Key informant interviews (Adult stakeholders)

Adult key informants were initially nominated by partners at the American Samoa Department of Health and Division of Behavioral Health Services; additional participants were identified using snowball sampling. Speaking English was a requirement for participation, although likely contributed very little bias since >80% of the general population and almost all those in professional roles speak English fluently [3]. While identifying as Samoan was not an inclusion criterion for adult participants, the research team recruited participants of Samoan ethnicity when possible.

To sample for diversity in community perspectives, the Fa’afaletui methodological framework, developed for research in Samoan communities [17, 18] was used. This framework prioritizes the recruitment and weaving together of varying views on adolescent mental health, from the broader outlook ‘the top of the mountain’ (e.g., mental health providers, policymakers, and those working in non-governmental organizations), the mid-distance lens ‘from the top of the tree’ offered by individuals who work directly with adolescents like teachers, and the finer observations ‘from the person in the canoe fishing’ that young adults and adolescents could provide [17, 18]. The MacDonald et al. [19] framework on pathways to mental health services for young people was also followed to maximize diversity when recruiting participants and to ensure that various professions with different degrees of involvement along the mental health services pathways–from mental health professionals to school staff and religious leaders–were included. Aligning the MacDonald et al. framework with the Fa’afaletui framework resulted in a sampling frame that aimed for diversity by age, gender, region, residence, and education level.

Fifty-six individuals and four organizations were invited to participate; 36 KIs (64%) expressed interest in participating. Of these, eight KIs were unable to participate because of scheduling problems or due to the sample reaching saturation. A total of 28 KIs therefore comprised the final adult sample.

Adolescent focus groups

Five focus groups were conducted between May 2022 and June 2022 with English-speaking school-age adolescents. The primary aim of these discussions was to validate the results gathered from the adult interviews. To participate in the focus groups, adolescents were required to identify as ethnically Samoan and have lived in American Samoa for at least one year. Participants were primarily recruited using a Facebook advertisement, supplemented with snowball sampling using email, texts, and Facebook messenger leveraging our collaborators’ and participant’s social networks.

Thirty-five adolescent participants were in the final sample. We convened one group of all boys, two with all girls, and two mixed gender groups. Each focus group session was led by two moderators from American Samoa who are Samoan, speak Samoan, and have expertise in Samoan culture. Although interview prompts were mostly read in English, the moderators used English and Samoan languages based on participant preference.

Analysis

Interviews and focus groups were transcribed verbatim with the assistance of Temi software [20]. Deductive thematic analysis was primarily used to identify explicit meanings of the data. Most frameworks on health-related stigma focus on the individual experiencing stigma and/or those who stigmatize an individual [21, 22], but more researchers in high-income countries (HIC) and low- and middle-income countries (LMIC) are now addressing the individual, social, and structural pathways in which stigma manifests through a socio-ecological framework [21–24]. Therefore, a socio-ecological model was used to guide the assessment of mental health stigma into different forms or manifestations: structural stigma, public (or social) stigma, interpersonal stigma, and internalized (or self) stigma. Employing this framework allowed for the visualization of the effects of stigma across multiple domains and different populations, particularly adolescents. Evaluating the different levels of mental health stigma may help organizations, community leaders, and advocates develop interventions that target stigma at certain or multiple levels. Illustrative quotes are included to demonstrate the depth and breadth corresponding to each level of mental health stigma. To identify the characteristics of the 28 adults and 35 adolescents who participated in our interviews and focus groups, respectively, the following labeling system was developed. Adults are referred to as “A” and adolescents–or youth–are referred to as “Y”. For the adult participants, an uppercase superscript was included to identify whether they represent perspective from the top of the mountain (“M”), top of the tree (“T”), or person in the canoe fishing (“C”); for adolescents, a lower-case superscript was included to identify their gender as male (“m”) or female (“f”).

Structural stigma: “Human capital is really limited” (A-ID#10^M)

Structural stigma refers to institutional policies and societal-level conditions that result in unfair treatment of the individual experiencing stigma. Multiple adult KIs cited a lack of investment by policymakers in mental health infrastructure, reflected in insufficient funding and resource allocation toward mental health services, especially in the school system: “Unfortunately, it has been years since we have had adequate training to actually empower [school] counselors…what has happened over time is that we have school counselors who are school counselors, on paper, but they do not have the skills, nor do they possess the abilities from the Department of Education to actually deal with some of the mental health issues” (A-ID#07^M).

While one adolescent participant mentioned a positive experience with their school counselor (Y-ID#18^m), many other adolescent participants expressed their disappointment with high school students receiving a lack of mental health support “because of an inactive counselor” (Y-ID#20^m) or because counselors are “not able to see that our kids are struggling” (Y-ID#22^f).

“My counselor has had a lot of students come into her office for acting out, but she doesn’t see that if she could actually talk to these kids, she would actually know the reason and purpose as to why these kids act out, why they misbehave in class instead of labeling them as the bad kids or the naughty kids” (Y-ID#20^m).

Adult KIs also commented on the limited number of mental health professionals in American Samoa, believing the current number is, “not enough to do assessments for all the kids…I think that there’s a lot [mental health conditions] that’s out there that’s just not been identified or diagnosed” (A-ID#04^M).

Many KIs often mentioned the lack of a clear referral system for adults to follow if they were concerned about an adolescent struggling with a mental health challenge: “The way the system works now, it’s only those who…have severe behavioral problems” (A-ID#01^M).

Adult KIs also explained the roles of legal authorities and the court system when attempting to find resources for an adolescent who may be struggling with behavioral and/or mental health issues: “…Instead of possibly going into the hospital, to look for help, it’s more of arresting the person and seeing them stay in prison rather than seeking a…mental health professional to see if maybe possibly they have a mental health condition” (A-ID#21^M).

One KI described a negative experience with police involvement after the KI had expressed concern about a student’s signs of self-harm to the school administrators:

“I’m just going to take [the student] with me…went to the principal’s office. He called the police…[they] came in and then started questioning her…I’m like, ‘Oh my goodness, she’s the victim here? Why are you treating her like she is the abuser?’…Where are the social workers? Is there a psychiatrist?” (A-ID#11^M). Another KI commented on the need to strengthen school mental health screenings because, “[adolescents] who…have had a long history of school disciplinary problems…are generally not picked up and…reach mental health services until they are involved in the legal system” (A-ID#01^M).

The lack of sufficient funding for mental health care in American Samoa also limits the availability of educational resources on mental health. This form of structural stigma drives the stigmatization of mental health and illness at the public, interpersonal, and individual levels, ultimately shaping the way mental health is perceived among the community and communicated between adolescents and their families. Both adult KIs and adolescent participants alike frequently cited a lack of mental health literacy and education among the community, schools, and families in areas such as:

1. how to healthily express one’s emotions: “It’s because [adolescents are] depressed and they don’t really know how…to express themselves or…talk to someone” (A-ID#23^M).
2. knowing whom to go to for mental health support: “…when someone falls down at school and breaks their leg, who do you call?’, and you’re like, ‘the ambulance’, they know. ‘But if you have something that’s bothering you emotionally, who do you call?’ Everybody just kind of looks around, and ‘I don’t know’” (A-ID#13^M).
3. maintaining mental wellness: “We don’t see that we need to have a solution…to help ourselves…And we’re just blinded to the fact that we are mentally unhealthy” (Y-ID#16^f).

Several KIs listed recent efforts to combat mental health stigma by increasing mental health awareness among the American Samoan population and encouraging community input. For instance, these two cases show efforts from the government and church community, respectively: “…a Task Force for Suicide Prevention just started…headed by the Department of Health, with mental health services…presentations in school and [going] to groups in villages and talk to parents and children, so…the adolescents would get information from that public awareness.” (A-ID#16^M; note, minor edits were made to remove potentially identifying information)

“There’s just been this huge outpouring of community involvement…being spearheaded by this particular Christian pastor. And we’ve seen positive feedback from the kids who are telling their school principals and their school teachers, that there needs to be more…opportunities for them to speak and to feel heard and safe spaces…” (A-ID#07^M).

Additionally, a young adult KI listed the church community as a positive source of social support to an adolescent who may be struggling with their mental health: “I think a lot of kids turn to the church because they feel like the church won’t judge them” (A-ID#02^C).

Public stigma: “We just don’t have enough discussions about it” (A-ID#15^M)

Defined as the cultural norms and negative attitudes the public may hold toward individuals living with mental illness, adult and adolescent participants described the effects of public mental illness stigma in American Samoa, in terms of mental health not being “openly talk[ed] about. We don’t talk about depression and anxiety and stress. It’s…wrapped up tightly, put in a box and left for later” (A-ID#13^M).

Adult KIs outlined two potential ways the broader American Samoan community may respond to topics on mental health and illness: 1) being “taught that [mental health problems don’t] exist” (A-ID#14^T) or 2) having it “swept under the rug” (A-ID#03^T).

There was consensus among adult KIs and adolescent participants that mental health in American Samoa is seen as “such a taboo topic” (A-ID#02^C), despite adolescents agreeing that “mental health should be prioritized” (Y-ID#14^f) and “most teens are unhealthy mentally” (Y-ID#18^m). Multiple KIs believed this negative perception of mental health meant that “there’s not really a culture of…open dialogue, especially when it comes to emotional issues” (A-ID#14^T). Adult informants also stated that the topic of mental health was seen as “Palagi [foreign], not Samoan” (A-ID#10^M, A-ID#14^T) and “a white person thing” (A-ID#05^C).

Some mental health topics the public might find “disrespectful to talk about” (A-ID#15^M) include depression and suicide, though some community leaders reported trying to increase opportunities for education: “We’re trying to…create a space to talk about suicide” (A-ID#12^T). When mental health is discussed in the community, several adult KIs stated it was often done in a negative light: “in Samoa, we have this stigma… that mental health, anything pertaining to mental health means that someone’s crazy” (A-ID#21^M). Anyone who might show signs of struggling or living with “a mental health problem, is just labeled as crazy” (A-ID#22^C).

Most KIs noted how the stigmatizing nature of mental illness in the community can be linked with individuals being “…not informed…we don’t know about mental health from a very young age” (A-ID#12^T). An adolescent stated this may prevent students from knowing “where to seek help from” (Y-ID#25^m). Many KIs commented the broader community’s “lack of education on the island about mental health issues” (A-ID#07^M) also means the population is “missing the plain language…And we’re asking people to try to measure their feelings…but not giving them all the tools to be able to do that” (A-ID#11^M).

Increasing opportunities for mental health education would require policymakers and community leaders in American Samoa to address structural stigma and increase cross-sectoral collaboration, funding, and resource allocation for mental health programs, a need that one adult KI stressed: “I would like to see some kind of organized, consolidated collaboration by churches, NGOs, and the government…because there’s just a lot of fragmentation right now…” (A-ID#07^M).

Additionally, adult KIs and adolescents described a “social pressure” that hinders individuals from disclosing how they may be feeling, especially among men and boys, as one young adult mentioned how “it’s not masculine to talk about your feelings” (A-ID#05^C). Another young adult KI stated that many boys in the community are “taught to be strong for their families and we need to suck it up and move on” (A-ID#18^C), a sentiment that was echoed by multiple male and female adolescent participants:

“I feel like boys, we’re misunderstood sometimes…we’re supposed to be tough…but sometimes we need a break and sometimes we have our moments where we can’t hold the load.” (Y-ID#6^m) “But the boys…if you’re too emotional, then you’ll be judged by a lot of boys, especially if they’re your friends. The boys feel like they can’t be emotional” (Y-ID#11^f).

Some adult KIs explained how gender roles shape perceptions of mental health and emotional well-being among adolescent boys: “…the male Samoan male archetype is tough exterior…whatever comes along, just grin and bear it… put it in a box…deal with it some other time” (A-ID#13^M). The majority of KIs perceived that gender-related differences in emotional expression are influenced by cultural norms, and these differences may affect an individual’s ability to find social support when facing a significant stressor or when needing to address a mental health-related need: “Men aren’t supposed to show feelings…more so here in a Pacific culture where everything is [a] patriarchal hierarchy. And so young men don’t feel comfortable sharing their feelings with other men or other peers…they just seem to bottle up a lot of that aggression or a lot of those negative feelings that they have until they burst…I feel like for young women, they’re able to reach out, they have the capacity to reach out to their peers. And for young men, there’s always this, stigma, oh ‘I’m a guy, I’m a man I’m not supposed to share show or share any feelings.’ And so that becomes an obstacle for them to seek the kind of help that they need” (A-ID#07^M).

Multiple adult KIs also discussed the role of religion in the community’s perception of mental health: “There’s a lot of people on [the] island who think that if you say you’re depressed or that you’re going through depression, there’s a lot of people who think that that’s all like the devil’s work” (A-ID#10^M). While several KIs cited the church community as an important source of support for an adolescent struggling with their mental health, others noted “the role that the church plays …could be another one of those areas where discussion of themes such as mental health is discouraged” (A-ID#13^M). An adult KI further expressed concern over “this minimizing attitude towards [mental health] as if, ‘Okay, let’s not talk about it, let’s pray about it’” (A-ID#25^T). A young adult KI held similar thoughts: “Everybody tells you to turn to God…we’re already doing enough to make them feel like they should pray instead of talking to somebody” (A-ID#05^C).

Most KIs believed that the negative public perception of mental illness may affect an adolescent’s interactions with friends and families–described as interpersonal stigma–while also preventing them from seeking help for any issues related to mental health: “[Adolescents] don’t feel safer at home and now there’s nobody else to talk to at the school level. They don’t feel comfortable talking to adults in their village. So, the question becomes, who are they talking to?” (A-ID#07^M).

KIs also observed that some of the public’s most recent response to the cluster of suicides in the community may further stigmatize mental illness: “The public was responding to the recent suicides here on [the] island and there was a lot of victim shaming and victim blaming going on social media. So [adolescents who had attempted suicide] were feeling defeated or they were feeling like they were back in that place because the stigmas are still alive and well here” (A-ID#03^T). Furthermore, an adolescent was concerned that certain classmates who had posted signs of suicidal ideation on social media were not treated or heard seriously because “sometimes people would think it’s for attention” (Y-ID#29^f).

The perceived stigma around mental health is why adult and adolescent participants stressed the need to increase mental health literacy among the adult and adolescent population in American Samoa: “Yes, everyone is aware of suicide and mental health but they’re not understanding the perspective or view from a person who has thoughts of committing suicide…. I feel that people should be educated on what depression is and how we can help with it, instead of saying ‘I wish I can help’ or ‘You’ll get through this’. Our youth just needs someone to listen to, and when I mean to listen, I mean actually listening” (Y-ID#21^f).

Interpersonal stigma: “People see mental health as a weakness” (A-ID#25^T)

Interpersonal stigma refers to interactions that occur between a non-stigmatized individual and a stigmatized person. Adult KIs and adolescents described a myriad of outcomes that may occur if an adolescent struggling with their mental health confides in their parents on how they are feeling. The first three were most frequently mentioned, but references to physical punishment were also common:

1. Shaming: “It’s frowned upon…If the parents perceive [their children], they’re not in their place. They’ll say that, you know, like fiapoko [smart aleck, know it all] …” (A-ID#15^M)
2. Parental dismission of claims: “…when they do turn to their parents, it’s not a very pretty outcome…they kind of just push it aside…where it’s like, ‘If you’re an abled body person, then why are you depressed?’” (A-ID#05^C)

“Whenever I try sharing with my family, they always say mind over matter and just get through it.” (Y-ID#11^f)

1. 3) The usage of negative stereotypes associated with mental illness: “…My students had been sharing that they know a lot of youth who don’t speak up because they’re either shamed for it …their parents would tell them they’re just being lazy or cowardice” (A-ID#03^T).
2. 4) Physical punishment: “We, all Samoans, we spank our kids, so they would, be obedient. They’ll learn to listen and obey…. It [spanking] was like our way of discipline here on Island” (A-ID#18^C).

Participants listed the pressure of fulfilling familial expectations as reasons why an adolescent may not feel comfortable discussing their emotions and mental well-being with parents: “Our culture is brought up in such a way that you’re supposed to be mentally fit and strong to overcome anything. I’ve also come across some parents who will not acknowledge the fact that their child has mental health problems, that they’re actually going through depression and suicidal tendencies. They won’t see it, or they won’t acknowledge it…” (A-ID#07^M).

“..the fact that some families pressure their kids to achieve more even if that means putting their mental health at risk” (Y-ID#13^f).

Several KIs said families may also be influenced by the public stigma around mental health to the point that they “would rather brush the behavior [of the adolescent] under or hide it under the rug rather than, bring it up to light and asking for help from professionals” (A-ID#21^M).

KIs and adolescents stated the negative interactions between parents or peers and a stigmatized adolescent may make the adolescent less likely to ask for help in dealing with a mental health issue: “Kids are taught to toughen it out…when you’re struggling and especially if you’re crying about something, there’s not really the process, ‘Let me help you organize your thoughts and help you feel and calm you down’… A lot of it…it’s invalidating, ‘Why are you crying? That’s not even a big deal. It’s not anything you should be crying about’.” (A-ID#14^T).

“I think [adolescents] should open up, but then again, most of the boys, every time we open up to our parents and some of the adults, most of them will judge us, calling us weak and calling us girls, cause most of them think that boys should always be tough in life” (Y-ID#2^m).

Adult stakeholders, including young adult KIs, have also described instances of adolescents being shunned or bullied on social media after showing signs of suicide ideation or self-harm: “Someone…already feeling weak for having suicidal thoughts and then going on Facebook and seeing people write things about other youth who have committed suicide, ‘They took the easy way out’ or, ‘They were cowards’…It discouraged [adolescents] to even speak out” (A-ID#03^T).

“Because [self-harm] is a taboo thing here and a lot of kids are made fun of for self-harm, instead of comforted. I know there are kids here who post self-harm and a lot of other kids… screenshot that and share it amongst friends…calling them weak” (A-ID#02^C).

Some adolescent participants also noted similar negative experiences with school counselors: “My counselor likes to yell at me every time when I try to come to her for help!” (Y-ID#17^m). An adult KI also remarked on a similar moment: “And one of our counselors is saying, ‘Why are you crying like a baby?’… just ‘Suck it up’… They’re not very sensitive to what the adolescent is going through” (A-ID#13^M).

These potential instances of interpersonal stigma an individual with a mental health concern may experience can influence whom they choose to confide in and whether they seek a mental health professional. For example, both adult KIs and adolescent participants believed that adolescents’ concern over confidentiality may prevent them from seeking help or utilizing local mental health services: “Nowhere have I had more questions about confidentiality than here in Samoa. And it makes sense because, you know, it’s a small place…so that question of where does my information or material, where does it go? Who do you know, who are you going to tell?” (A-ID#10^M).

Interpersonal stigma may also negatively influence the self-image and self-esteem of a stigmatized individual, potentially resulting in the manifestation of self-stigma.

Self-stigma: “We don’t actively seek help, even though we might be suffering mentally” (Y-ID#13^f)

Internalized stigma, or self-stigma, occurs when an individual living with a mental illness holds negative attitudes about their self and shames themselves for their mental health condition or struggles. Adults KIs and adolescent participants frequently described how adolescents may be struggling with addressing their emotional needs while juggling the social pressures they feel from their families, peers, and the broader community, at the expense of their mental health:

“…expectations that may be had by family members…not wanting to disappoint their family members, feeling a huge sense of responsibility…but this feeling that they’re taking on a lot…they can’t really express themselves to others…[and] needing to kind of create this façade” (A-ID#10^M).

“…making my parents proud is a lot of pressure. I do love my parents, but the consequences are too much for me. I have to meet their every request…It is a battle to myself that I have to meet everything my parents want from me just to make them proud but for me, it is not particularly what I want for myself. So it comes with being depressed and stressed trying to do something that I do not want to do yet it is what I feel like I have to do just to make my parents proud” (Y-ID#17^m).

Aside from adolescents potentially hiding their mental health struggles to preserve a positive image for themselves and their families, one adolescent participant also explained that the social pressure by the community to be perfect may be associated with poor mental health among adolescents: “I don’t really think our youth is mentally healthy mostly because of the impact from social media and also all the pressure that we get from our parents, of them wanting us to be perfect, wanting us to set an image that sometimes we think we can’t fulfill or that we can’t reach.” (Y-ID#15^f) Two other adolescent participants agreed with this sentiment and the effect of internalizing negative attitudes on an adolescent’s mental health: “Pride…always stop me from asking people for help even though I know I desperately need it…that I may look weak or stupid. Pride in my family that it might be a disgrace that I cannot stand on my own. Pride as a guy that people always expect us to be the stronger person” (Y-ID#17^m).

“You gotta always watch what you’re doing, make sure you don’t take the wrong path…And all you’re gonna think is…’Why am I even doing this when all I’m gonna get back is scolding?’ We can all feel that one mistake…all you can feel is, ‘I’m not even good enough for this family, that’s why they keep lecturing me.’ And that’s where this bad mental health comes in” (Y-ID#33^f).

Adolescent participants also commented on the fear of judgment if they tell family members how they are feeling, resulting in a ‘bottling up’ of emotions that negatively affects their mental health: “In some cases [adolescents] really see it as the only option to turn to suicide…because opening up would mean admitting one’s vulnerability and, possibly being subjected to criticism due to their quote unquote ‘lack of strength’.” (Y-ID#13^f) Additionally, several adolescent KIs believed that the current actions adolescents take to keep emotions to themselves may prevent the utilization of current mental health services: “The mindset many of our youth have that they can just keep all their emotions to themselves instead of expressing them…I’m guessing that’s why most of the youth don’t want to dial the [hotline crisis] numbers…because even at our school…they give out the numbers…they give out the pamphlets…but it’s just that some of the students just think…they don’t need people to listen” (Y-ID#14^f).

Do you need mental health support?

If you are struggling with your mental health, please call the +988 Suicide and Mental Health Helpline to connect with a mental health counselor in American Samoa and across the US.