CALIFORNIA STATE UNIVERSITY, NORTHRIDGE Barriers to Mental

Home , Armenian Americans

CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

Barriers to Mental Health Services Among Armenian-American Aged 55 and Over

A graduate project submitted in partial fulfillment of the requirements

For the degree of Master of Social Work

Marine Bambakyan

In collaboration with

Lilian Arellano

May 2016

The graduate project of Marine Bambakyan is approved:

______

Dr. Amy C. Levin Date

______

Dr. Jodi L. Brown Date

______

Dr. Hyun Sun Park, Chair Date

California State University, Northridge

TABLE OF CONTENTS

Signature Page ii

Abstract iv

Chapter 1: Introduction 1 1

Problem Statement and Research Question

Chapter 2: Literature Review 3

Chapter 3: Methods 7

Research Design 7

Sampling 7

Data Collection 8

Measurement 9

Chapter 4: Analysis & Findings 10

Chapter 5: Discussion 13

Limitations 14

Implications 15

Conclusion 15

References 17

Appendix A: Table 1- Characteristics of Demographic Variables 19

Appendix B: Table 2- Barriers to Accessing Mental Health Services 21

Appendix C: Survey Questionnaire 23

Appendix D: Addendum 30

iii

Abstract

Barriers to Mental Health Services Among Armenian-American Aged 55 and Over

Marine Bambakyan

Master of Social Work

The purpose of this study is to identify the barriers that prevent older

Armenian-Americans aged 55 and over, who live in residential buildings, from accessing mental health services. Limited research exists on the berries older

Armenian-Americans encounter while trying to access mental health services. The available research found that there is a significant under-utilization rate of mental health services by ethnically diverse groups. This research was a quantitative study, for which sampling took place in Magnolia Towers, a residential building which houses a diverse group of older Armenian American adults. Survey questionnaires were distributed to one hundred Armenian residents at the building and a sample size of 37 completed surveys was collected as a result. Researchers concluded that, depending on the age, length of residency, language proficient and education levels,

the significance of identified barriers of accessing mental health services might wary among Armenian American older adults.

CHAPTER 1

INTRODUCTION

Problem Statement and Research Question

Armenian-American older adults, ages 55 and above, encounter various barriers in obtaining mental health services. Sate of the State II 2013, articulates there is approximately half a million Armenians currently residing in the US and the number is growing. Despite the increasing population, there is a lack of research focused on issues of access and barriers to services as well as outreach strategies within the Armenian community. Therefore, a valuable and needed problem to be studied is the barriers older

Armenian-American adults encounter when seeking mental health services. The purpose of the study is to identify the barriers that prevent older Armenian-Americans who live in residential buildings from accessing mental health services. Since mental health issues are viewed and understood differently by individuals from various cultures and ages, the identification of the barriers older Armenian-Americans encounter will provide an understanding of the specific barriers, which may relate to culture, stigma, societal views both in Armenia and United states, and familial experiences. An examination of barriers is vital to mental health providers for the purpose of understanding the issues of access and to determine how to improve greater access for older Armenian-American adults.

The research is a quantitative study, which will utilize an anonymous survey that was developed by the study’s researchers. The survey seeks to address the study’s research question, which is, what are the barriers older Armenian-Americans encounter while accessing mental health services? The survey includes questions regarding participants’ demographics, as well as attitudes and beliefs about mental health. The

results of the study will demonstrate to be significant for the social work profession by adding to the limited research available regarding older Armenian-Americans. In addition, the results will promote a greater understanding of the Armenian-American culture and will encourage the development of methods to better serve the Armenian-American community. Furthermore, identifying barriers to accessing mental health services will improve providers’ ability to serve this community more effectively.

CHAPTER 2

LITERATURE REVIEW

Within research, there are limited studies, which focus on Older-Armenian American adults and the barriers they experience when accessing mental health services. A reason for this may that racial and ethnic minorities in the United States have less access to mental health services and are more likely to receive poor-quality care compared to the dominant population

(McGuire, & Miranda, 2008), therefore, creating less of an emphasis on the minority groups such as the Armenian population. According to McCarthy, Harutyunyan, Smbatyan, and Cressley

(2013), there is a similar pattern of disregard internationally for Armenians, for example various research on mental health issues and counseling has recently been addressed in regards to

“neighboring Turkey, Ukraine, and Iran, but the literature is scant on these topics specific to

Armenia”. Hence, the lack of research is not only within the United States but also internationally, which further illustrates the need to develop a greater understanding and research on the

Armenian population

Within the research that is available, some studies have focused on the Armenian community in the United States and Armenia by identify the role religion and family dynamics have regarding ideas about the cause of mental illness, while others focus on the impact of acculturation stress, opinions about mental illness and attitudes about seeking psychological help, as well as the importance of maintaining cultural identity and the relationship with seeking services (Ayvazian, 2008; Baliotis, 2004; “State of the State II”, 2013; Yesayan, 2014). For instance, according to Baliotis (2004), “high religious and Orthodox Christian commitment strongly predicts high levels of religious ideas about the causes of mental illness and religious attitudes toward seeking treatment”. Although not explicitly stated, religion can pose as a barrier to accessing mental health services and can be difficult to penetrate due to the high value placed on religion within the Armenian culture.

Furthermore, many studies have highlighted the role family dynamics have on attitudes towards mental health issues and services. For instance, Van Baelen, Theocharopoulos, and

Hargreaves (2005), identified that in Armenia, individuals with a mental health disorder are

“hidden away by their family members, who are ashamed of them”. The family members of individuals with mental health disorders may be afraid of the stigmatizing label that can persist for a lifetime which may have indirect consequences on other members of the family since mental health issues are considered to be hereditary (McCarty et al., 2012). Currently, in Armenia, individuals with a mental health disorder and their entire family are socially isolated from the community due to the stigma associated with mental health disorders. Furthermore, Van Baelen et al. (2005), found that the Armenian government reinforces the stigma aimed at individuals with mental health disorders by requiring them to obtain a psychiatrists’ approval before applying for a driver’s license or a government level employment. The shame and stigma of mental health disorders and services perpetuated in Armenia are found to carry over with immigrant Armenians residing in the United States and may impact their willingness to talk about and seek mental health services. Along with shame and stigma, a lack of knowledge surrounding mental health disorders within the Armenian culture truly poses immense barriers in the pursuit of mental health services for those suffering with a disorder.

Moreover, Older-Armenian Americans’ attitudes and beliefs about mental health may stem from Armenia’s mental health services’ history and current state. According to Von Schoen-

Angerer (2004), there has been a blatant disregard for the care of those with mental health disorders in psychiatric hospitals in Armenia. For instance, in 1995 one of the psychiatric hospitals in Armenia cut the electricity at night during winter and disposed of patients’ dead bodies by carrying them over a hill and leaving them for the animals eat. The blatant disregard for those with mental health disorders in Armenia may have an immense impact on the value and attitudes towards not only those with mental health disorders but also mental health services in the

United States. Despite the low number of studies done in Armenia, the studies present a

methodological strength due to the ability of tracing back perceptions of mental health to the populations’ country of origin. Additionally, these studies add to the understanding of mental health service systems as well as the stigma surrounding mental health disorders in Armenia, which in return, contribute to the attitudes, and beliefs Armenian-Americans have towards mental health.

Immigrating to a new country can create various health disparities, which warrants greater research centered on minority groups. According to the surgeon general’s report, there are recognizable health disparities among immigrant populations in the United States since “resettling in a foreign country is a significant source of stress, immigrants are at risk of developing more mental health disorders than members of the host country” (Martin, 2009). Furthermore, studies on mental health among immigrants attribute poor mental health to pre-migration and post- migration stress (Bogic et al., 2012). According to Hollander, Bruce, Burstrom, and Ekblad, “pre- migration factors include income level in the immigrant’s country of origin and immigrant subgroup, and, for refugees, fear of persecution and experience or threat of torture and injuries: the cumulative exposure to trauma such as torture is also a factor to include” (2013). Post- migration factors include working and living conditions, and personal factors such as time in the host country, social support, language, and acculturation status (Malmusi et al., 2010). These factors can influence the ability of Armenian immigrants to understand and adapt to the new culture, which may contribute, as previously mentioned, to stress and the development of mental health issues. The effects of pre and post-migration factors can be particularly impactful on first generation older Armenian immigrants due to their attempts to adjust to a westernized culture with limited resources and cultural knowledge of the host country while simultaneously struggling to maintain their cultural identity (Jernazian, 2012). Even if a mental health disorder is apparent due to pre and post-migration factors there may still be a push-back to mental health services as a means to maintain cultural identify. The struggle to maintain a cultural identity can act as a barrier

to accessing mental health services since services can be considered to be part of the westernized culture.

Similarities and contradictions regarding the barriers encountered by Armenians have been identified within the literature done in the United States. For example, as a result of historical and generational trauma, such as the Armenian genocide of 1915, some studies have found Armenians tend to be wary of outsiders when help is offered, taking time to assess whether outsiders are hostile, friendly, or neutral, which can cause a delay or refusal in accessing services

(Von Schoen-Angerer, 2004; George-Mullins, 2004). Additionally, previous studies have focused on the fact that services are not accessed because of stigma and beliefs surrounding mental health within the Armenian population (Tanielian, 2012). In contrast, some research argues the lack of access to mental health services within the Armenian-American community may be due to the lack of accessible healthcare services and the inability to pay for such services. In addition, some research states that as a result of many older Armenian-American adults immigrating to the

United States at a later age they may still view the healthcare system in the United States similar to that of Armenia which requires up front payment regardless of health insurance coverage and may ultimately deter them from accessing mental health services in the United States.

CHAPTER 3

METHODS

Research Design

The research design for the study is a quantitative survey created by researchers to identify the barriers older Armenian-Americans face when accessing mental health services. The rationale for the survey research design stems from a general understanding of the Armenian cultures’ apprehension to discuss mental health due to the stigma both in

Armenia and United States. Furthermore, the Armenian culture is a collective culture, which typically seeks help and support within their culture or immediate and extended family. Therefore, as a means to reduce resistance in answering questions from outsiders about information that may be perceived as private or as a family matter, the anonymous survey may prompt greater willingness to provide information. Another variable, which influenced the rationale for the utilization of a survey research design, is the purpose of the study, which seeks to identify the barriers rather than explain the impact of the barriers. A survey, therefore, will provide a clear and concise understanding of the barriers and will equip researchers with the desired information. In addition, surveying participants is convenient and feasible given the limited time and resources available to conduct the study.

Sampling

The sampling procedure took place in Magnolia Towers, a residential building which houses a diverse group of older adults who are low-income, immigrant residents.

Subjects have been recruited through convenient sampling from the MJ Housing and

Services agency which provides services to Magnolia Towers, and only included older

Armenian-American adults ages 55 and above, both male and female who were born outside of United States. Older Armenian-American adults born in the United States, if any, will be excluded. As a means of limiting recruitment of participants to older

Armenian-Americans born outside of the United States, researchers will use a list of residents, provided by the agency, which will only include the names and room numbers of Armenian residents born outside of the United States. The sample size collected is about 40 to 43 surveys, which still need to be analyzed by researchers. In terms of consent, consent has been obtained in an anonymous fashion and participants have received a cover letter with the survey which addresses the purpose of the study, a voluntary invitation to participate and the requirements of participation, an explanation of the survey, benefits, methods to ensure confidentiality and the researchers’ and faculty advisor’s information for inquiries.

Data Collection

Using the list of eligible participants, the onsite social worker distributed the surveys by dropping them in the participants’ mailboxes. After completion, the participants sealed the surveys in a provided envelope and submitted it into a box located within the social work office. Sealing the anonymous survey in an envelope has ensured further anonymity for participants and created a sense of privacy. Furthermore, ethical issues have been avoided in the process since there is no direct contact with participants and no identifiable information on the survey. In addition, placing the collection box in the social worker’s office provided participants with a convenient and familiar location to submit their survey. As a means of securing the surveys and ensuring unanimity, the surveys have been kept in a locked cabinet, limiting access only to the researchers.

Measurement

The variable measured in this research study is the perceived barriers that

Armenian-American older adults encounter while seeking mental health services in

United States. Barriers are defined as anything, which impedes and/or limits access to mental health services. The measurement instrument utilized for this research study is a survey questionnaire consisting of 15 questions based on research regarding possible barriers to accessing mental health services and researchers’ knowledge of Armenian culture. The survey with whom the instrument has been tested is older Armenian-

American adults. The survey has two versions, one in English and one in Armenian.

Translation for the Armenian survey was done by one of the researchers who is fluent in

English and Armenian and was reviewed by four non-participant individuals also fluent in

English and Armenian. Feedback, which was given by the non-participant reviewers, created greater clarity and measurement equivalence in the translated survey. Within the survey, there are 8 nominal questions and 7 Likert Scale questions ranging from strongly disagree to strongly agree. Since the researchers are not using a standardized survey and have developed their own survey questionnaire, the reliability and validity of the instrument is unknown and therefore limited.

CHAPTER 4

ANALYSIS & FINDINGS

The data was analyzed using SPSS (Statistical Package for the Social Sciences) version 22. Descriptive analysis was conducted for all the variables of the study, which include demographic variables and variables of barriers. Since this is a quantitative study, researchers decided to use SPSS in order to identify the frequencies for both demographic and barrier variables. This will provide researchers with information about the frequency of demographics and mental health barriers as well as the ability to make educated connections between variables. A total of 42 surveys were collected, three surveys were removed from the study due to missing information on either demographic or barrier variables. Furthermore, two surveys were removed due to participants not meeting criteria for the study, such as being a 2nd generation Armenian. Excluding the five surveys resulted in the sample size reducing to 37 qualified surveys. Using descriptive analysis for the 37 surveys, frequencies were run to identify the demographic and barrier variables of all the participants.

Table 1 shows the demographic characteristics of the participants. Out of 37 respondents, there were 13 males and 24 females. The majority of participants (56.8%) were Armenians from Armenia, and as required all of them were 1st generation

Armenians born outside of United States. More than half of the participants were 65 years old or over and only (35.1%) were 55-65 years old. Out of 37 participants, fourteen

(37.8%) reported being married, ten (27.0%) were widowed, six (16.2%) were single and seven (18.9%) were divorced. The majority of the participants (54.1%) reported having two children. In terms of education, slightly less than half (48.6%) of the participants

received a high school diploma, and the remaining participants reported having a bachelor’s degree (29.7%), having some college education (13.5%) and having less than a high school education (8.1%). The results for English language proficiency demonstrated that eighteen (48.6%) of the participants had basic knowledge, eight (21.6%) were conversant, ten (27%) were proficient and one (2.7%) of the participants was fluent. Table

1 below outlines the aforementioned demographics.

(INSERT TABLE 1)

The second part of the survey shown in table 2, sought to identify the barriers faced by older Armenian American adults who live within a residential building. The barriers ranged from insurance coverage to perceptions of shame surrounding seeking mental health services. Some findings within the survey ran contrary to research findings, suggesting participants within this study differ from participants in other studies such as living arrangements, more time within the United States, greater English language proficiency, greater access to resources, etc. Beginning with knowledge surrounding health insurance coverage, most participants believe their insurance covers mental health services (75.7%), while the remaining (24.3%) believe their insurance does not cover mental health services. Another barrier addressed in the survey is knowledge about mental health disorders. In general, the majority of participants (67.6%) felt they do not have enough knowledge about mental health disorders, whereas 32.4% of participants felt they are knowledgeable about mental health disorders. Contrary to the researcher’s knowledge and research findings, about 67.6% believe in mental health treatments, while only a smaller portion of the participants (32%) do not believe in mental health treatments. This finding demonstrates that mental health and/or mental health services are

not as stigmatized within residential buildings, which provides convenient services to its residents. Despite the high percentage of participants’ belief in mental health treatment,

75.7% of participants stated they are unaware of what services are available to them. The lack of awareness about services may be due to the absences of Armenian mental health providers, about 63% of participants stated there is a lack of Armenian providers. Similar findings regarding the lack of Armenian mental health providers were cited in other studies as a major barrier to accessing services, specifically within Armenian and other immigrant communities. Another barrier which could be impeding participants’ access to mental health services is their country of origin’s availability of mental health services which, if widely available, could normalize seeking services in the United States. Within the study, slightly more than half of the participants (56.8%) expressed mental health services were not readily available in their country of origin, while 43.2% expressed it was readily available. Finally, the last barrier identified was the participants’ perceived shame surrounding seeking mental health services. Despite research linking mental health and shame within the Armenian culture, 67.6% stated they are not ashamed to seek mental health services, and 32.4%, stated they are ashamed. Refer to table 2 below for display of these results.

(INSERT TABLE 2)

CHAPTER 5

DISCUSSIONS

Previous studies have focused on the minimal access to mental health services within the

Armenian population due to the stigma and shame surrounding mental health disorders and even greater stigma attached to seeking professional services (Tanielian, 2012). The shame and stigma associated with mental health disorders and services can be considered to stem from mental health perceptions within Armenians country of origin. Research suggests, perceptions from their country of origin are found to carry over to the United States, which may impact the willingness of the Armenian community to seek mental health services. The findings in previous research is supported by the current research which identified that 54% of the participants stated mental health services were not readily available within their country which may be due to the strong stigma and shame associated with mental health within Armenia, Iran, and Lebanon. Although there were similarities within the previous research and the current research, numerous findings, regarding barriers, were inconsistent within the current study’s findings. For instance, this study demonstrated that 62% of participants reported not being ashamed to access mental health services. Moreover, 62% of participants disagreed with the statement ‘I do not believe in mental health treatment’, which may demonstrate a greater belief in the helpfulness of services and absence of shame and stigma associated with mental health disorders. Both finding could be a result of the participants’ ability to easily access services within their building through their residential social worker as well as the possibility of participants’ exposure to services and information regarding mental health.

Furthermore, research done in the United States found that because of historical and generational trauma due to the Armenian genocide of 1915, Armenians are found to be wary of outsiders and tend to have a hard time trusting those outside of their culture. Additionally, Von

Schoen-Angerer (2004), and George-Mullins, (2004) state that the lack of trust may also cause a

delay or refusal of services. The general lack of trust of outsiders may create a strong desire to access services provided by an Armenian mental health specialist within a culturally sensitive environment. The absence of Armenian mental health providers is evident to 54% of participants who agreed there is a lack of accessible Armenian mental health providers within their community. Along with previous research, this finding suggests the lack of Armenian providers may limit the Armenian community’s’ inclination to access mental health services; therefore, more Armenian providers are needed to assist this specific population. In addition, the current study found that 64% of participants believe their insurance covers mental health services; however, 67% of participants do not have enough knowledge about mental health disorders, which can limit their understanding of what is considered a mental health disorder, and the types of services they can access through their insurance. Other factors such as language proficiency, age, education, age of immigration, and marital status, can play an important role on Armenians’ perceptions of barriers to accessing mental health services.

Implications

Implications that can be extracted from the current study for social workers and researchers is to conduct more research within the Armenian-American older adult population as well as within the general Armenian population. Future research needs to be conducted regarding the barriers the Armenian population encounters while accessing mental health services and their impact as well as identifying effective outreach strategies that build upon the strengths of the

Armenian population such strong family ties, as well as care and respect for elders. Including these strengths within outreach strategies combined with education about mental health disorders can create a greater likelihood of minimizing stigma and shame within the family and creating an environment, both clinically and within the community, that is open and supportive of those with mental health disorders and services. New research can also help social workers better assess and understand the population, build rapport and develop effective engage strategies.

Limitations

There are several limitations within the present study. One of the limitations is the convenient sampling procedure, which minimized the opportunity to recruit a representative sample of the general Older Armenian-American adult population. Additionally, participants were exclusively recruited from a senior residential building, which offers resources and services onsite, therefore, focusing on a specific population that may differ from the general Older

Armenian-American adult population. Furthermore, the study focused on first generation

Armenians resulting in a small sample size of 37 completed surveys. This limitation was compounded due to the researcher’s time limitations, which restricted their ability to collect more surveys.

Another limitation is the researcher created survey questionnaire, which lacks validity and reliability as well as clarity in some questions that may have left participants to their own subjective interpretation of the question. Moreover, this survey lacked specific questions that could have helped address particular issues which emerged later in the study. These limitations existed within the study due to the researchers lack of experience regarding creating and conducting a research study. All of these limitations point to the need for further research within this particular population’s perception of mental health, barriers, and access to services.

Conclusion

Substantial research has been done around barriers to mental health services among minority groups; however, there is a need to conduct more culturally sensitive research among the

Armenian population. The purpose of current research was to identify the barriers older

Armenian-American adults, ages 55 and older experience while accessing mental health services.

The main findings contradicted previous research and the current study’s researchers’ knowledge about the Armenians’ views and understanding of mental health services. More culturally sensitive research will help identify barriers towards accessing mental health services and perceptions about mental health disorders. Furthermore, research will enhance mental health

providers’ pursuit in educating the Armenian community about mental health through improved outreach strategies, a greater understanding of the culture and culturally sensitive evidence based practices.

References

Ayvazian, A. (2008). Relationship between opinions about mental illness, help seeking

behaviors and acculturation among Armenian American women n.p.: ProQuest

Dissertations Publishing.

Baliotis, V. (2004) Ideas about causes of mental illness and attitudes towards seeking

treatment as related to acculturation style, religious commitment, and Orthodox

Christian commitment in Greek-Americans. n.p.: ProQuest Dissertation

Publishing

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A. , Priebe, S. (2012). Factors associated with mental disorders in long-settled war

refuges: refugees from the former Yugoslavia in Germany, Italy and the UK. BR J

Psychiatry. 200:216y223. doi:bip.bp.110.084764; pii:10.1192/bjp.bp.110.084764

George-Mullins, D. (2004). Identifying and addressing cultural obstacles to accessing

domestic violence services for Armenian-speaking battered women. n.p.:

ProQuest Dissertations Publishing.

Hollander, A. , Bruce D. , Burström, B. , & Ekblad, S. (2013). The association between

immigrant subgroup and poor mental health: A population-based register study.

The Journal of Nervous and Mental Disease, 201(8), 645-652.

Jernazian H. D. (2012). Differences in perceptions of psychotherapy between first-and

second-generation Armenians. Doctoral dissertation. Retrieved from ProQuest

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showing the complex interactions between gender, social class, and place of

origin. . Soc Sci Med. 71:1610Y1619. doi:DOI 10.1016/j.socscimed.2010.07.043.

Martin, S. (2012). Exploring discrimination in american health care system:

Perceptions/experiences of older iranian immigrants. Journal of Cross-Cultural

Gerontology, 27(3), 291-304.

McCarthy, J. , Harutyunyan, H. , Smbatyan, M. , & Cressley, H. (2013). Armenia:

Influences and organization of mental health services. International Journal for

the Advancement of Counselling, 35(2), 100-109.

McGuire, T., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities

in mental health: Policy implications. Health Affairs, 27(2), 393-403.

STATE OF THE STATE II: 2013 Reducing Disparities in Mental Health (2013).

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Association in California. Retrieved from http://remhdco.org/wp-

content/uploads/2013/05/State-of-the-State-II-Armenian-DeafHard-of-Hearing-

Communities-FINAL.pdf

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psychological services. Alliant International University.

Appendix A

Table 1- Characteristics of Demographic Variables

Table 1 Characteristics of Demographic Variables (N=37)

Variables n % M SD

Gender Male 13 35.1 Female 24 64.9

Ethnic Background Armenian From Armenia 21 56.8 Persian-Armenian 8 21.6 Lebanese-Armenian 8 21.6

Age 55-65 13 35.1 65-75 16 43.2 75-85 7 18.9 85-over 1 2.7

Marital Status Single 6 16.2 Married 14 37.8 Divorced 7 18.9 Widowed 10 27.0

Children 0 6 16.2 1 7 18.9 2 20 54.1 3-more 4 10.8

Generation 1st Generation 37 100.0

Level of Education Less than High School 3 8.1 High School 18 48.6 Some college 5 13.5 Bachelor’s Degree 11 29.7

Appendix B

Table 2- Barriers to Accessing Mental Health Services

Table 2 Barriers to Accessing Mental Health Services (N=37)

Variables n % M SD

English Language Knowledge Basic Knowledge 18 48.6 Conversant 8 21.6 Proficient 10 27.0 Fluent 1 2.7

My insurance does not cover mental health services Strongly disagree 4 10.8 Disagree 24 64.9 Agree 9 24.3 Strongly Agree 0 0

I do not have enough Knowledge about mental health disorders Strongly disagree 2 5.4 Disagree 10 27.0 Agree 25 67.6 Strongly Agree 0 0

I do not believe in mental health treatment Strongly disagree 2 5.4 Disagree 23 62.2 Agree 11 29.7 Strongly Agree 1 2.7

I am unaware of what (mental health) services are available Strongly disagree 2 5.4 Disagree 7 18.9 Agree 27 73 Strongly Agree 1 2.7

There is a lack of Armenian mental health providers Strongly disagree 2 2.7 Disagree 13 35.1 Agree 22 59.5 Strongly Agree 1 2.7

Mental health services were not readily available in my country of origin Strongly disagree 3 8.1 Disagree 13 35.1 Agree 20 54.1 Strongly Agree 1 2.7

I am ashamed to seek mental health services Strongly disagree 2 5.4 Disagree 23 62.2 Agree 12 32.4 Strongly Agree 0 0

Appendix C Survey Questionnaire

Research Information Researchers: Marine Bambakyan & Lilian Arellano Department of Social Work 18111 Nordhoff St. Northridge, CA 91330 (818) 859-0502 & (818) 383-3274 [email protected] & [email protected] Faculty Advisor: Hyun-Sun Park, MSSW, Ph.D. Department of Social Work 18111 Nordhoff St. Northridge, CA 91330 (818)677-4328 [email protected]

The purpose of this research study is to identify the berries to mental health services among Armenian-American adults, aged 55 and over. You are invited to participate in the study if you are of Armenian descent and are at least 55 years of age or older. The study will involve approximately 15 to 20 minutes of your time. Please complete the following survey that asks about your demographics, attitude and knowledge about mental health services and deposit it in the provided envelope to the box located in the social worker’s office. There are no known harms or discomforts associated with this study beyond those encountered in normal daily life. Your participation is voluntary and you can refuse participation at any time. You may not directly benefit from participating in this study; however your input will be beneficial for the Armenian community and future research. All information that will be collected from you will be anonymous; please do not include your name or any identifiable information on the survey. All research data will be stored in a locked cabinet and only researchers and advising faculty will have access to the information. All data will be destroyed upon the completion of the study in May 2016. If you have any comments, concerns, or questions regarding the conduct and analysis of this study please contact the research team listed at the top.

Thank you for your time and participation, Marine & Lilian

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Survey Questionnaire (

)

1. What is your gender? ( ?)

Male ()

Female ()

Other ()

2. What is your ethnic background? ( ?)

Armenian from Armenia ( ) Persian-Armenian ( ) Lebanese-Armenian ( ) Other () Specify: ()

3. What is your age? ( ?)

55-65 years old ()

65-75 years old ()

75-85 years old ()

85 or over ( )

4. What is your marital status? (

Single ()

Married ()

Divorced ()

Widowed ()

Other () Specify: ()

5. How many children do you have? ( ?)

3 or more ( )

6. What generation Armenian-American are you? (

1st generation (born outside of United States) ( ,

)

2nd generation (born in United States) ( ,

)

7. What is the highest level of former education you have completed? (

Less than High School Education ( )

High School Diploma ()

Some College ( )

Bachelor’s Degree ()

Master’s Degree ()

Doctoral or Professional Degree (

8. How do you rate your knowledge of the English language? (

Basic knowledge ( )

Conversant ()

Proficient ()

Fluent ()

9. My insurance does not cover mental health services. (

Strongly disagree ( )

Disagree ( )

Agree ( )

Strongly agree ( )

10. I do not have enough knowledge about mental health disorders. (

Strongly disagree ( )

Disagree ( )

Agree ( )

Strongly agree ( )

11. I do not believe in mental health treatment. (

Strongly disagree ( )

Disagree ( )

Agree ( )

Strongly agree ( )

12. I am unaware of what services are available. (

Strongly disagree ( )

Disagree ( )

Agree ( )

Strongly agree ( )

13. There is a lack of Armenian mental health providers. (

Strongly disagree ( )

Disagree ( )

Agree ( )

Strongly agree ( )

14. Mental health services were not readily available in my country of origin.

(

Strongly disagree ( )

Disagree ( )

Agree ( )

Strongly agree ( )

15. I am ashamed to seek mental health services. (

Strongly disagree ( )

Disagree ( )

Agree ( )

Strongly agree ( )

Appendix D Addendum Barriers to Mental Health Services Among Armenian-American Aged 55 and Over

Barriers to Mental Health Services Among Armenian-American Aged 55 and Over is a joint graduate project between Marine Bambakyan and Lilian Arellano. This document will explain the division of responsibilities between the two parties. Any additional information can be included in a separate document attached to this Addendum page.

Marine Bambakyan is responsible for all the following tasks/document sections: • Contacted MJ Housing and services and gained permission to conduct a study among their Armenian-American residents regarding their experienced and perceived barriers to mental health services • Translated the survey questionnaires from English to Armenian • Distributed the surveys to Armenian-American participants at MJ Housing and Services • Ran the analysis for barriers of mental health services among Armenian-American older adults using SPSS • Discussed analysis and findings of mental health barriers and developed table 1

Lilian Arellano is responsible for all the following tasks/document sections: • Conducted research regarding Armenian, and Armenian-Americans surrounding shame, stigma, attitudes and beliefs about mental health, trauma, mental health services in Armenia & U.S., cultural identity, and acculturation • Discussed analysis and findings of mental health barriers and developed table 2 • Edited paper to meet APA, and ETD formatting standards • Proofread paper and survey: checked for grammatical, spelling, and punctuation errors

Both parties shared responsibilities for the following tasks/document sections: • Both parties shared responsibilities for the following tasks/document sections: • Developed surveys in both English and Armenian • Joint writing of research paper: introduction, literature review, methods, and discussion • Formatted paper to meet APA, and ETD formatting standards • Created poster template for research presentation and presented at the Capstone Poster Presentation

______Marine Bambakyan Date Lilian Arellano Date

______Dr. Hyun Sun Park, Dr. Amy Levin, Committee Chair Date Graduate Coordinator Date

______Dr. Amy Levin, Dr. Amy Levin Committee Member Date Department Chair Date

______Dr. Jodi L. Brown, Committee Member Date