Use of Korean dramas to facilitate precision mental health understanding and discussion for Asian Americans

Summary

Precision mental health holds great potential for revolutionizing care and reducing the burden of mental illness. All races and ethnicities such as Asian Americans, the fastest growing racial group in the United States (U.S.), need to be engaged in precision mental health research. Owing to its global popularity, Korean drama (‘K-drama’) television shows may be an effective educational tool to increase precision mental health knowledge, attitudes and behaviors among Asian Americans. This qualitative study examined the participants’ perspectives about and acceptance of using K-dramas to educate and engage Asian Americans about precision mental health. Twelve workshops were conducted in English, Vietnamese and Korean with a convenience sample in the San Francisco Bay Area in the U.S. (n = 122). Discussions were coded for themes. Findings revealed that all language groups reported positive reactions to using K-dramas to learn about precision health, genetics and mental health. Overall, participants shared that they learned about topics that are not generally talked about (e.g. precision health; genetic testing; mental health), from other people’s perspectives, and the importance of mental health. Participants expressed how much they enjoyed the workshop, how they felt relieved due to the workshop, thought the workshop was interesting, and had an opportunity for self-reflection/healing. This pilot test demonstrated that K-dramas has promise to be used as a health educational tool in a workshop format focused on mental health among a diverse group of Asian Americans. Given the widespread access to K-dramas, they present a scalable opportunity for increasing awareness about specific health topics.

INTRODUCTION

Precision mental health

Precision mental health is an approach to mental health prevention and treatment that aims to address the individual’s needs, mental health and preferences while taking into account the current scientific knowledge about the mental health condition as well as other factors such as environmental considerations (Bickman et al., 2016). Precision mental health may play a significant role in reducing the burden of mental illnesses (World Health Organization, 2018a); however, it can only be effective if all groups, including Asian Americans, are equitably engaged in the research that informs these approaches.

Asian Americans and mental health

The burden of mental disorders is well documented with depression as the leading cause of disability globally (World Health Organization, 2018a). Adverse consequences such as poorer quality of life and suicide may result due to untreated mental disorders (World Health Organization, 2018a).

One population that warrants special attention is Asian Americans, who are the fastest growing racial group in the U.S. and comprise 6% of the population. Asian Americans experience great mental health and health care disparities. Data from the California Health Interview Survey (CHIS) indicated that, compared to non-Hispanic Whites, Asians overall have a lower prevalence of mental distress (20% vs. 19%, respectively) but that there were significant differences by Asian subgroups (from 9% among Japanese Americans to 32% Korean Americans) (Park et al., 2018). This CHIS paper highlights the need to disaggregate data by race in order to better understand the health disparities that do exist.

Specific populations, such as, Southeast Asian Americans, also have high rates of post-traumatic stress disorder (PTSD) due to the trauma that they experienced before, during and after their immigration to the U.S. with rates as high as 62% (Marshall et al., 2005). For Southeast Asian Americans who have sought mental health care, 70% were diagnosed with PTSD (U.S. Department of Health and Human Services Office of Minority Health, 2019).

Moreover, experiences with discrimination and acculturative stress increase the risk of psychopathology among Asian Americans. Despite the mental health risks, racial disparities in mental disorder diagnosis and treatments exist between Asian Americans and non-Hispanic Whites. In 2018, the percent of adults (18 years old and older) with past year major depressive episode who received treatment for the depression for Asian Americans is lower than non-Hispanic Whites (43.9% vs. 68.5%, respectively) (U.S. Department of Health and Human Services Office of Minority Health, 2019).

Furthermore, Asian Americans who suffer from mental disorders or distress do not always receive or seek the care that they need. Common barriers to effective care for many populations include the social stigma and inaccurate or lack of assessment (World Health Organization, 2018a). Compounding these factors is the heterogeneity in languages and dialects, cultures, immigration experiences, and socio-economic status that exist in Asian Americans, which also serve as barriers to mental health care.

Asian Americans in the United States and San Francisco Bay, California: a heterogeneous group

There are approximately 21.4 million Asian Americans (U.S. Census Bureau, 2018). The largest Asian American group by population size are Chinese, Filipino, Vietnamese, Asian Indian and Korean. Asian Americans encompass immigrants and their descendants from many countries with diverse histories, cultures, traditions and languages.

Three out of ten Asian Americans reside in California, specifically (U.S. Census Bureau, 2018). The San Francisco Bay has more than 7 million people in 9 counties (e.g. San Francisco, Santa Clara) (Metropolitan Transportation Commission, 2020) and 101 cities (e.g. San Jose). In San Francisco Bay, 23% are Asian Americans with 33.4% in San Francisco and 32.1% in Santa Clara County (Bay Area Census, 2010). There are interesting demographic data in the San Francisco Bay, such as San Jose being the city with the largest number of Vietnamese Americans in the U.S. (U.S. Census Bureau, 2010) and about 1 in 5 Bay Area Korean Americans reporting serious psychological distress (Korean American Community Foundation of San Francisco, 2020).

Since 2010, more Asian Americans (vs. Hispanic) immigrants have come to the U.S. (Pew Research Center, 2017). By 2055, Asian Americans are projected to become the largest group of immigrants in the U.S., and by 2065, nearly two out of five immigrants will be Asian Americans (Pew Research Center, 2017).

In terms of language, 35% of Asian Americans had low English language proficiency in the U.S. (Association of Asian Pacific Community Health Organizations (AAPCHO), 2014). However, this varied considerably by Asian American group (e.g. Asian Indian, 22%; Filipino, 22%; Korea, 46%; Vietnamese, 53%) (Association of Asian Pacific Community Health Organizations (AAPCHO), 2014).

Television as a medium for health messages: Korean dramas (K-dramas as an innovative approach to precision mental health education)

Innovative approaches to increase awareness of the importance of participating in precision medicine research for mental health treatment are urgently needed. Prior research supports the use of television shows as a health education medium in the U.S. For example, researchers collaborated with a popular television show to incorporate health education information in some episodes. Based on their study findings, they concluded that ‘viewers are interested in health-related story lines, and some learn about health topics and have been motivated to seek additional health information, even engaging in discussions about health issues with their friends and families, and sometimes their doctors’ (Brodie et al., 2001).

Given the focus of this study to focus on Asian Americans, this study developed an innovative strategy to use the television medium for precision mental health education, namely using Korean drama (a.k.a. ‘K-drama’) television shows to educate Asian Americans about precision mental health including genetics and genetic testing as well as mental health and help-seeking among English-, Vietnamese- and Korean-speaking Asian Americans. K-dramas have global popularity among all ages and races, including Asian Americans (Chung and Korea Ministry of Culture & Sports & Tourism, 2011).

K-dramas are aired for a brief period of time (e.g. two episodes per week for two months), translated in many languages, watched in about a hundred countries, and accessible online for free or low-cost (i.e. monthly subscription to skip the commercials) such as on Hulu, Netflix and YouTube (Ambrosino, 2014; Chung and Korea Ministry of Culture & Sports & Tourism, 2011; The Korea Times, 2014). By nature, K-dramas typically have strong emotional storylines that elicits a connection to a global audience (Ambrosino, 2014; Lee and Georg, 2016; Orsini, 2018). As compared to U.S. television shows, K-dramas usually do not have sexual scenes because of the overarching themes of Confucian values (Ambrosino, 2014).

The K-drama ‘enterprise’ is large and revenue generating with sizable exports outside of South Korea (Hwang, 2010; Kenny, 2017) including the U.S. with an estimated following of 18 million Americans (Orsini, 2018; The Korea Times, 2014), many of whom are non-Korean speaking (Ambrosino, 2014; Heine, 2014). Also, K-dramas are extremely popular worldwide including Southeast Asian countries such as Vietnam. Specifically, ‘Vietnamese overwhelmingly favor South Korean TV dramas over other content on Netflix Vietnam, accounting for seven of the top 10 most watched shows’ (VN Express International, 2020).

Purpose of study

The purpose of this qualitative study was to examine the attitudes of English-, Vietnamese- and Korean-speaking Asian Americans toward K-drama as a health promotion tool, specifically on the topic of precision mental health. This research is the first known study to use this new and innovative approach to health education. Given the proportion of Asian Americans with limited English proficiency, it is essential that research be conducted in non-English languages, such as Vietnamese and Korean, to help ensure maximum potential for research participation among these groups.

MATERIALS AND METHODS

Design and methods

This study employed convenience sampling to recruit participants to participate in a one-time 90-minutes K-drama workshop. Participants signed up to participate in one of 12 workshops (four in each language group- English, Vietnamese, Korean), which were held at four community sites in the San Francisco Bay area.

Recruitment methods included announcements that were made at local community organizations that serve Asian Americans, Vietnamese language radio, flyers, word of mouth and Facebook. Bilingual and bicultural Vietnamese and Korean American research staffs were trained to screen potential participants for study eligibility. The participant self-selected into a workshop delivered in the language they were most comfortable with. Participants signed an informed consent and completed a socio-demographic questionnaire at the beginning of the workshop. Participants were informed about the study’s purpose, which was to examine their perspectives about and acceptance of a K-drama precision mental health workshop.

For their participation, interviewees received a $25 dollar gift card to a local store, a Certificate of Completion that the participants attended the workshop, and a folder with local mental health resources. Based on previous experiences from this study’s community partner, this study provided a Certificate of Completion because it allows the participants to feel a sense of accomplishment and acts as a positive reinforcement on behavioral changes (Gneezy et al., 2011).

Participants

The study’s inclusion criteria included: (i)self-identified as Asian Americans; (ii) could read, write and speak English, Vietnamese or Korean; (iii) were at least 18 years old; (iv) had ever watched or currently watched K-drama; and (v) resided in the San Francisco Bay Area, California, U.S. During the screening, potential participants were asked if they self-identified as Asian or Asian American (for English-speaking), Korean or Korean American (for Korean-speaking), Vietnamese or Vietnamese American (for Vietnamese-speaking). Of the 140 people who signed up to participate in the study, 18 people did not participate due to family emergencies, work conflicts, or other reasons that were not specified.

Participants were asked questions about their socio-demographic background such as gender, age, marital status, education, employment, household income, nativity and English-language proficiency. Participants were asked an open-ended question, ‘What ethnic or cultural group(s) do you identify with? (Please list all)’.

K-Drama precision mental health workshops developed by the study team

The K-drama precision mental health workshops were developed by the study team. We designed the K-drama workshop to be delivered distinctly for three primary language-speaking Asian American audiences: English, Korean and Vietnamese. We developed the workshop curriculum to explore participants’ knowledge and attitudes through facilitated group discussions on the following topics: precision mental health; mental health and help-seeking behaviors; genetic testing; and accessing mental health care. We used K-drama scenes that illustrated these topics to spark these conversations (Table 1). There were four 6–8 minute K-drama scenes that were drawn from three different K-dramas shows. This curriculum comprised of these various topics in order to piece together the concept of ‘precision mental health’ since this term is relatively new and not commonly understood by the public, including Asian Americans. Furthermore, in order to explore the attitudes and behaviors about precision mental health, the workshop included discussion on mental health and help-seeking in general to help de-stigmatize these topics. Such a discussion was critical to determine participants’ knowledge, attitudes and behaviors in what precision health is, their willingness to get genetic testing for health conditions such as mental health, their comfort to discuss genetic testing with and receive mental health care, if needed, from health professionals.

Table 1:

Korean drama (K-drama) precision mental health curriculum

Topic	K-dramaa	Scene
Compassion	It’s Okay, It’s Love	This scene shows the treatment process of a student who has a mental health illness, and the importance of compassion and positive outcome from his treatment. It also shows the negative consequence of not getting help.
Depression	Me Too, Flower	This scene shows a woman in her 30 s who experiences depression. She receives a phone therapy session where she confesses that she hates herself and that she did not want to live to her therapist.
Genetic Testing	Bubblegum	This scene was drawn which shows a middle-aged woman who experiences episodes of memory loss and her friend convinces her to get testing done. After learning that she has Alzheimer's disease, she urges her son to get a genetic test for Alzheimer’s disease.
Help-seeking	It’s Okay, It’s Love	This scene shows a radio host who talks about mental health stigma and the importance of seeking help.

^aThese K-drama shows were released in 2011–2015.

Each K-drama workshop was audio-recorded and had a bi-lingual and bi-cultural (English and Korean or English and Vietnamese) workshop facilitator and at least one other supporting research staff present. There were three facilitators, one for each language (English, Vietnamese, Korean) as the workshops were conducted in these respective languages.

Health promotion framework

This study was guided by Bettinghau’s description of the five central elements of the information-processing model—source, message, channel, receiver, destination—as particularly appropriate for health promotion media campaigns/programs, and, is therefore used as our health promotion framework (Bettinghaus, 1986). It is important to note that this framework was not used to quantitatively evaluate the effectiveness of the K-drama workshops.

The ‘source’ of information is important as it may affect who will attend to the message and how the message will be received. For this study, source may be both the bilingual workshop facilitators as well as who was supporting the study (i.e. local university; community organizations). ‘Message’ is how an idea is presented to the audience. For this study, our messages include the various discussion topics such as precision health and mental health (described further in section Health promotion framework. K-drama precision mental health workshops). ‘Channel’ is where the audience (i.e. research participants) will receive the messages. In our study, we used a facilitated workshop format that included K-drama scenes to convey the messages. ‘Receiver’ is the recipient of the message and the same message is presented in a similar way to all receivers. It is also recommended that the receivers are involved in the learning process. In our study, the receiver is the research participant who is engaged in a facilitated workshop. ‘Destination’ involves the examination of the health education campaign after it is done, though is rarely evaluated beyond a post-test measure. For our study, we did conduct a pre- and post-test survey on the participants’ knowledge, attitudes and potential behavior changes on precision mental health (results are described in Ta Park et al. (2019)); however, given the nature of the pilot study, we did not examine this variable, destination, beyond this one-time post-test survey that was administered immediately after the workshop participation.

Workshop semi-structured discussion topics

A series of discussions on the following topics were discussed and guided by a trained facilitator: precision health, genetic testing, mental health, willingness to participate in research, help-seeking, patient-provider trust and compassion. All topics were themes of the K-drama scenes, which were pieced together to inform participants about what ‘precision health’ was. After each K-drama scene was shown, the participants’ reactions (i.e. thoughts; feelings) were elicited. A facilitator guided a semi-structured discussion on specific topics and how these related to precision health (e.g. definition of precision health and its role with mental health) (Appendix 1).

Translation process and validity

Study materials were translated into Korean and Vietnamese including the recruitment flyers, screening eligibility questions, informed consent, sociodemographic questionnaire, workshop presentation and local information about mental health resources. The World Health Organization’s process of translation and adaptation of instruments (World Health Organization, 2018b) was used to guide the translations of the study materials such as forward and backward translation methods to attain ‘conceptually equivalent’ Korean and Vietnamese language versions of the English materials, which were translated to be ‘cross-cultural and conceptual, rather than on linguistic/literal equivalence’ (World Health Organization, 2018b). Bilingual and bicultural Korean and Vietnamese research staff conducted the translations.

Data analysis

Descriptive statistics of the study sample were performed using Chi-square test statistics to compare socio-demographic characteristics across workshops (i.e. language groups including English, Korean, Vietnamese). It is important to provide context about the similarities/differences in the socio-demographic characteristics of the participants who volunteered to participate in this research study. Data were analyzed using R, version 3.5, tableone package.

The audio recordings from the discussions were transcribed and translated by bilingual staffs. We used content analysis (Krippendorff, 2013), using a directed content analysis approach (Hsieh and Shannon, 2005). The principal investigator created a coding dictionary based on the workshop discussion topics (see section Workshop semi-structured discussion topics) as a starting point for qualitative analysis. Then, two independent coders in each language (English, Vietnamese and Korean) independently utilized the coding dictionary to analyze the qualitative data and identified themes and sub-themes. ‘Themes, or categories, are the classification of more discrete concepts’ and come from the data itself (i.e. inductive approach) as well as from the investigators’ prior theoretical understanding of the subject matter being studied (i.e. an a priori approach) (Ryan and Bernard, 2003). Degrees of variations of themes are referred to as sub-themes (Ryan and Bernard, 2003). The inter-coder reliability, defined as ‘the amount of agreement between two or more coders for the codes applied to qualitative text’ (MacPhail et al., 2016), was 95%. The coders resolved the discrepancies in the emergent sub-themes by agreeing to re-code two sub-themes into existing sub-themes. Next, the coders pieced together the themes and sub-themes to present the overall qualitative findings (Ryan and Bernard, 2003).

RESULTS

Sample characteristics (Table 2)

Table 2:

Sample characteristics, overall and by workshop participation (n = 122)

Characteristics	All	Workshop Participation by Language
		English a (n = 36)	Korean (n = 45)	Vietnamese (n = 41)	p-Value
Gender (%)					0.936
Female	71.3	69.4	71.1	73.2
Male	28.7	30.6	28.9	26.8
Mean Age (years) at recruitment, (SE)	100	29.3 (15.8)	67.4 (19.9)	51.9 (15.9)	<0.001
Age Group (years)					<0.001
<35	32.8	83.3	2.2	22.0
35–64	35.2	11.1	37.8	53.7
≥65	32.0	5.6	60.0	24.4
Current marital status (%)					<0.001
Single	29.5	72.2	8.9	14.6
Married/Living together	50.8	13.9	60.0	73.2
Separated/Divorced/Widowed	19.7	13.9	31.1	12.2
Education (%)					0.003
Less than high school	10.7	0.0	11.1	19.5
High school	17.2	19.4	15.6	17.1
Some college	28.7	33.3	13.3	41.5
College or more	43.4	47.2	60.0	22.0
Employment status (%)					<0.001
Full time	15.6	22.2	0.0	26.8
Part time	23.8	36.1	8.9	29.3
Homemaker	23.7	5.6	48.9	12.2
Not looking	21.3	2.8	40.0	17.1
Disabled/Retired	10.6	22.2	0.0	12.2
Other/Unknown	4.9	11.1	2.2	2.4
Household income (%) b					<0.001
<$25,000	42.6	19.4	48.9	56.1
$25,000–75,000	27.9	44.4	11.1	31.7
$75,001–150,000	15.5	22.2	13.3	12.2
>$150,000	11.5	8.3	24.4	0.0
Nativity (%)					<0.001
US-born	19.7	63.9	0.0	2.4
Foreign-born	80.3	33.1	100.0	97.6
English Language Proficiency (%)					<0.001
Proficient	42.6	94.4	4.4	39.0
Some	48.4	5.6	77.8	53.7
None	9.0	0.0	17.8	7.3
Number of years watching K-dramas (%) b					0.316
≤1	17.2	11.1	8.9	9.5
>1	82.8	88.9	91.1	80.5
Currently watches K-dramas					0.052
Yes	69.7	66.7	82.2	58.5
No	30.3	33,3	17.8	41.5
Number of hours per week watching K-dramas b					0.085
≤1	18.9	16.7	21.6	16.7
2–5	43.5	29.2	45.9	54.2
≥5	23.5	20.8	24.3	25.0
Varies	14.1	33.3	8.1	4.2
Enjoy watching K-dramas b					0.677
Yes	76.9	83.3	73.3	75.0
No	16.5	13.9	20.0	15.0
Not sure	6.6	2.8	6.7	10.0

Notes:.

^aThe English-speaking participants included Chinese (including Taiwanese) n = 7, Filipino n = 3, Japanese n = 4, Burmese n = 1, Vietnamese, n = 4, Korean n = 3, Mixed n = 7, and ‘Asian’ unspecified, n = 6.

^bHousehold income does not add to 122 as three participants declined to report it. For number of hours per week watching K-dramas, the n was based on their affirmative (‘Yes’) response to ‘currently watches K-dramas’ (n = 85) There was one participant who did not respond to the question about whether they ‘Enjoy watching K-dramas’.

Among 122 participants, 30% participated in a workshop conducted in English (n = 36), 37% in Korean (n = 45) and 34% in Vietnamese (n = 41). Participants in the English-speaking workshop self-identified as Chinese, Filipino, Japanese, Burmese, Vietnamese, Korean, Mixed, and Asian, not specified. Overall, the sample was predominately female (71%). Socio-demographically, the participants varied broadly across age groups, marital status, educational attainment, employment status and household income.

Across workshop participation by language, most socio-demographic variables differed significantly (p < 0.05), with the exception of gender distribution (p = 0.94). Specifically, the Korean workshop participants were disproportionately older (60% were 65 years or older), more educated, and mostly foreign born. More than half of the Vietnamese workshop participants were middle-aged (35–64 years old; 53.7%), working part-time or full-time (56.1%), and had household incomes less than $25,000 per year (56.1%). English-speaking participants were notably younger (83% were less than 35 years old), single (72.2%), and had household incomes between $25,000 and $75,000 per year (44.4%). There were significant differences by English-language proficiency across workshops with most of the English-speaking workshop participants (94.4%) reporting that they are proficient in English compared to 4.4% of the Korean-speaking and 39.0% of the Vietnamese-speaking workshop participants. There were no significant differences in K-drama behaviors including number of years watching K-dramas, currently watching K-dramas, number of hours per week watching K-dramas, and whether they enjoy watching K-dramas by workshop participation (language).

Qualitative findings: Themes and participant quotes

There were four themes based on the workshop discussions. The themes are as follows: (i) reactions to the K-drama scenes; (ii) knowledge about precision health and mental health; (iii) attitudes about precision health and mental health; and (iv) overall reaction to workshop. The following is a description of these qualitative findings. Table 3 includes the themes, sub-themes and selected participant quotes.

Table 3:

Qualitative themes, sub-themes, and selected participant quotes

Themes and sub-themes	Selected participant quotes
Theme 1: Reactions to the K-drama scenes
Genetic testing scene: Informative; relatable	Participant 129 (Vietnamese): ‘Before watching this drama, I did not know that Alzheimer's is a genetic disease. I thought that the older you get, you don’t need to use your mind as much, therefore you will get Alzheimer's, but I didn’t think that it can be passed to someone else.’
Depression scene: Encouraging; made them happy; stressed the importance of getting treated; informative Shared personal examples of their depression experiences	Participant 32 (English): ‘I felt really bad for the character but in the end when she was able to find out the reason for her depression, it was encouraging for if I ever have that problem’. Participant 112 (Vietnamese): ‘I sometime feel sad but I don’t know why. I don’t know if it is called depression or not. I feel like that on the days that I am not happy and do not know the reasons why. But usually when I think about depression, I thought it will be a more severe condition. A person who is sad for a period of time, then that is called being depressed’.
Help-seeking scene: Reminded or taught them about the importance of empathy in treatment of mental illness, and stressed the importance of the role of the doctor in treatment.	Participant 53 (Korean): ‘I haven’t watched the drama (It’s okay, it’s love), but from just seeing the clip, I think that Gong Hyo Jin (actress playing psychiatrist) was able to understand the patient and show sympathy because she had a similar experience herself and because of that I think the patient was able to open up, seeing her sympathy’. Participant 114 (Vietnamese): ‘I think the role of a doctor is really important. They don’t discriminate the illness of the patients then when they can sympathize, they can help the patients’.
Compassion scene: Informative; reflective; relatable; empowering (the self-ability to do something about one’s emotions); helpful/supportive (in affecting the outcome) Provided suggestions on how to be compassionate towards a person with mental health needs.	Participant: 58 (Korean): ‘…. you feel lonely and afraid at certain times, but if someone can relate to you and if they give you their genuine connection, it gives you the strength, courage, and willpower to get through it’. Participant 101 (Vietnamese): ‘Open up your heart to accept them (people with mental illness), encourage them’.
Theme 2: Knowledge about precision health and mental health
Limited or no prior knowledge about precision health.	Participant 12 (English): ‘It helped me get a better understanding of everything, and how precision health works’.
Korean dramas can be potentially used for mental health education in the community.	Participant 4 (English): ‘I’ve seen that drama once but never actually analyzed like oh he has this symptom, it shouldn’t matter, he should seek help. It made me realize, you should seek help when you need it’. Participant 25 (English): ‘Interesting way to inform…more approachable’. Participant 59 (Korean): ‘I didn't know that these dramas had such important messages for us to know about even when I watched it, but, looking at it this way made things easier to digest, rather than just talking about it’. Participant 81 (Korean): ‘Dramas made it easy for me to relate myself to the topics’. Participant 137 (Vietnamese): ‘Yes, because watching drama like this then we will understand more about the illness. How do we treat it if we have pressure in our life’.
K-dramas depict a ‘more ideal’ life than ‘real life’	Participant 83 (Korean): ‘In the video that we watched, the person met a good counselor. But in real life, it’s not that easy, right? (after watching Depression video)’.
Theme 3: Attitudes about precision health and mental health
Overall positive feelings/thoughts about having their personal genetic information be used for their health and in health care	Participant 6 (English): ‘If you have a family history of something and you get tested and you know you’re predisposed to it and maybe the doctor would tell you ways to slow it down or something…’
Comfortable speaking with their doctors about getting a genetic test	Participant 51 (Korean): ‘If you find out that you have the Alzheimer’s’ gene in your DNA, then, you can prepare and accept it mentally and put more effort in to prevent it. And I think that the shock of being diagnosed with the disease can be reduced’.
Mixed reactions about willingness to receive a genetic test to see if a certain drug or treatment would work better for their genetic condition	Participant 12 (English): ‘I would do it because it’s like you care about your kids and stuff right? You want to help them out and you already lived your life, you want them to have that and the life they want’. Participant 8 (English): ‘I don’t need it if I have a family history of it’. Participant 9 (English): ‘If the procedure is very risky, I would not do it’. Participant 86 (Korean): ‘I feel like you can get unnecessarily overwhelmed and stressed if you have that information’.
Comfortable talking with their doctor about mental health. Not feel comfortable speaking with their doctor about their mental health	Participant 54 (Korean): ‘Since I have the trust that the doctor will provide professional solution, I think that it would be beneficial for me to be honest and open about it in order to get the best advice or treatment.’ Participant 23 (English): ‘I’ve had my primary care doctor/provider for a long time. She’s Vietnamese, so I feel that speaking with her about mental health is different, just because of the cultural aspect’.
Mixed reactions about sharing their mental health with other persons	Participant 58 (Korean): ‘Our society is so small—especially in the U.S.—our community is so small that everyone knows one another. And because of that I’m afraid of rumors going around’.
Theme 4: Overall reaction to workshop
Learned about topics that are not generally discussed Listened to other people’s perspectives Recognized the importance of mental health	Participant 2 (English): ‘I think it was very informative, cause I have done other surveys and they all just mostly ask you like to fill out the questions and they don’t tell you much about it’. Participant 111 (Vietnamese): ‘I’ve learned a lot of things about diseases through those dramas’. Participant 20 (English): ‘Interesting, it was a combination of learning and socializing’. Participant 50 (Korean): ‘I hope that these sorts of research get done a lot in order to allow people to take care of their mental health as much as they do their body health’. Participant 51 (Korean): ‘The fact that precision health is not only for the benefit of an individual, but also for our family and our society, and how we should go around and share this information with others, I think it’s all really good’.
Liked/loved the workshop Learned from other people’s perspectives Opportunity for self-reflection/healing	Participant 66 (Korean): ‘While watching drama, it feels like I have gained and learned a lot. And watching the dramas made me become aware of my own mental health. How important mental health is. My family. Myself. You did something good for our community’. Participant 137 (Vietnamese): ‘I feel that okay, I will be more sympathy with those people. Be less scared with them. After this workshop, I think I will sympathize and understand more. And more importantly, using love to help them overcome those obstacles’. Participant 52 (Korean): ‘Through this experience today, I feel like I’ve been healed’.

Theme 1: Reactions to the K-drama scenes

All groups reported positive reactions to all of the K-drama scenes (scenes are described in Table 1). For example, for the scene on the genetic testing, many stated that the scene was informative and relatable, and they were able to reflect on the messages of the scene.

In regard to the depression scene, some expressed the scene was encouraging, made them happy (that there was a positive outcome), stressed the importance of getting treated, and was informative. After watching the depression scene, several participants from all groups shared personal examples of their depression experiences.

In regard to the help-seeking scene, some felt that watching the K-drama scenes reminded or taught them about the importance of empathy in treatment of mental illness, and stressed the importance of the role of the doctor in treatment.

Participants from the Korean and Vietnamese workshops shared that they agreed with the message of the compassion scene (to be compassionate of persons with mental illness) and felt that the scene was informative, reflective and relatable. For all workshop groups, some shared that the scene felt empowering (the self-ability to do something about one’s emotions) as well as helpful/supportive (in affecting the outcome). Some provided suggestions on how to be compassionate towards a person with mental health needs.

Theme 2: Knowledge about precision health and mental health

There were several participants in all workshop (language) groups that stated that they had limited or no prior knowledge about precision health. Some participants in the English and Vietnamese workshops identified genetics as a part of precision health. Only participants in the Vietnamese workshops stated that the environment was a part of precision health. Some in the English and Korean groups shared that conditions such as cancer and diabetes had a genetic component. Some shared that they learned more about precision health through their workshop participation.

Many participants in all three workshop groups agreed that Korean dramas can be potentially used for mental health education in the community. Participants commented how K-dramas are inviting as viewers could relate to the characters, make it easy to understand the topics (compared to just reading or talking/listening), is an innovative approach (an interesting way to inform), and is non-stigmatizing for difficult topics (e.g. mental health).

A few participants from the English and Korean workshops commented that K-dramas depict a ‘more ideal’ life than ‘real life’ and some have predictable stories.

Theme 3: Attitudes about precision health and mental health

Participants in all groups reported overall positive feelings and thoughts about having their personal genetic information be used for their health and in health care. Some felt that it could be a way to prevent and/or treat genetic conditions.

Some participants in all groups reported that they would be comfortable speaking with their doctors about getting a genetic test. Some also felt that they would get a genetic test because they would like to ‘know’.

On the other hand, when participants were asked if they would be willing to receive a genetic test to see if a certain drug or treatment would work better for their genetic condition, the responses included both ‘yes's’ and ‘no's’. Some in the English and Korean groups (and none in the Vietnamese) said they were willing to receive such a test.

Among participants who said, ‘no’, the reasons included refusing to receive bad news, having a fatalistic view on life, and other reasons such as questioning the potential benefit.

Some participants from all groups shared that they would be comfortable talking with their doctor about mental health. Some reasons for this include desire to receive appropriate and timely treatment because they trust their doctors and they are willing to seek help.

A few participants from the English workshops expressed that they would not feel comfortable speaking with their doctor about their mental health. Reasons for this include sharing the same cultural background as their doctor, fearing that a family member may get in trouble with the law, and feeling more comfortable speaking with their friends.

Other participants from all groups shared that they would be comfortable sharing their mental health with other persons if they are trustworthy, caring and/or friendly. Still others from all groups stated they would not feel comfortable because of the stigma, of fear that rumors would spread around in their small community, and unwillingness to share or confide with their family or close friends.

Theme 4: Overall reaction to workshop

There were similar sub-themes found in all three workshop groups. Overall, participants learned about topics that are not generally discussed (e.g. precision health; genetic testing; mental health), listened to other people’s perspectives, and recognized the importance of mental health.

Participants expressed how much they liked/loved the workshop, shared that they felt happy, thought the workshop was interesting, learned from other people’s perspectives, and had an opportunity for self-reflection/healing.

DISCUSSION

Summary of findings

Our qualitative study offers a breadth of interesting findings. The overarching findings suggest that K-dramas can be used successfully in a workshop focused on mental health among a diverse group of Asian American cultures and languages. Findings also revealed that all language groups (English, Korean and Vietnamese) reported positive reactions to using K-dramas to learn about precision health, genetics and mental health. Many participants shared that they learned about topics that are not commonly discussed in their communities (e.g. precision health; genetic testing; mental health), understanding of different perspectives, and the importance of mental health. Across all language groups, participants also had positive attitudes towards the health education workshop.

This study focused on precision mental health, which is relatively a ‘new’ topic for many. Delgadillo and Lutz note that a development pathway towards precision mental health care is very early in the development compared to other fields such as cancer and cardiovascular care (Delgadillo and Lutz, 2020). One of the types of research in this model is, Type 4, which asks the question, ‘Does the application of targeted interventions work better than routine care?’ with the goal being to evaluate the acceptability, effects and costs of various research including feasibility studies. Our study may be designated a Type 4 research in this developmental pathway for precision mental health care in that we asked participants about their perspectives and reactions of using K-drama as a precision mental health education tool for Asian Americans. A potential next step is to design a study that compares outcomes (differences in knowledge, attitudes and behaviors) among control participants (e.g. patients who do not participate in K-drama workshops) and intervention participants (e.g. patients who do participate in K-drama workshops).

The qualitative findings reported complement the quantitative findings of this study, which found a significant difference in the pre- and post-test knowledge, attitudes, and behaviors scores overall, by genetics and genetic testing, and by mental health and help-seeking (Ta Park et al., 2019). In addition, while this is the first study of its kind (i.e. K-drama precision mental health education workshop), as mentioned previously, prior research lends support for the use of television shows as a health education medium in the U.S. (Brodie et al., 2001).

Our study has some similarities with another entertainment medium, which is the popular Latin American soap operas called telenovelas (Public Broadcasting Service, 2012). Telenovelas are similar with K-dramas in that they have a ‘contained story arc, ending after a few seasons’ (Public Broadcasting Service, 2012). Telenovelas have also been used as a health education medium. Research showed that knowledge about various health topics such as alcohol prevention, stroke and heart disease prevention, and end-stage renal disease increased and that participants reported the use of telenovelas to be culturally appropriate as a health education medium for Latino communities (Forster et al., 2016; Lalonde et al., 1997; Vaughn, 2012).

Strengths and limitations

A strength of this community-based study was that it engaged Asian Americans in three languages – English, Vietnamese and Korean. Research has shown that language access has important implications for health, health care access and research participation (Chen et al., 2007; Jacobs et al., 2006; Watson et al., 2014). Given the low rates of English language proficiency for certain Asian Americans such as Vietnamese and Koreans, as previously stated, it was important that we conducted the study in these respective languages other than English. However, due to the nature of the study (i.e. pilot study), we did not target other Asian languages, which future research may consider doing.

This intervention was innovative in that it used K-dramas, a widely available and popular entertainment medium (Chung and Korea Ministry of Culture & Sports & Tourism, 2011), to educate and engage Asian Americans about a relatively new topic (‘precision medicine’ or ‘precision health’) (Collins and Varmus, 2015; National Institutes of Health, 2016) and a stigmatizing topic (‘mental health’) (Masuda and Boone, 2011; Shea and Yeh, 2008). Given the tremendous global popularity among Asians and Asian Americans (Chung and Korea Ministry of Culture & Sports & Tourism, 2011), future research may continue to explore its potential reach for mental health education.

This study also utilized qualitative methods, which is a strength given how K-dramas have not really been used as a health education tool before and we aimed to better understand the nuances of using a novel approach (i.e. using selected K-drama scenes to for precision mental health education). Qualitative inquiry aided us in the understanding of the reactions of using K-dramas as a health education tool through the lens of the participants (Al-Busaidi, 2008).

Conclusions

This study offers promising findings that using K-drama television shows may be culturally acceptable as a precision mental health educational intervention, particularly as a health education workshop, for Asian Americans. Future work may include working directly with producers of K-dramas to include specific health topics. Given the widespread access to K-dramas, they present a scalable opportunity for increasing awareness about specific health topics.

ACKNOWLEDGEMENTS

We would like to thank the study participants, our community partners with their assistance with recruitment, and research staff (Cate Jongkyung Park, Charles Kim, Nhi Cristina Y. Nguyen, Anh T. Tran, Anna Chiang, Si-inn J. Rho, Derek Nguyen, and Yuna Kwon).

FUNDING

This research was supported by the Stanford Clinical and Translational Science Award (CTSA) to Spectrum (UL1 TR001085). The CTSA program is led by the National Center for Advancing Translational Sciences (NCATS) at the National Institutes of Health (NIH). This research was also supported by the National Institute on Minority Health and Health Disparities of the NIH under Award Number U54MD010724. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

APPENDIX 1. Semi-guided discussion questions included

1. What is precision health? What is precision mental health?

2. How many people do you think are affected by mental health disorders each year? What factors affect our mental health in both a positive and negative way?

3. What is mental health? Why is it important?

4. (Questions after each video was shown) What is your reaction? Thoughts? Feelings?

5. Is the use of personal genetic information in health care beneficial to patients? Why or why not?

6. Do you feel comfortable talking with your doctor(s) about genetic testing? Why or why not?

7. Would you get a genetic test for Alzheimer’s disease? Would you get a genetic test for a certain drug or treatment if it would work better for your condition?

8. Would you be comfortable to talk with your doctor about your mental health?

9. Are you comfortable sharing your mental health with others?

10. Where do you think people with mental health issues seek help? What are barriers to seeking mental health help? Your examples?

11. What can happen when a person with mental health needs do not seek help? What can happen when a person with mental health needs does seek help?

12. What is compassion? Why is compassion important in mental health? How can we be more compassionate?

13. What is your overall reaction today?