesses.28 In general, these MHNGOs seek to raise awareness about mental health in different sectors, from teachers and laypersons to health workers. An example of this model is the Mental Health Awareness Foundation (MHAF) based in Maldives.29 Their goal is to destigmatize mental health using social media platforms, television, and radio. They also organize training programs in pre-existing human resources (health care workers and non-health professionals) to improve their knowledge and broaden their perspectives on mental illness.
Many MHNGOs employ both the community-based model (Model 1) and treatment-based rehabilitation model (Model 2) simultaneously, specifically by engaging community health workers in towns and villages to leverage social networks to more efficiently reach people. Many MHNGOs focus on acute care of the illness or mental health issue, as well as rehabilitation to promote long-term functioning. Oftentimes, government-funded mental health care by integration within primary health care services is not fulfilled properly. Thus, MHNGOs have initiated community-based programs, ranging from suicide prevention activities to providing community-based rehabilitation. For example, the Schizophrenia Research Foundation (SCARF) in Chennai, India, provides both treatment and rehabilitation through outreach clinics, and subsequent individual interventions such as independent living skills training and vocational skills training. A common thread with successful NGOs is the commitment to partnering with specialists, mental health professionals, and counselors to aid in the reintegration of the client into society.
In partnering with other community organizations and NGOs, MHNGOs can utilize its connections to link clients with employment opportunities, while implementing programs to destigmatize mental illnesses in the workplace. Some other examples of community based service delivery models include home visits for family support and attentive care (Raja et al., 2012),26 and school-based mental health services. MHNGOs utilize multidisciplinary care teams, which include lay-health workers (LHW), social workers/care managers, and mental health specialists. The international MHNGO BasicNeeds-UK supports a developmental NGO, NBJK, which manages several field-based community-based mental health programs. Within NBJK, a program manager liaises with a care manager, who sets up a specialist-LHW connection depending on the client’s need. The specialist trains and supervises the LHW, who goes on to provide psychosocial support. Furthermore, NBJK has partnered with a government psychiatric hospital (RINPAS) whose psychiatrists perform monthly outreach clinics.30
MHNGO activities supported by multidisciplinary teams of doctors, therapists, health workers, other professionals and volunteers provide the richest care, promoting partnerships not only between the medical and non-medical professionals, but also close collaboration between professionals and the clients’ family. Another important focus of NGOs is to address a deeper, culturally embedded barrier to mental health care, by creating awareness programs that focus on stigma reduction.
This second part of the study presents a qualitative case study of two South Korean NGOs, ASSIST and Asian-Maeul: Migrant Community Center, that have partnered to provide mental health support for intracontinental Asian migrant communities in South Korea. ASSIST provides legal and mental/general health relief clinics for migrant and returnee populations in South Korea, Bangladesh, Japan, China, Thailand, Nepal, and the Philippines. ASSIST aims to create a joint legal and psychological support system for migrants experiencing domestic abuse, sexual exploitation, forced/voluntary repatriation, and industrial accidents. 31 Asian-Maeul provides educational, legal, and health services to various Asian migrant communities in South Korea.32
ASSIST provides comprehensive mental health care to migrants through two avenues. First, ASSIST connects migrants to mental health professionals from psychiatry and psychology clinics in South Korea at no cost. Second, ASSIST provides online support groups that are led by EAP-certified counselors. ASSIST aims to “create a safe space for migrants to connect with others who have similar cultural backgrounds, experiences, and languages”.31 Through a partnership with Asian-Maeul, ASSIST has provided mental health support for more than 70 migrants in South Korea. ASSIST falls into the first and second categories of MHNGOs, providing treatment-based care and rehabilitation as well as community-based activities and prevention programs.
To better understand the role of MHNGOs and their categorizations, this section of the study interviews two NGO personnel from Asian-Maeul and three migrants that have engaged with ASSIST for mental health care. Data was collected using semi-structured interviews. All respondents that participated gave informed consent. Given that this was a case study, no formal IRB process was employed other than the internal processes with the Asian-Maeul. Data presented in this study conceals participants’ identities. The study design is detailed in Table 1.
The opinions of NGO personnel and migrants on the role and categorization of NGOs are presented in Table 2 and Table 3.
Table 1: Study Design
N = 2
A semi-structured interview
N = 4
A semi-structured interview
Table 2: Summary of opinions on NGO roles
Summary of opinions on NGO roles
NGO Personnel 1
Role of MHNGOs:
NGO Personnel 2
Role of MHNGOs:
Role of MHNGOs:
Role of MHNGOs:
Role of MHNGOs:
Table 3: Summary of opinions on NGO categorizations
Summary of opinions on NGO categorizations
Model 1: Treatment-based care & rehabilitation
· Most direct, effective type of care an MHNGO can provide, but is incredibly costly and difficult to maintain.
· Most practical and effective solution, but very costly.
· Most direct, effective type of care an MHNGO can provide, but could not locate and identify long-term programs. It was also difficult to get through the screening processes for certain programs.
· Effective but limited knowledge of these programs within migrant communities presented barriers to access.
· Most direct, effective type of care an MHNGO can provide. Language facilitators through ASSIST were especially helpful.
Model 2: Community-based activities & prevention programs
· Given the nature of mental health support, culturally nuanced care is especially important. This is only possible through community-based care and activities.
· Community-based groups can provide group support, given that migrant communities are closely tied and reliant on each other.
· This type of service is only effective if provided with treatment-based care & rehabilitation. This model alone does not help with migrants obtaining actual medical care.
· Effective in fostering a community among newcomers and providing stability.
· Not very important given that migrant communities rely on each other to begin with, so there is very little impact.
Model 3: Research & training-based activities
· Not as effective, as research & training-based activities are usually very costly and cannot be conducted within MHNGOs but rather at universities or academic institutions.
· Not as effective, as research & training-based activities are often conducted in a scholarly setting.
· Did not see examples of this at the centers or programs.
· Not sure, as there were no research/training-based activities in centers.
· Have not seen examples of research/training-based activities.
Model 4: Advocacy & rights
· Advocacy & rights activism increase awareness but doesn’t necessarily result in tangible support for migrants.
· Advocacy & rights activism provides awareness and brings important change for youth groups specifically.
· Important in concept, but direct action and support are more integral to solving mental health problems in migrant communities.
· Advocacy & rights activism provide awareness, but this doesn’t necessarily tangibly support migrants.
· Important ideas but tangible effects are hard to measure or see, would rather prefer financial support or connections to access medical care in mental health.
The summary of findings led to the following identification regarding the key roles of MHNGOs:
There were some key differences in understanding of NGOs’ role in providing mental health support depending on perspectives. NGO personnel placed more importance on ‘community-based care’ and ‘advocacy and rights’. On the other hand, migrants focused on direct, tangible impact by emphasizing the importance of ‘financial support’ and ‘access to mental health services’.
Previous research has demonstrated the “importance of understanding the role of NGOs in the country and in the mental health care system” as well as “the practical ways to improve the understanding of individual providers’ roles and cooperation”.23 Findings show that migrants and NGO personnel who have been involved in ASSIST and Asian-Maeul have differing perspectives on the role of NGOs. Migrants involved in the research study demonstrated a strong preference for a combination of community-based care and direct medical access. NGO personnel were more cognizant about the lack of funding surrounding such programs, especially given that they are ‘extremely expensive’ and ‘difficult to maintain’. NGO personnel were more encouraging of non-direct activism, including advocacy and rights movements.
A notable finding drawn from this study demonstrates that both NGO personnel and migrants recognized the need for an integrated approach to providing direct medical access and community-based care. This model was discussed earlier in this paper, with NGOs often combining Model 1 and Model 2. Upon further interviews, however, it was also identified that there were differences in specific integration processes that were thought to be effective. Migrants preferred a community-based approach to accessing medical care. For example, by having community centers provide financial support and connections to medical facilities, migrants would be able to get access and gain support of a larger system. On the other hand, NGO personnel emphasized the need for support within the migrant community centers in terms of support groups, classes, and activities. Therefore, it is clear that migrants in this study preferred community-centered provision of care rather than specific community-based activities.
The contribution is an analysis of ASSIST and Asian-Maeul, two NGOs based in South Korea. Due to this, there are several key limitations in this study. First, since this is a case study with a small sample size, the results cannot be generalized to the greater migrant population or the NGO landscape. Second, since the study is based in South Korea, there are cultural nuances of other Asian countries that were not fully understood in this study. Finally, there are study limitations due to the “sample selection and cross-sectional design, which to a certain extent, limit the findings’ generalizability.23
Further research needs to be conducted to better understand and analyze the role of NGOs in providing mental health support and services for migrants. With improved awareness of migrant community needs, communication with migrant communities, and implementation of new directions and programs, opportunities for mutual collaboration and improvement will arise between NGO providers, local migrant communities, and hospital service providers. Furthermore, there are clear differences in various forms of integration in medical access and community-based care. Therefore, it is especially important to include migrant perspectives to provide services that will best serve these migrant communities. It is critical to better understand and balance key stakeholders’ opinions surrounding intra-Asian MHNGOs to provide community-engaged care in mental health.
This study partnered with two non-governmental organizations.
Naryeong Kim is the executive director of ASSIST. Megan Rabe, Isha Shah, Phillip Ding, and Deney Li are undergraduate mental health coordinators of ASSIST.
Naryeong Kim is an undergraduate student at Stanford University double majoring in Bioengineering and Political Science. She is also the current executive director of ASSIST.
Megan Rabe is an undergraduate student at Duke University majoring in Neuroscience with a minor in Psychology. She is a current mental health service coordinator for ASSIST.
Phillip Ding is an undergraduate student at Duke University majoring in Statistics and Computer Science. He is a mental health service coordinator for ASSIST.
Deney Li is an undergraduate at Duke University majoring in Biology and double minoring in Chemistry and Psychology. She is a general health service coordinator for ASSIST.
Isha Shah is an undergraduate student at Duke University pursuing a self-designed major regarding the application of the biopsychosocial model to brain disorders. She is also a mental health coordinator for ASSIST.