East Asian Arch Psychiatry 2025;35:21-7 | https://doi.org/10.12809/eaap2467

ORIGINAL ARTICLE

Samara Hussain, Janet Hiu Ching Tse, Paul Wai Ching Wong, Mike Muk Yan Cheung, Rachel Ngan Yin Chan, Yun Kwok Wing, Steven Wai Ho Chau

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Samara Hussain, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
Janet Hiu Ching Tse, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
Paul Wai Ching Wong, Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China
Mike Muk Yan Cheung, Multicultural, Rehabilitation and Community Service, Hong Kong Christian Service, Hong Kong SAR, China
Rachel Ngan Yin Chan, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
Yun Kwok Wing, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
Steven Wai Ho Chau, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

Address for correspondence: Dr Samara Hussain, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. Email: samarahussain@cuhk.edu.hk

Submitted: 30 December 2024; Accepted: 3 February 2025

Introduction

During the COVID-19 pandemic, the prevalence of mental health issues increased worldwide, particularly among ethnic minorities. In Hong Kong, those from ethnic minority backgrounds often lack physical and psychological resources owing to language and cultural barriers and lower socioeconomic status. Pandemic control measures such as social distancing, home-schooling, and the closure of community centres hinder effective coping¹ and adversely affect mental health.^2-4 South Asians (ie, Pakistani, Indian, Nepali, and Bangladeshi) represent the largest ethnic minority group in Hong Kong.^5,6

For ethnic minority families, stable income from multiple elementary jobs is crucial for fulfilling basic expenses and supporting family members in their home country.7 In Hong Kong, the unemployment rate rose from 2.8% in 2019 to 7.2% in 2020 and was significantly higher among ethnic minorities.8 The suspension of flight services also prevented ethnic minorities from attending funerals in their home countries.9

Being homebound increases family conflicts and worsens parent-child relationships due to parental stress, particularly in low-income families.^2,10,11 Discrimination against virus carriers and a lack of multilingual COVID-19 updates also lead to uncertainty.^12,13 At peak pandemic stages, most mental health services from non-governmental organisations were suspended.¹⁴

Mental health issues are more prevalent among those of lower socioeconomic status and from ethnic minority backgrounds.^15,16 Among Hong Kong Chinese, 3 months after the first confirmed COVID-19 case, 19% had depression and 14% had anxiety, based on a cutoff score of >9 for the Patient Health Questionnaire-9 (PHQ-9) and the Generalised Anxiety Disorder-7 (GAD-7), respectively.¹⁷

This trend was also observed in the United Kingdom and the United States.^18,19 Among those with depression, 23.8% were of lower income and 11.2% were of higher income, whereas among those with anxiety, 22.5% were of lower income and 9.3% were of higher income.¹⁹ In the United States, compared with White people, the age-adjusted odds ratio for having depression symptoms nearly every day (a PHQ-2 score of ≥3) was 1.21 for Black people and 1.²³ for Hispanic people.³ Among Hong Kong South Asians, 72.6%, 12.9%, and 14.5% had moderate, severe, and extremely severe depression, respectively; similarly, 52.3%, 16.1%, and 31.6% had moderate, severe, and extremely severe anxiety, respectively.⁴

Poor sleep is a risk factor and an early sign of mental health disorders.²⁰ During the pandemic, the pooled prevalence of insomnia reached 23.87% worldwide.²¹ In Hong Kong, the prevalence of insomnia was 33.6% in April 2020,^22,23 whereas 62.8% reported poor sleep quality between August and October 2021; quarantine was associated with sleep disturbances.²⁴ In the United Kingdom, the prevalence of sleep loss was 24.7% overall and 32.0% among ethnic minorities.²⁵ In the United States, Black people had 4.3 times higher odds of having severe insomnia (Insomnia Severity Index [ISI] ≥22) owing to income loss or unemployment.²⁶ Ethnic minorities are disproportionately burdened by insufficient and poor- quality sleep.^27,28

Ethnic minorities face mental health inequalities, which were accentuated during the pandemic.¹⁴ Factors of such inequalities can be individual, family, social, cultural, and institutional. Individual factors consist of interpretation of mental health issues, expression of such needs, lack of such information, and poor access to such services. Spirituality is commonly used to conceptualise mental health.^29,30 Emotions and feelings are not fully expressed because they are considered shameful. Family and peers, despite being components of social support and coping, may hinder help-seeking and service utilisation. In Hong Kong, during the early stages of the pandemic, being single or divorced, having lower perceived knowledge of COVID-19, and having worries about losing job were predictive of higher levels of anxiety, depression, and/or stress, whereas being male, having a low monthly household income, and having worries about losing job were predictive of higher level of post-traumatic stress disorder symptoms.⁴

Stigma towards mental health and discrimination against ethnic minorities hinder help-seeking and access to mental health services.²⁹ Culturally adapted counselling services may cater the needs of ethnic minorities.³¹ This study aimed to determine the mental health status and help-seeking barriers and to identify predictors of help-seeking barriers among South Asians in Hong Kong at the end of the COVID-19 pandemic.

Methods

This cross-sectional study was conducted between January and August 2023. Using convenience sampling, South and Southeast Asian Hong Kong residents aged ≥18 years were invited to complete an online questionnaire in English (interpretation was available upon request) via booths in Yau Tsim Mong Districts. Compensation in terms of a HK$50 supermarket coupon was provided.

Anxiety in the prior 2 weeks was assessed using the GAD-7. The seven items are rated on a four-point Likert scale ranging from 0 (not at all) to 3 (nearly every day); total scores range from 0 to 21: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), and 15-21 (severe). A cut-off score of ≥10 was defined as at risk.

Depression in the prior 2 weeks was assessed using the PHQ-9. The nine items are rated on a four-point Likert scale ranging from 0 (not at all) to 3 (nearly every day); total scores range from 0 to 27: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), 15-19 (moderately severe), and 20-27 (severe). A cut-off score of ≥10 was defined as at risk.³²

Insomnia in the prior 2 weeks was assessed using the ISI.³³ The seven items are rated on a five-point Likert scale; total scores range from 0 to 28: 0-7 (none), 8-14 (subthreshold), 15-21 (moderate), and 22-28 (severe).³⁴ A cut-off score of ≥15 was defined as at risk.

Perceived barriers to help-seeking were measured using eight statements; responses were either ‘agree’ or ‘disagree’. Additionally, quality of life and quality of health were assessed using a visual analogue scale ranging from 0 to 100.

Results

Of 474 respondents, 273 were verified to be South or Southeast Asians and were included in the analysis (Table 1). Our sample differed significantly with the population in the 2021 Census³⁵ in terms of ethnic groups (p < 0.001) and age groups (p < 0.001). Our sample over-represented Pakistani (59.3% vs 17.5%) and under-represented Filipino (2.2% vs 18.8%), Indonesian (1.1% vs 6.4%), Thai (0.4% vs 8.2%), Indian (20.1% vs 27.8%), and Nepalese (16.9% vs 21.3%). Additionally, our sample over-represented those aged 15 to 24 years (27.8% vs 11.4%) and those aged 25 to 44 years (59.0% vs 34.4%) and under-represented those aged 45 to 64 years (12.5% vs 25.8%) and those aged ≥65 years (0.7% vs 8.6%). Internal consistency (Cronbach’s alpha) was 0.92 for the GAD-7, 0.90 for the PHQ-9, and 0.90 for the ISI.

Of the participants, 13.6%, 22.8%, and 12.1% were at risk of developing anxiety, depression, and insomnia, respectively. Self-report quality of life and quality of health scores were 70.3 and 67.9, respectively. Regarding perceived barriers to help-seeking, 24.9% to 33.3% agreed that they were unwilling to seek help from family/friends or professionals; 37.0% were unsure where to seek help; 56.0% agreed having cultural/language barriers; 68.9% agreed having cost concerns; 48.7% agreed being too busy to seek help; 42.9% believed that the problem would go away by itself; and 32.6% agreed that having a mental health disorder would be considered shameful by their family.

Compared with those not at risk, those at risk of developing mental health disorders (anxiety, depression, or insomnia) were younger (34.0 vs 29.6 years, p = 0.003), not married (27.7% vs 43.6%, p = 0.02), and had lower quality of life score (77.3 vs 52.6, p < 0.001) and quality of health score (75.4 vs 49.1, p < 0.001). They also more frequently reported having cultural/language barriers (50.2% vs 70.5%, p = 0.004), having cost concerns (64.1% vs 80.8%, p = 0.011), being too busy to seek help (41.5% vs 66.7%, p < 0.001), and that their family considered having mental health disorders to be shameful (25.1% vs 51.3%, p < 0.001) [Table 1].

In the Pearson correlation analysis, those who were younger and not married were more likely to be at risk of developing mental health disorders, whereas males, full- time workers, those with a lower education level, and those at risk of developing mental health disorders were more likely to report having help-seeking barriers (Table 2).

In the multiple regression analysis, after controlling for age, sex, ethnicity, marital status, total monthly household income, quality of life, and quality of health, predictors of perceived barriers to help-seeking were full- time employment (p = 0.02), having a lower education level (p = 0.02), and being at risk of developing mental health disorders (p = 0.02) [Table 3]. These predictors explained 14.3% (adjusted R2 = 0.11) of the variance (F(10, 248) = 4.135, p < 0.001).

Discussion

Compared with the early stages, at the end of the pandemic, the prevalence of anxiety remained at 13.6%, but the prevalence of depression slightly increased from 19.8% to 22.8%.¹⁷ Approximately one-third of the participants were at risk of developing one or more mental health disorders; depression was more common than anxiety and sleep problems. Those at risk tended to be younger and not married and had more help-seeking barriers (cultural and/ or language barriers, cost concerns, being too busy to seek help, and their family considering mental health issues to be shameful). Younger South Asians have constantly evolving roles and responsibilities and therefore are subject to additional pressures.^3,4,30 In Hong Kong, there are double stigmas towards ethnic minorities and mental health disorders,²⁹ as well as a lack of culturally sensitive and language barrier-free mental health services.³⁰ South Asians may face employment difficulties due to language barriers; they often work in elementary or labour-intensive jobs, and the nature of these jobs can be stressful and cause mental health issues,³⁶ leaving limited time for self-care. In Hong Kong public hospitals, the cost per attendance is HK$60 (US$7.66) for psychiatric services and HK$180 (US$22.99) for accident and emergency services.³⁷ South Asians may be unfamiliar with the psychiatric services that are available in the public sector. Additionally, long waiting times38 and cultural and/or language barriers may limit their help-seeking.

To address the help-seeking barriers, culturally sensitive, multilingual information about access to mental health services, fees and charges, and mental health education should be provided. Immediate attention is needed for those who are too busy (ie, those in full-time employment) to seek help. Workplace mental health programmes can be organised, which may include mental health awareness, stress management, work-life balance promotion (eg, flexibility in working hours, paid leave for mental health issues, short breaks for praying), and promotion of a culturally sensitive working environment. The availability of mental health service is limited; District health centres should customise mental health support elements and improve their promotion to those from ethnic minority backgrounds. Mental health service providers should recruit more frontline staff or peer support workers from minority backgrounds to facilitate more effective communication and education. Multilingual digital platforms can be used to minimise time and cost concerns, as well as language and cultural barriers.³⁹ For example, the Salamat platform is a multilingual online platform for mental health screening and referrals.⁴⁰

This study has several limitations. The cross-sectional design cannot establish causality or capture changes over time. Pakistani people were over-represented; this limits the generalisability of findings to the other South Asian populations in Hong Kong. The self-report assessment tools may differ from the clinical evaluation by psychiatrists.

Conclusion

Among South Asians in Hong Kong, those who were younger and not married were more likely to be at risk of developing mental health disorders, whereas males, full-time workers, those with a lower education level, and those at risk of developing mental health disorders were more likely to report having help-seeking barriers. The predictors of perceived barriers to help-seeking were full- time employment, a lower education level, and being at risk of developing mental health disorders.

Contributors

SWHC designed the study, acquired the data, analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. SH acquired the data, analysed the data, and drafted the manuscript. JHCT designed the study. MMYC acquired the data. YKW, RNYC, and PWCW critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

Funding / support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Ethics approval

This study was approved by the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (reference: SBRE-22-0238). The participants provided written informed consent for all treatments and procedures and for publication.

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