The number of North Korean refugees who are entering South Korea has been rapidly increasing since the late 1990s, and the total in 2013 was 26 000 [1]. North Korean refugees have experienced life in North Korea, starvation during their escapes and immigration, torture, forced labor, surveillance, violation, family separations, witnessing of death, rape, life in concentration camps, diseases, malnutrition, physical injuries, large-scale massacres, and hostage situations [2,3]. All these things lead to psychological and emotional pain and stress responses in their post-immigration lives [3-8]. After the North Koreans enter South Korea, they face more distress, in line with the aftereffects of their past psychological trauma while they adapt to the new culture, and many of them admit to mental health problems such as depression, lethargy, post-traumatic stress responses, and drug addiction [4,5,9-14].

However, medical service utilization due to mental health problems in particular is not easy for North Korea refugees because of their cultural, linguistic, institutional, and normative differences, as well as economic difficulties [15]. The cultural differences between North and South Korea increase the importance of establishing mental health literacy among North Korean refugees, which will be quantitatively different than of the South Koreans [16]. Negative literacy and a low mental illness knowledge level formed in North Korea combined with closed socialism proves a strong obstacle to the North Koreans obtaining proper medical services in South Korea [13]. As such, totally different literacy with regard to the terms and contents of “mental health” and mental illnesses used in the South Korean mental health and medical system can lead to an underestimation of the prevalence rates of health problems and an overestimation of the utilization of mental health promotion services and visits to treatment facilities. This difference in mental health literacy leads to differences in medical use behavior, which ultimately induces a difference of service delivery systems and contents.

Whereas there is no systematic definition of mental health literacy, the definition in this study includes the ability to discuss certain diseases with knowledge and the presence of beliefs concerning mental illnesses that promote literacy, management, and prevention, as well as increase the knowledge of how to obtain mental health information, recognition of the causative and risk factors of diseases, knowledge of self-treatment and professional help, and attitudes toward obtaining proper help, based on a concept suggested by Jorm et al. [17]. Measuring the mental health literacy of the North Korean refugees allows for the evaluation of their mental health knowledge and literacy levels and a more positive, informed attitude toward mental illnesses. Mental health literacy development further assists in developing alternatives to prevent mental health problems and handle them properly in an timely manner. For the prevention of mental illnesses and the development of early intervention, a widespread distribution of mental health literacy is required [17]. In order for this to occur, mentahealth knowledge should be measured, and studies of the factors that affect that knowledge should be conducted.

The most widely known, highest-prevalence mental illness North Korea is schizophrenia. No other mental illness has yet gained much attention in the literature [18,19]. Schizophrenia, a disease with the main symptoms of auditory hallucination and delusion, as “jungshinbunyeolbyung (mind-split disorder)” in Japan, Korea, and Taiwan for a long time, but it has recently been renamed as “johyeonbyung (attunement disorder),” which metaphorically implies that schizophrenia is a brain disorder with inadequately tuned neural circuitry, to dispel the stigma associated with the name [20]. This is a chronic disease and has been the focus of mental health services globally among local communities globally. Since it shows a constant worldwide prevalence rate of 1% of the total population and exhibits the same disease patterns throughout all areas, it is mainly used to compare differences in mental illness literacy.

‘Hospital 49’ is responsible for the existing mental health examination process in North Korea as well. The Hospital 49 is established in each province, and Hospital 49 is present as an examination department among both county and large-scale hospitals. Hospital 49 is known to examine severe mental illnesses such as schizophrenia [16]. Although depression has rapidly increased among Koreans and is known to be a representative mental health problem, even North Korean doctors who were interviewed in a qualitative study that was separately performed by our team mentioned that they had seen the terminology “depression” once in a book but had never heard or used it in North Korea. As such, unlike South Koreans, North Korean refugees understand mental health as a mental illness that is mainly represented by one mental disorder (schizophrenia) [21].

This study aimed to investigate the level of knowledge concerning mental illnesses and its treatments in order to measure North Korea refugees’ mental health literacy and identify the factors influencing their levels of mental illness knowledge.

This study analyzed North Korean refugees’ knowledge regarding mental illnesses, which presents a basis for designing and providing mental health services within the local community as if they were treating a chronic disease. Additionally, we assessed subjects’ knowledge and attitudes toward mental health. The mental illness knowledge scores for the North Korean refugees ranged from 3 to 24 points, with an average score of 13.0. This was lower than the average knowledge score of the caregivers of mental illness patients assessed in the study by Lim and Ahn [22], which was 16.4 points. It is also lower than the average score for the families of mental illness patients assessed by Kim and Jung [24], which was 17.0 points. Such a discrepancy seems to be associated with the more frequent exposure to mental health problems and relevant information among the caregivers and family members of the patients.

As a result of analyzing the correct answer rates of the 28 knowledge tool questions, we found that there is a substantial lack of knowledge regarding the relationships between drug side effects and mental illness recurrences. However, the study by Lim and Ahn [22] showed a similar correct answer rate of 19% for the drug-related question among family caregivers of mental illness patients, so knowledge of how drug use affects mental illness is lacking for family caregivers as well as for North Korean refugees. However, the results also indicate that most North Korean refugees are well aware that they need to administer prescribed drugs as instructed. When we compared each correct answer rates, there was no significant difference from the results of the study with family caregivers, but overall correct answer rate was low. This indicated that more opportunity to contact mental illness patients improves knowledge about their conditions.

TV and newspapers in North Korea only report good aspects of society, so mental illnesses and Nuber 49 wards are not mentioned in the media [16]. Moreover, Hospital 49 that segregates patients with severe mental illnesses are located in isolated areas; therefore, the chances are very rare to have any contact with them [16]. As a result, the level of knowledge on mental illness among North Korean refugees were generally quite low.

However, the knowledge scores were increased with the experience of psychiatric clinic utilization, the higher education levels obtained in South Korea, and the longer duration of stay in South Korea. These results showed that the increased experience of mental health service utilization and getting education in South Korea would positively influence on the acquisition of relevant knowledge on mental illness.

As for mental illness knowledge scores according to the characteristics of the subjects, those who had experienced occupational turnover, those who considered mental health among North Korean refugees as being serious, and those who had experience with psychiatric clinic utilization showed higher knowledge score. In addition, the subjects with at least a college education had higher knowledge scores than those who had received no education in South Korea. Similarly, those who were satisfied with life in South Korea showed higher knowledge scores than those who were not. This indicates that the mental illness knowledge of North Korean refugees is improved via education after their entrance into South Korea. Consequently, it is essential to provide North Korea refugees with education on mental health in order to improve their knowledge level and encourage them to utilize proper medical services when needed.

The mental health of North Korean refugees is deeply associated with the experience of escaping North Korea and entering South Korea, as well as their experiences while residing in North Korea [15, 25]. A number of North Korean refugees suffer from severe trauma and stress while escaping from North Korea and in settling down in South Korea. Such conditions can trigger the onset of mental and physical illnesses and the worsening of existing diseases. Health problems are barriers for North Korean refugees against settling down successfully in South Korea, so their mental health is very important [26]. Despite the importance of mental health for North Korean refugees and the highlighted necessity of diagnosis, refugees’ limited knowledge and illiteracy has been an obstacle to proper medical service use. In March 2010, the Ministry of Unification amended their Act on North Korea Refugee Protection and Settlement Support and designated so called ‘professional counselors for North Korea refugees’ to Hana Centers at 32 sites in order to support the settlement and mental health of North Korean refugees. However, besides mental health support, the professional counselors are to perform many other tasks including taking care of emergency situations and complaints, and giving career counseling. There is only a small number of counseling experts and registered counselors; thus, so far, this program is critically lacking in professional expertise and link to mental health care system preexisting in South Korea.

In order to enhance the mental health status of North Korean refugees and improve their literacy of service utilization, education to provide them essential knowledge on mental health with consideration to cultural understanding should be performed with proper data using Hanawon and the Hana Center. Hanawon and Hana Center are government organizations that provide social fundamental education for North Korean refugees. As such, these organizations serve as early settlement education for North Korean refugees, although their levels of understanding may be slightly low. It is therefore important to provide relevant data and options for the refugees to make decisions based on their specific time constraints and needs. According to Cho’s study [27], 70% of North Korean refugees responded that they do not, or almost do not, know the roles of counseling centers or psychological counselors. More than half (58%) of them answered that they do not know, or almost do not know, the roles of the psychiatrists. As such, it is important to provide data to help them to understand mental health-related organizations and experts.

Second, education for North Korean refugees should be performed by existing mental health professionals, instead of establishing separate organizations and jobs without sufficient training and education by mental health professionals. Mental health professionals cannot be trained within a short period of time. Their Korean national qualifications require long-term clinical training. As such, when well-trained and managed professionals understand the distinctiveness of North Korean refugees, they would be able to provide more qualified services. In particular, 60% of North Korean refugees reside in Seoul and Incheon. Since they reside in dense permanent and national rental housings, tailored education should be performed to this unique situation and should be centered on guiding the North Korean refugees to making optimal mental health decisions.

This study has a couple of limitations. First, study subject selection was restricted. There are 26 000 North Korean refugees distributed throughout the country. However, the subjects in this study were selected via a snowball sampling method centered on residents in the metropolitan areas with support from the North Korea Refugees Support Institute. It is therefore hard to consider this to be an optimum sample representing the overall population of North Korean refugees. However, considering the characteristics of North Korean refugees, such as limited opportunities to contact them and restricted information collection and reduced accessibility without the support from relevant centers, this limitation is somewhat inevitable. In order to overcome such limitations, the authors tried to match the sex ratios of the subjects and the distribution of the residential areas (metropolitan) according to the relevant population ratios.

The second limitation is the issue of the responder’s level of understanding with regards to survey tools. Our team performed preliminary surveys and revised the surveys in order to increase the respondent’s understanding of them. However, difficulty in understanding the surveys may still have remained due to large differences in the socio-cultural backgrounds of the North Korean refugees.

Third, the knowledge was measured with the common name of “mental illnesses,” instead of measuring the direct overall knowledge of diverse mental illnesses. Despite such limitations, the significance of this study rests in the fact that it the first study to measure and evaluate the level of mental illness knowledge among North Korean refugees. Investigating these mental illness knowledge levels and their influencing factors further generates basic data that can form a foundation for other studies of mental health literacy and attitudes. Furthermore, this study provides basic data necessary for solving mental health problems that are highly likely to occur in the future unification of North and South Korea.