J Immigrant Minority Health DOI 10.1007/s10903-014-9978-x
ORIGINAL PAPER
Acculturation, Gender, and Mental Health of Southeast Asian Immigrant Youth in Canada Carla T. Hilario • Dzung X. Vo • Joy L. Johnson Elizabeth M. Saewyc
•
Springer Science+Business Media New York 2014
Abstract The relationships between mental health, protective factors and acculturation among Southeast Asian youth were examined in this study using a gender-based analysis. Population-based data from the 2008 British Columbia Adolescent Health Survey were used to examine differences in extreme stress and despair by acculturation. Associations between emotional distress and hypothesized protective factors were examined using logistic regression. Stratified analyses were performed to assess gender-related differences. Recent immigrant youth reported higher odds of emotional distress. Family connectedness and school connectedness were linked to lower odds of extreme stress and despair among girls. Family connectedness was associated with lower odds of extreme stress and despair among boys. Higher cultural connectedness was associated with lower odds of despair among boys but with higher odds of extreme stress among girls. Findings are discussed in relation to acculturation and gender-based patterns in protective factors for mental health among Southeast Asian immigrant youth.
C. T. Hilario (&) J. L. Johnson School of Nursing, University of British Columbia, Vancouver, BC, Canada e-mail: [email protected] D. X. Vo Division of Adolescent Health and Medicine, University of British Columbia and BC Children’s Hospital, Vancouver, BC, Canada E. M. Saewyc McCreary Centre Society, Division of Adolescent Health and Medicine, and School of Nursing, University of British Columbia, Vancouver, BC, Canada
Keywords Mental health Acculturation Gender Protective factors Southeast Asian youth
Introduction The recent launch of Canada’s first national mental health strategy has sparked new dialogues on mental health promotion [1]. The Mental Health Commission of Canada advances the World Health Organization’s definition of mental health and outlines key strategic directions for improving mental well-being among all Canadians. Among these priorities, the report emphasizes the need for mental health promotion and prevention across the life course, especially among children and youth, and to address inequities in the social determinants of mental health faced by particular groups, including immigrants, refugees, ethno-cultural and racialized groups. Immigrant youth and their families face multiple challenges that affect their mental health, e.g. underemployment, difficulties securing adequate housing, and earning sufficient income [2]. In Canada, evidence suggests widening inequities in income between newcomers and Canadian-born families; for instance, one in two newcomer families in British Columbia live in poverty during their first 5 years in Canada [3]. Immigrant children are more than twice as likely to live in poverty, compared to Canadian-born children, and nearly one in three immigrant families in Canada live below the official poverty line during their first 10 years of residence [4]. Poverty shapes patterns of disadvantage and exposures to determinants of mental health including food and housing security, education, opportunities for employment and social support [5, 6]. Higher rates and likelihood of poverty among recent immigrants places them at higher
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risk for mental health challenges [7, 8]. For instance, poverty has been found to have a direct effect on the mental health of immigrant children while among Canadian-born children this relationship is mediated through other factors such as family dysfunction and parental mental illness [4]. Apart from material circumstances, young immigrants face other stressors related to migration and resettlement. In particular, experiences of psychological and social acculturation may compound the stress of normative tasks such as identity development and establishing a sense of belonging [9]. Acculturation can be defined as ‘‘a process whereby contact between different cultural groups results in changes in both groups’’ and is related to the process of ethnic identity development [10, 11]. Findings suggest that a sense of belonging to one’s cultural group and approach to acculturation are linked to young people’s psychological and sociocultural adaptation following migration [12]. Being able to balance a sense of one’s cultural identity while striving to integrate into the new society has been shown to lead to better mental health outcomes [13]. The migrant health literature in Canada has been characterized by three dominant approaches: the morbiditymortality hypothesis in which immigrants are believed to have worse health; the healthy immigrant effect in which immigrants are perceived as having better health; and the transitional effect hypothesis that posits that health advantages on immigration decrease over time [14]. Initial adaption processes are crucial for immigrants and can impact their mental health in the years following settlement. In Canada, national longitudinal data suggests that while immigrants arrive with better mental health than their Canadian-born counterparts, this ‘healthy immigrant effect’ deteriorates over time to resemble the mental health status of the non-immigrant population [15]. However, much of this research has been on adult migrants moving through mainstream immigrant classes. Few studies have examined immigrant youth mental health in a Canadian context [2, 16]. In the field of adolescent health promotion, there is burgeoning interest in the role of protective factors that may help mitigate the effects of stressors on mental health outcomes. Previous studies in North America have demonstrated the impact of caring and social connectedness on adolescent behavior and emotional stress [17] and in mitigating the effects of risk factors for adolescent health outcomes [18, 19]. For instance, young people who feel strongly connected to their families and schools experience lower levels of emotional distress [20]. However, little is known about the factors that promote mental health among immigrant youth [7], especially those from particular ethno-cultural backgrounds.
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Our understanding of mental health and protective factors in migrant populations remains nascent. In particular, there is a lack of research on the health of young immigrants despite the recognition of adolescence as an important developmental period [2]. The role of gender in the relationships between protective factors and mental health must also be investigated [21, 22]. Research on the mental health of immigrant youth in Canada is especially needed given the country’s pivotal role in global migration. In Canada, approximately one in three young people are growing up in immigrant families [23] and an estimated 35,000 immigrant youth arrive in the country every year [24]. In particular, individuals who have migrated from Southeast Asia represent a significant proportion of immigrants to Canada [23]. For instance, Philippines was the top source country for permanent residents to Canada in 2011 [25]. British Columbia is a leading province for new immigrants and for permanent residents to Canada, 69 % of which are from the Asia and Pacific [25]. The goals of this study were to describe gender-based and migration-related differences in mental health and to examine the linkages between acculturation and protective factors for mental health among Southeast Asian youth using a population-based sample. Conceptual Framework Drawing on ecological theories of adolescent development [27], this study examined relationships between migration and the social contexts that support mental health among Southeast Asian youth in Canada. This model proposes that, among immigrant youth, mental health is shaped by the interactions between various levels of socio-ecological influences that interact with factors related to migration and acculturation. Ethnic identity is understood as a component of larger acculturation processes that involve individuals, communities and societal approaches to ethno-cultural diversity. The focus of this study is on young people’s sense of belonging to a cultural group, ethnic identity connectedness, as a hypothesized protective factor among ethno-cultural youth [28]. It was hypothesized that there would be migrationrelated differences in self-reported stress, despair, selfharm and suicide behavior. Specifically, it was hypothesized that higher odds of self-reported stress and despair would be associated with less acculturation, conceptualized in this study using commonly used measures in the literature: foreign-born status, length of stay, and speaking a language at home other than English most of the time. It was expected that Southeast Asian young women would report higher stress and despair based on population-based data with adolescent populations in Canada.
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Lastly, it was hypothesized that lower odds of stress and despair would be associated with known protective factors in the adolescent health literature, especially level of connectedness to parents and families. In particular, cultural connectedness was hypothesized to have a protective effect against stress and despair among Southeast Asian youth.
Methods Study Sample To conduct this analysis, we used data from the 2008 British Columbia Adolescent Health Survey (BC AHS), a province-wide questionnaire with a cluster-stratified sampling design. It is administered approximately every 5 years to a representative sample of secondary school students (aged 12–19, grades 7–12) across BC. Over 29,300 students participated in the 2008 BC AHS, providing data that was weighted and scaled to reflect the 283,120 youth attending public schools in the province at the time of the survey. A detailed description of the BC AHS survey methodology can be found elsewhere [26]. Our analytical sample in this study included all survey participants between the ages of 12 and 19 years of age (grades 7–12) who selected ‘Southeast Asian (e.g. Cambodian, Filipino, Indonesian, Vietnamese, etc.)’ in response to the survey question ‘What is your cultural or ethnic background?’ Participants who selected Southeast Asian as well as another response were also included. In this study, immigrants are defined as youth born outside of Canada. Recent immigrants are defined as youth who have lived in Canada for 5 years or less. This sample theoretically included all migrant classes, e.g. economic and family, as well as refugees although the BC AHS did not specifically ask youth to report this information. A community advisory group was established at the beginning of the study and comprised of members of local Southeast Asian community groups as well as teachers, adolescent health providers and two youth members of the McCreary Centre Society’s Youth Advisory Council who self-identified with Southeast Asian cultural identities. The advisory group met with the investigators to review and provide feedback on the research questions, study design, measures included in the analysis, conceptual framing and the interpretation of data. Findings from the statistical analyses were shared with members of the group and limitations discussed. Measures The primary outcome variables of interest, stress and despair, were examined using emotional distress scale
items in the 2008 BC AHS. This scale, adapted from the general well-being scale, has been used in other large-scale adolescent health surveys and evaluated for psychometric performance. A detailed description including psychometric properties of the scales in the BC AHS can be found elsewhere [28]. Emotional distress scale items, which asked youth to rate their level of stress and despair in the past 30 days, were dichotomized at the most extreme responses: •
•
Stress: ‘Have you felt you were under any strain, stress or pressure?’ (Extreme response: ‘Yes, almost more than I could take’) Despair: ‘Have you felt so sad, discouraged, hopeless or had so many problems that you wondered if anything was worthwhile?’ (Extreme response: ‘Extremely so, to the point I couldn’t do my work or deal with things’).
Social connectedness was assessed using three scales in the BC AHS: family connectedness (11 items), school connectedness (6 items), and cultural connectedness (6 items). The family connectedness scale asks how youth perceive their relationships with their family members, the extent to which they feel cared about and feel that their family understands them. The school connectedness scale questions the extent to which youth feel they belong to their school, feel happy, feel safe, and feel that their teachers care about them. The cultural connectedness measure is based on the Multi-Ethnic Identity Measure-R [29] and asks about the extent to which youth feel they belong to their cultural group. Acculturation was examined using three measures in the BC AHS that are also frequently used in the immigrant health literature: foreign-born status; language other than English spoken at home most of the time (dichotomized to ‘never’ or ‘sometimes’, and ‘most of the time’); and length of time lived in Canada (5 years and less was recoded as recent immigrant, between six and ten years as short-term immigrant, and more than 10 years in Canada as long-term immigrant). Analysis Data analysis was conducted using Statistical Package for the Social Sciences (SPSS) version 19. Complex Samples was used to account for the complex random clusterstratified design of the BC AHS. Ethics approval for this study was received from the University of British Columbia Behavioral Research Ethics Board and all data was analyzed at the McCreary Centre Society. Descriptive statistics were used to determine the prevalence of emotional distress. General linear modeling tests and Wald F statistics were used to examine whether level of connectedness varies by gender or immigrant status.
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123 14.86 [14.70, 15.02] 39.8 [35.3, 44.4]
Mean age in years, 95 % CI
% Foreign born, 95 % CI
5.1 [3.4, 7.5]
0.77 [0.75, 0.78] 0.69 [0.68, 0.71] 0.65 [0.63, 0.67]
Extreme despair: % in past 30 days, Feeling sad, discouraged, hopeless or had so many problems that wondered if anything was worthwhile and responded ‘‘Extremely so, to the point I couldn’t do my work or deal with things’’, 95 % CI
Family connectedness [scale 0–1] Mean, 95 % CI
School connectedness [scale 0–1] Mean, 95 % CI
Cultural connectedness [scale 0–1] Mean, 95 % CI
0.66 [0.65, 0.68]
0.69 [0.68, 0.71]
0.72 [0.70, 0.74]
9.8 [7.6, 12.5]
17.2 [14.2, 20.7]
34.8 [30.6, 39.2]
69.1 [64.7, 73.2]
12.4 [9.8, 15.6]
18.5 [15.4, 22.1]
37.8 [33.5, 42.3]
14.84 [14.67, 15.01]
55.8 [52.6, 58.9]
Young women
a
Source: British Columbia Adolescent Survey, 2008, McCreary Centre Society. Results shown are weighted The adjusted F is a statistical test used in IBM SPSS Complex Samples and is a variant of the Rao-Scott Chi Squared statistic
10.6 [8.0, 14.0]
Extreme stress: % in past 30 days, feeling under strain, stress or pressure that was ‘‘Almost more than [they] could take’’, 95 % CI
69.6 [65.2, 73.7]
More than 10 years 33.8 [29.3, 38.5]
12.5 [9.8, 15.9]
Between 6 and 10 years
% Speaking language other than English at home (most of the time), 95 % CI
17.9 [14.6, 21.6]
5 years and less
% Time lived in Canada, 95 % CI
44.2 [41.1, 47.4]
% within entire sample, 95 % CI
Young men
Gender
Table 1 Descriptive characteristics of a population-based sample of Southeast Asian high school students in British Columbia 2008
Wald F = 1.32
Wald F = 0.001
Wald F = 11.76
Adjusted F = 7.94
Adjusted F = 7.94
Adjusted F = 0.10
Adjusted F = 0.03
Adjusted F = 0.40
t = 0.19
Adjusted F = 5.85
a
Test statistic
1, 494
1, 492
1, 498
1, 499
1, 499
1, 499
2, 987
1, 499
1
1
df
0.252
0.972
0.001
0.005
0.005
0.75
0.97
0.53
0.85
\0.05
p
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J Immigrant Minority Health Table 2 Odds ratios of self-reported extreme despair by acculturation and protective factors, stratified by gender Characteristics
Age
Unadjusted OR
Adjusted OR
Southeast Asian young men
Southeast Asian young women
Model 1 Southeast Asian young men Model v2 41.64, p \ 0.001
Model 2 Southeast Asian young women Model v2 80.28, p \ 0.001
OR
95 % CI
OR
95 % CI
OR
95 % CI
OR
95 % CI
1.35**
1.09, 1.68
0.91
0.79, 1.05
1.30*
1.02, 1.66
0.84*
0.70, 1.00
Immigrant status Canadian-born
Ref
–
Ref
–
Ref
–
Ref
–
Foreign-born
1.63
0.75, 3.54
0.91
0.54, 1.54
0.55
0.15, 2.05
0.36
0.12, 1.04
Length of residence More than 10 years
Ref
–
Ref
–
Ref
–
Ref
–
6–10 years
0.66
0.14, 3.14
1.45
0.71, 2.96
1.30
0.21, 7.91
4.64**
1.49, 14.46
5 years and less
2.65
1.14, 6.17
1.40
0.75, 2.59
5.34*
1.24, 23.05
4.84**
1.50, 15.62
Ref 1.30
– 0.59, 2.91
Ref 0.79
– 0.45, 1.36
Ref 1.27
– 0.49, 3.32
Ref 0.79
– 0.40, 1.58
Family connectedness (0–1)
0.02***
0.003, 0.09
0.01***
0.004, 0.04
0.05**
0.01, 0.37
0.02***
0.004, 0.06
School connectedness (0–1)
0.02***
0.003, 0.12
0.02***
0.004, 0.07
0.13
0.01, 1.53
0.08**
0.014, 0.46
Cultural connectedness (0–1)
0.07**
0.01, 0.46
0.08***
0.02, 0.33
0.11*
0.01, 0.98
0.40
0.08, 2.10
Non-English language spoken at home Never or sometimes Most of the time Protective factors
Source: British Columbia Adolescent Survey, 2008, McCreary Centre Society. Results shown are weighted * p \ 0.05; ** p \ 0.01; *** p \ 0.001
Table 3 Odds ratios of self-reported extreme stress by acculturation and protective factors, stratified by gender Characteristics
Unadjusted OR
Adjusted OR
Southeast Asian young men
Southeast Asian Young women
Model 1 Southeast Asian young men Model v2 33.06, p \ 0.001
Model 2 Southeast Asian young women Model v2 69.91, p \ 0.001
OR
95 % CI
OR
95 % CI
OR
95 % CI
OR
95 % CI
Age
1.29**
1.10, 1.51
1.14*
1.03, 1.27
1.16
0.98, 1.38
1.088
0.96, 1.23
Immigrant status Canadian-born
Ref
–
Ref
–
Ref
–
Ref
–
Foreign-born
1.37
0.78, 2.43
0.81
0.53, 1.22
2.09
0.96, 4.55
0.60
0.29, 1.26
More than 10 years
Ref
–
Ref
–
Ref
–
Ref
–
6–10 years
0.52
0.18, 1.53
1.57
0.92, 2.68
0.39
0.12, 1.30
2.42*
1.09, 5.38
5 years and less
1.08
0.52, 2.24
0.61
0.34, 1.08
0.57
0.21, 1.54
0.99
0.41, 2.38
Length of residence
Non-English language spoken at home Never or sometimes
Ref
–
Ref
–
Ref
–
Ref
–
Most of the time
0.98
0.53, 1.80
0.73
0.47, 1.12
0.82
0.41, 1.65
0.71
0.43, 1.17
Family connectedness (0–1)
0.05***
0.02, 0.19
0.05***
0.02, 0.12
0.09**
0.02, 0.42
0.07***
0.02, 0.21
School connectedness (0–1)
0.07***
0.02, 0.28
0.03***
0.01, 0.10
0.17
0.03, 1.03
0.07***
0.02, 0.29
Cultural connectedness (0–1)
0.67
0.14, 3.17
0.71
0.23, 2.14
2.57
0.48, 13.86
4.15*
1.10, 15.72
Protective factors
Source: British Columbia Adolescent Survey, 2008, McCreary Centre Society. Results shown are weighted * p \ 0.05; ** p \ 0.01; *** p \ 0.001
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Emotional distress was assessed by gender and by immigrant status using modified Rao Scott Chi square tests. Multivariate logistic regression analyses adjusting for age were conducted to examine the relationships between social connectedness, migration and mental health. Analyses were stratified by gender and four regression models were conducted to examine potential gender-related differences in factors related to emotional distress.
Results Approximately 1 in 20 Southeast Asian youth participated in the 2008 BC AHS (5 % of survey sample; n = 1,225; population estimate = 14,283). Young women reported significantly higher rates of extreme levels of stress and despair compared to young men (see Table 1). There were no significant differences in mean levels of school or cultural connectedness by gender although young men reported higher family connectedness. Results from bivariate tests suggest that higher family and school connectedness are associated with lower odds of extreme stress and extreme despair, while higher cultural connectedness is related to lower odds of extreme despair. There were, however, no significant relationships between acculturation-related measures (foreign born status, time lived in Canada, language spoken at home) and emotional distress in bivariate analyses, even when examined by gender. In multivariate analyses, recent immigrant status was associated with five times higher odds of extreme despair among Southeast Asian youth (see Table 2). Being in Canada for more than five but less than 10 years was related to higher odds of extreme despair as well as extreme stress among young women (see Table 3). Higher cultural connectedness was associated with lower odds of extreme despair among young men (after adjusting for age and acculturation), yet was associated with higher odds of extreme stress among young women. Findings suggest gender-related patterns in protective factors for mental health. In terms of extreme despair, lower odds were associated with higher family and cultural connectedness in young men; while family and school connectedness were significant protective factors for extreme despair among young women. Among young men, family connectedness was the only significant protective factor against extreme stress. In contrast, connectedness to families and schools was associated with lower odds of reporting extreme stress among young women even though there were no significant gender-related differences in levels of school connectedness in bivariate analyses (p = 0.97). Although there was a significant relationship between school connectedness and
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extreme stress in bivariate analysis, school connectedness was not significantly associated with young men’s selfreported extreme stress in the final regression model.
Discussion Findings from this study suggest that emotional distress may be related to level of acculturation as measured by length of residence in Canada. In particular, extreme despair was found to be more likely among newcomer youth. Differences in the findings between the models for despair and stress suggest that these outcomes are experienced in distinct ways by Southeast Asian youth. Further, the concept of despair may be more related to experiences of acculturative stress than with notions of general stress and strain. Based on general stress and adaptation theories [30], acculturative stress can be understood as responses to events or changes in people’s lives that ‘‘challenge their cultural understandings about how to live’’ [31]. Within an acculturation framework, individual behavior and experiences interact with the contexts in which different cultures come into contact such as in migration. In this way, acculturative stress may be a stress response among young immigrants navigating the complex experience of psychological and social acculturation. While long-term effects associated with acculturative stress may range from adaptive to non-adaptive, findings from our study suggest that young immigrant men who have lived in Canada for more than five but less than 10 years (short-term immigrant) are no more likely to experience extreme stress or despair compared to their peers living in Canada for over 10 years. Among young women, however, short-term immigrant status was associated with higher odds of extreme stress and despair even after controlling for age and level of connectedness. Possible explanations for these findings might be that, in terms of extreme stress, young women may initially experience positive adaptation, but after the first 5 years face greater stressors. In terms of extreme despair, young women may face unique stressors that may persist for a longer period of time. Findings from this study do not support the ‘healthy immigrant effect’ phenomena in the mental health of Southeast Asian youth [15]. Rather, as hypothesized, findings from this study suggest higher odds of extreme despair among recent immigrant youth. These results are similar to findings from a previous school-based survey study in Canada that found higher symptoms of psychological distress among first-generation immigrant youth compared to subsequent generations [32]. However, in this study, extreme stress was not associated with level of acculturation in the same way that the latter was linked
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with extreme despair, suggesting that acculturative stress may be better captured in this population with the concept of despair. Findings from this study also highlight the protective role of social connectedness in experiences of emotional distress among Southeast Asian youth although these relationships may vary by gender and type of distress (despair versus stress). Family connectedness appeared to have the strongest protective effect against emotional distress, a finding consistent with previous adolescent health studies [17–20]. In contrast, higher school connectedness was protective only against emotional distress among young Southeast Asian women, suggesting gender-related differences in the ways that connectedness is linked to mental health. Some gender-related patterns of mental health observed in this study are consistent with other studies that suggest greater rates of depression among adolescent girls [33, 34]. Findings based on data from the Longitudinal Survey of Immigrants to Canada also show that immigrant women report higher rates of emotional problems compared to immigrant men [35], suggesting that gender differences in mental health may be salient in adolescence and potentially persist into adulthood. Another gender-based difference was related to the role of cultural or ethnic identity connectedness. The observed relationship between cultural connectedness and extreme stress among young Southeast Asian women was surprising given previous studies suggesting the protective role of ethnic identity on self-esteem and depressive symptoms, especially among ethnic minority groups [11, 36, 37]. It is possible that differences in study findings may be related in part to the particular indicators used for mental health, potential interaction effects between risk and protective factors or the role of other variables related to mental health such as physical and sexual abuse [38]. Additionally, these findings are limited by the unidimensional linear model of acculturation used in the study (e.g. length of residence) rather than complex multidimensional models of acculturation that can provide important information about acculturation strategies used by youth and their effect on health outcomes [12]. Another possible explanation is that ethnic identity may actually contribute to poorer mental health by exacerbating the negative effects of perceived racial discrimination on mental health. Some findings suggest that visible minorities and immigrants who experience discrimination are also more likely to report declines in self-assessed mental health status compared to other newcomers while perceptions of discrimination in neighborhood and school settings may affect youth’s sense of belonging, which in turn shapes their mental well-being [39, 40]. Alternately, a sense of belonging to a particular cultural community may create
greater stress or conflict for individuals if they do not perceive their social identity as favorable [41]. For instance, some findings suggest that, among Southeast Asian groups in Canada, experiences and perceptions of discrimination may marginalize individuals as ethnic minorities and increase risk for psychological distress [42]. Among newcomer families in Canada, perceived discrimination has been associated with various health problems in immigrant children and younger adolescents including aggression, hyperactivity, and emotional problems [43]. Conversely, cultural connectedness was a protective factor against extreme despair among young men in the final regression models. One possible explanation is that cultural connectedness may not be related to discrimination in Southeast Asian young men in the same way as for young women and may be linked to healthier acculturation strategies. Limitations There are several limitations to findings in this study. First, the 2008 BC AHS does not ask about generational status so it was not possible to examine differences in mental health status between foreign-born youth and second-generation youth born in Canada to immigrant parents. Second, the relationship between cultural connectedness and mental health may have been better examined using multidimensional measures of specific acculturation strategies [12]. Further, the study did not include a question on immigrant class, e.g. economic immigrant or government-assisted refugee, or a measure of socioeconomic status. Because it is conducted among youth aged 12–19 years, there is no robust measure for socioeconomic status or poverty in the BC AHS although recent statistics provide such estimates among newcomer families [3]. The emotional distress items used in the BC AHS were based on the general well-being scale and were not developed to specifically capture distress related to acculturation. Additionally, not all immigrants may experience acculturative stress or perceive migration experiences in terms of acculturation. While the measures of extreme stress and despair were drawn from the same scale, it is important to note that they are measuring distinct concepts. That we found differences in the relationships between acculturation and these two mental health outcomes suggests that the items are measuring unique concepts despite being dimensions of emotional distress. Other limitations include the administration of the survey in English, which may have affected the responses of youth who lacked the language or literacy skills to complete the questionnaire. Since the BC AHS was administered at school, this data cannot provide information on youth who are not in school or are in alternative education
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programs including those in government custody or streetinvolved youth. Lastly, there is the potential for the aggregation of data on ethnic or cultural backgrounds into the larger Southeast Asian category to mask possible differences between the groups in terms of mental health status and factors associated with emotional distress.
Conclusions Findings from this research contribute to current understandings about mental health and protective factors among Southeast Asian youth. Our results suggest that newcomers experience higher likelihood of extreme despair that, for young women, may persist up to 10 years following immigration. Health providers who work with immigrant youth may need to assess for potential emotional distress related to their experiences of migration and acculturation, especially among recent immigrants. Health providers and educators should promote family and school connectedness among Southeast Asian youth and help immigrant families to maintain caring family relationships. Tailored interventions may be needed to support immigrant youth in negotiating experiences of psychological and social acculturation, especially in the initial period after migration. It is evident that there is a need for gender considerations in mental health research that examine not only differences by gender but also potentially unique patterns in the factors that support immigrant youth’s health. Applying multidimensional acculturation models and concepts will also strengthen study designs with immigrant populations and help providers to understand how to best promote healthy acculturation and identity development. Lastly, qualitative research approaches are much needed to further understand the intricate relationships between mental health and protective factors such as cultural connectedness at the intersections of gender, adolescence and migration. Acknowledgments The authors would like to thank the reviewers for their thoughtful feedback. Conflict of interest
None.
References 1. Mental Health Commission of Canada. Changing directions, changing lives: the mental health strategy for Canada. Alberta: Author; 2012. 2. Salehi R: Intersection of health, immigration, and youth: a systematic literature review. J Immigrc Minor Health Cent Min Public Health. 2010; 12:788–797. 3. First Call: BC Child and Youth Advocacy Coalition: 2011 British Columbia Child Poverty Report Card. 2011.
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4. Beiser M, Hou F, Hyman I, Tousignant M. Poverty, family process, and the mental health of immigrant children in Canada. Am J Public Health. 2002;92:220–7. 5. Raphael D. The health of Canada’s children. Part I: Canadian children’s health in comparative perspective. Paediatr Child Health. 2010;15:23–9. 6. Simich L, Beiser M, Stewart M, Mwakarimba E. Providing social support for immigrants and refugees in Canada: challenges and directions. J Immigr Health. 2005;7:259–68. 7. Smith A, Poon C, Steward D, Hoogeveen C, Saewyc E. McCreary Centre Society: making the right connections: promoting positive mental health among BC youth. Vancouver, B.C: McCreary Centre Society; 2011. 8. Dashiff C, DiMicco W, Myers B, Sheppard K. Poverty and adolescent mental health. Journal of child and adolescent psychiatric nursing: official publication of the Association of Child and Adolescent Psychiatric Nurses, Inc. 2009;22:23. 9. Sam D. Berry JW: acculturation: when individuals and groups of different cultural backgrounds meet. Perspect Psychol Sci. 2010; 5:472–81. 10. Berry JW. A Psychology of Immigration. J Soc Issues. 2001;57: 615–31. 11. Phinney JS. The multigroup ethnic identity measure: a new scale for use with diverse groups. J Adolesc Res. 1992;7:156–76. 12. Berry JW, Phinney JS, Sam DL, Vedder P. Immigrant youth: acculturation, identity, and adaptation. Appl Psychol Int Rev. 2006;55:303–32. 13. Berry JW. Acculturation and adaptation of immigrant youth. Canadian Divers. 2008;6:50–3. 14. Khanlou N. Migrant mental health. Canadian Issues / The`mes Canadiens. Summer 2010; 9–16. http://canada.metropolis.net/ pdfs/immigrant_mental_health_10aug10.pdf. 15. Ng E, Omariba DWR. Is there a Healthy Immigrant Effect in Mental Health? Evidences from Population-Based Health Surveys in Canada. Canadian Issues / The`mes Canadiens. Summer 2010; 23–28. http://canada.metropolis.net/pdfs/immigrant_men tal_health_10aug10.pdf. 16. Hamilton, H. A., Noh, S., Adlaf, E. M. (2009). Adolescent risk behaviours and psychological distress across immigrant generations. Canadian journal of public health = Revue canadienne de sante´ publique, 100(3), 221–5. Retrieved from http://www.ncbi. nlm.nih.gov/pubmed/19507727. 17. Resnick MD, Harris LJ, Blum RW. The impact of caring and connectedness on adolescent health and well-being. J Paediatr Child Health. 1993;29(Suppl 1):S3–9. 18. Saewyc EM, Tonkin R. Surveying adolescents: focusing on positive development. Paediatr Child Health. 2008;13:43–7. 19. Saewyc EM, Edinburgh LD. Restoring healthy developmental trajectories for sexually exploited young runaway girls: fostering protective factors and reducing risk behaviors. J Adolesc Health. 2010;46:180–8. 20. Resnick MD, Shew M, Ireland M, Bearinger LH, Udry JR, Bearman PS, Blum RW, Bauman KE, Harris KM, Jones J, Tabor J, Beuhring T, Sieving RE. Protecting adolescents from harm. Findings from the national longitudinal study on adolescent health. JAMA. 1997;278:823–32. 21. Vo DX, Park MJ. Stress and stress management among youth and young men. Am J Men’s Health. 2008;2:353–66. 22. Vo DX, Park MJ. Helping young men thrive: positive youth development and men’s health. Am J Men’s Health. 2009;3:352–9. 23. Statistics Canada. Proportion of foreign-born population, by province and territory. 2010; 2012. 24. Citizenship and Immigration Canada. Facts and Figures 2009: immigration overview. 2009; 2012. 25. http://www.cic.gc.ca/english/resources/statistics/facts2012/tem porary/09.asp.
J Immigrant Minority Health 26. Saewyc E, Green R. Survey methodology for the 2008 BC adolescent health survey IV. Vancouver, B.C: McCreary Centre Society; 2009. 27. Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32:513–31. 28. Saewyc EM, Homma Y. Psychometric properties of scales in the BC Adolescent Health Surveys of McCreary Centre Society. Vancouver, B.C: McCreary Centre Society; 2010. 29. Phinney JS, Jacoby B, Silva C. Positive intergroup attitudes: the role of ethnic identity. Int J Behav Dev. 2007;31:478–90. 30. Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer; 1984. 31. Berry JW: Acculturative stress: In: Handbook of multicultural perspectives on stress and coping. Boston, MA: Springer; 2006: 287–298. 32. Hamilton HA, Noh S. Adlaf EM: adolescent risk behaviours and psychological distress across immigrant generations. Can J Public Health. 2009;100:221–5. 33. Afifi TO, Enns MW, Cox BJ, Martens PJ. Investigating health correlates of adolescent depression in Canada. Canadian Journal of Public Health = Revue canadienne de sante´ publique 2005; 96:427–431. 34. Marcotte D, Fortin L, Potvin P, Papillon M. Gender differences in depressive symptoms during adolescence: role of gender-typed characteristics, self-esteem, body image, stressful life events, and pubertal status. J Emot Behav Disord. 2002;10:29–42.
35. Robert A, Gilkinson T. The mental health and well-being of recent immigrants. Health Policy Res Bull. 2010;17:24–5. 36. Mossakowski KN. Coping with perceived discrimination: does ethnic identity protect mental health? J Health Soc Behav. 2003;44:318–31. 37. Yoo HC, Lee RM. Does ethnic identity buffer or exacerbate the effects of frequent RACIAL discrimination on situational wellbeing of Asian Americans? J Couns Psychol. 2008;55:63–74. 38. Buzi RS, Weinman ML, Smith PB. The relationship between adolescent depression and a history of sexual abuse. Adolescence. 2007;42:679–88. 39. Noh S, Beiser M, Kaspar V, Hou F, Rummens J. Perceived racial discrimination, depression, and coping: a study of Southeast Asian refugees in Canada. J Health Soc Behav. 1999;40:193–207. 40. Edge S, Newbold B. Discrimination and the health of immigrants and refugees: exploring Canada’s evidence base and directions for future research in newcomer receiving countries. J Immigr Minor Health Center Minority Public Health. 2013;15:141–8. 41. Tajfel H. Social identity and intergroup relations. Cambridge: Cambridge University Press; 1982. 42. Beiser M, Hou F. Ethnic identity, resettlement stress and depressive affect among Southeast Asian refugees in Canada. Soc Sci Med. 2006;63:137–50. 43. George MA, Bassani C, Armstrong RW. Influence of perceived racial discrimination on health and behaviour of immigrant children in British Columbia. Int J Popul Res. 2012; 1–9.
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ORIGINAL PAPER
Acculturation, Gender, and Mental Health of Southeast Asian Immigrant Youth in Canada Carla T. Hilario • Dzung X. Vo • Joy L. Johnson Elizabeth M. Saewyc
•
Springer Science+Business Media New York 2014
Abstract The relationships between mental health, protective factors and acculturation among Southeast Asian youth were examined in this study using a gender-based analysis. Population-based data from the 2008 British Columbia Adolescent Health Survey were used to examine differences in extreme stress and despair by acculturation. Associations between emotional distress and hypothesized protective factors were examined using logistic regression. Stratified analyses were performed to assess gender-related differences. Recent immigrant youth reported higher odds of emotional distress. Family connectedness and school connectedness were linked to lower odds of extreme stress and despair among girls. Family connectedness was associated with lower odds of extreme stress and despair among boys. Higher cultural connectedness was associated with lower odds of despair among boys but with higher odds of extreme stress among girls. Findings are discussed in relation to acculturation and gender-based patterns in protective factors for mental health among Southeast Asian immigrant youth.
C. T. Hilario (&) J. L. Johnson School of Nursing, University of British Columbia, Vancouver, BC, Canada e-mail: [email protected] D. X. Vo Division of Adolescent Health and Medicine, University of British Columbia and BC Children’s Hospital, Vancouver, BC, Canada E. M. Saewyc McCreary Centre Society, Division of Adolescent Health and Medicine, and School of Nursing, University of British Columbia, Vancouver, BC, Canada
Keywords Mental health Acculturation Gender Protective factors Southeast Asian youth
Introduction The recent launch of Canada’s first national mental health strategy has sparked new dialogues on mental health promotion [1]. The Mental Health Commission of Canada advances the World Health Organization’s definition of mental health and outlines key strategic directions for improving mental well-being among all Canadians. Among these priorities, the report emphasizes the need for mental health promotion and prevention across the life course, especially among children and youth, and to address inequities in the social determinants of mental health faced by particular groups, including immigrants, refugees, ethno-cultural and racialized groups. Immigrant youth and their families face multiple challenges that affect their mental health, e.g. underemployment, difficulties securing adequate housing, and earning sufficient income [2]. In Canada, evidence suggests widening inequities in income between newcomers and Canadian-born families; for instance, one in two newcomer families in British Columbia live in poverty during their first 5 years in Canada [3]. Immigrant children are more than twice as likely to live in poverty, compared to Canadian-born children, and nearly one in three immigrant families in Canada live below the official poverty line during their first 10 years of residence [4]. Poverty shapes patterns of disadvantage and exposures to determinants of mental health including food and housing security, education, opportunities for employment and social support [5, 6]. Higher rates and likelihood of poverty among recent immigrants places them at higher
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risk for mental health challenges [7, 8]. For instance, poverty has been found to have a direct effect on the mental health of immigrant children while among Canadian-born children this relationship is mediated through other factors such as family dysfunction and parental mental illness [4]. Apart from material circumstances, young immigrants face other stressors related to migration and resettlement. In particular, experiences of psychological and social acculturation may compound the stress of normative tasks such as identity development and establishing a sense of belonging [9]. Acculturation can be defined as ‘‘a process whereby contact between different cultural groups results in changes in both groups’’ and is related to the process of ethnic identity development [10, 11]. Findings suggest that a sense of belonging to one’s cultural group and approach to acculturation are linked to young people’s psychological and sociocultural adaptation following migration [12]. Being able to balance a sense of one’s cultural identity while striving to integrate into the new society has been shown to lead to better mental health outcomes [13]. The migrant health literature in Canada has been characterized by three dominant approaches: the morbiditymortality hypothesis in which immigrants are believed to have worse health; the healthy immigrant effect in which immigrants are perceived as having better health; and the transitional effect hypothesis that posits that health advantages on immigration decrease over time [14]. Initial adaption processes are crucial for immigrants and can impact their mental health in the years following settlement. In Canada, national longitudinal data suggests that while immigrants arrive with better mental health than their Canadian-born counterparts, this ‘healthy immigrant effect’ deteriorates over time to resemble the mental health status of the non-immigrant population [15]. However, much of this research has been on adult migrants moving through mainstream immigrant classes. Few studies have examined immigrant youth mental health in a Canadian context [2, 16]. In the field of adolescent health promotion, there is burgeoning interest in the role of protective factors that may help mitigate the effects of stressors on mental health outcomes. Previous studies in North America have demonstrated the impact of caring and social connectedness on adolescent behavior and emotional stress [17] and in mitigating the effects of risk factors for adolescent health outcomes [18, 19]. For instance, young people who feel strongly connected to their families and schools experience lower levels of emotional distress [20]. However, little is known about the factors that promote mental health among immigrant youth [7], especially those from particular ethno-cultural backgrounds.
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Our understanding of mental health and protective factors in migrant populations remains nascent. In particular, there is a lack of research on the health of young immigrants despite the recognition of adolescence as an important developmental period [2]. The role of gender in the relationships between protective factors and mental health must also be investigated [21, 22]. Research on the mental health of immigrant youth in Canada is especially needed given the country’s pivotal role in global migration. In Canada, approximately one in three young people are growing up in immigrant families [23] and an estimated 35,000 immigrant youth arrive in the country every year [24]. In particular, individuals who have migrated from Southeast Asia represent a significant proportion of immigrants to Canada [23]. For instance, Philippines was the top source country for permanent residents to Canada in 2011 [25]. British Columbia is a leading province for new immigrants and for permanent residents to Canada, 69 % of which are from the Asia and Pacific [25]. The goals of this study were to describe gender-based and migration-related differences in mental health and to examine the linkages between acculturation and protective factors for mental health among Southeast Asian youth using a population-based sample. Conceptual Framework Drawing on ecological theories of adolescent development [27], this study examined relationships between migration and the social contexts that support mental health among Southeast Asian youth in Canada. This model proposes that, among immigrant youth, mental health is shaped by the interactions between various levels of socio-ecological influences that interact with factors related to migration and acculturation. Ethnic identity is understood as a component of larger acculturation processes that involve individuals, communities and societal approaches to ethno-cultural diversity. The focus of this study is on young people’s sense of belonging to a cultural group, ethnic identity connectedness, as a hypothesized protective factor among ethno-cultural youth [28]. It was hypothesized that there would be migrationrelated differences in self-reported stress, despair, selfharm and suicide behavior. Specifically, it was hypothesized that higher odds of self-reported stress and despair would be associated with less acculturation, conceptualized in this study using commonly used measures in the literature: foreign-born status, length of stay, and speaking a language at home other than English most of the time. It was expected that Southeast Asian young women would report higher stress and despair based on population-based data with adolescent populations in Canada.
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Lastly, it was hypothesized that lower odds of stress and despair would be associated with known protective factors in the adolescent health literature, especially level of connectedness to parents and families. In particular, cultural connectedness was hypothesized to have a protective effect against stress and despair among Southeast Asian youth.
Methods Study Sample To conduct this analysis, we used data from the 2008 British Columbia Adolescent Health Survey (BC AHS), a province-wide questionnaire with a cluster-stratified sampling design. It is administered approximately every 5 years to a representative sample of secondary school students (aged 12–19, grades 7–12) across BC. Over 29,300 students participated in the 2008 BC AHS, providing data that was weighted and scaled to reflect the 283,120 youth attending public schools in the province at the time of the survey. A detailed description of the BC AHS survey methodology can be found elsewhere [26]. Our analytical sample in this study included all survey participants between the ages of 12 and 19 years of age (grades 7–12) who selected ‘Southeast Asian (e.g. Cambodian, Filipino, Indonesian, Vietnamese, etc.)’ in response to the survey question ‘What is your cultural or ethnic background?’ Participants who selected Southeast Asian as well as another response were also included. In this study, immigrants are defined as youth born outside of Canada. Recent immigrants are defined as youth who have lived in Canada for 5 years or less. This sample theoretically included all migrant classes, e.g. economic and family, as well as refugees although the BC AHS did not specifically ask youth to report this information. A community advisory group was established at the beginning of the study and comprised of members of local Southeast Asian community groups as well as teachers, adolescent health providers and two youth members of the McCreary Centre Society’s Youth Advisory Council who self-identified with Southeast Asian cultural identities. The advisory group met with the investigators to review and provide feedback on the research questions, study design, measures included in the analysis, conceptual framing and the interpretation of data. Findings from the statistical analyses were shared with members of the group and limitations discussed. Measures The primary outcome variables of interest, stress and despair, were examined using emotional distress scale
items in the 2008 BC AHS. This scale, adapted from the general well-being scale, has been used in other large-scale adolescent health surveys and evaluated for psychometric performance. A detailed description including psychometric properties of the scales in the BC AHS can be found elsewhere [28]. Emotional distress scale items, which asked youth to rate their level of stress and despair in the past 30 days, were dichotomized at the most extreme responses: •
•
Stress: ‘Have you felt you were under any strain, stress or pressure?’ (Extreme response: ‘Yes, almost more than I could take’) Despair: ‘Have you felt so sad, discouraged, hopeless or had so many problems that you wondered if anything was worthwhile?’ (Extreme response: ‘Extremely so, to the point I couldn’t do my work or deal with things’).
Social connectedness was assessed using three scales in the BC AHS: family connectedness (11 items), school connectedness (6 items), and cultural connectedness (6 items). The family connectedness scale asks how youth perceive their relationships with their family members, the extent to which they feel cared about and feel that their family understands them. The school connectedness scale questions the extent to which youth feel they belong to their school, feel happy, feel safe, and feel that their teachers care about them. The cultural connectedness measure is based on the Multi-Ethnic Identity Measure-R [29] and asks about the extent to which youth feel they belong to their cultural group. Acculturation was examined using three measures in the BC AHS that are also frequently used in the immigrant health literature: foreign-born status; language other than English spoken at home most of the time (dichotomized to ‘never’ or ‘sometimes’, and ‘most of the time’); and length of time lived in Canada (5 years and less was recoded as recent immigrant, between six and ten years as short-term immigrant, and more than 10 years in Canada as long-term immigrant). Analysis Data analysis was conducted using Statistical Package for the Social Sciences (SPSS) version 19. Complex Samples was used to account for the complex random clusterstratified design of the BC AHS. Ethics approval for this study was received from the University of British Columbia Behavioral Research Ethics Board and all data was analyzed at the McCreary Centre Society. Descriptive statistics were used to determine the prevalence of emotional distress. General linear modeling tests and Wald F statistics were used to examine whether level of connectedness varies by gender or immigrant status.
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123 14.86 [14.70, 15.02] 39.8 [35.3, 44.4]
Mean age in years, 95 % CI
% Foreign born, 95 % CI
5.1 [3.4, 7.5]
0.77 [0.75, 0.78] 0.69 [0.68, 0.71] 0.65 [0.63, 0.67]
Extreme despair: % in past 30 days, Feeling sad, discouraged, hopeless or had so many problems that wondered if anything was worthwhile and responded ‘‘Extremely so, to the point I couldn’t do my work or deal with things’’, 95 % CI
Family connectedness [scale 0–1] Mean, 95 % CI
School connectedness [scale 0–1] Mean, 95 % CI
Cultural connectedness [scale 0–1] Mean, 95 % CI
0.66 [0.65, 0.68]
0.69 [0.68, 0.71]
0.72 [0.70, 0.74]
9.8 [7.6, 12.5]
17.2 [14.2, 20.7]
34.8 [30.6, 39.2]
69.1 [64.7, 73.2]
12.4 [9.8, 15.6]
18.5 [15.4, 22.1]
37.8 [33.5, 42.3]
14.84 [14.67, 15.01]
55.8 [52.6, 58.9]
Young women
a
Source: British Columbia Adolescent Survey, 2008, McCreary Centre Society. Results shown are weighted The adjusted F is a statistical test used in IBM SPSS Complex Samples and is a variant of the Rao-Scott Chi Squared statistic
10.6 [8.0, 14.0]
Extreme stress: % in past 30 days, feeling under strain, stress or pressure that was ‘‘Almost more than [they] could take’’, 95 % CI
69.6 [65.2, 73.7]
More than 10 years 33.8 [29.3, 38.5]
12.5 [9.8, 15.9]
Between 6 and 10 years
% Speaking language other than English at home (most of the time), 95 % CI
17.9 [14.6, 21.6]
5 years and less
% Time lived in Canada, 95 % CI
44.2 [41.1, 47.4]
% within entire sample, 95 % CI
Young men
Gender
Table 1 Descriptive characteristics of a population-based sample of Southeast Asian high school students in British Columbia 2008
Wald F = 1.32
Wald F = 0.001
Wald F = 11.76
Adjusted F = 7.94
Adjusted F = 7.94
Adjusted F = 0.10
Adjusted F = 0.03
Adjusted F = 0.40
t = 0.19
Adjusted F = 5.85
a
Test statistic
1, 494
1, 492
1, 498
1, 499
1, 499
1, 499
2, 987
1, 499
1
1
df
0.252
0.972
0.001
0.005
0.005
0.75
0.97
0.53
0.85
\0.05
p
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J Immigrant Minority Health Table 2 Odds ratios of self-reported extreme despair by acculturation and protective factors, stratified by gender Characteristics
Age
Unadjusted OR
Adjusted OR
Southeast Asian young men
Southeast Asian young women
Model 1 Southeast Asian young men Model v2 41.64, p \ 0.001
Model 2 Southeast Asian young women Model v2 80.28, p \ 0.001
OR
95 % CI
OR
95 % CI
OR
95 % CI
OR
95 % CI
1.35**
1.09, 1.68
0.91
0.79, 1.05
1.30*
1.02, 1.66
0.84*
0.70, 1.00
Immigrant status Canadian-born
Ref
–
Ref
–
Ref
–
Ref
–
Foreign-born
1.63
0.75, 3.54
0.91
0.54, 1.54
0.55
0.15, 2.05
0.36
0.12, 1.04
Length of residence More than 10 years
Ref
–
Ref
–
Ref
–
Ref
–
6–10 years
0.66
0.14, 3.14
1.45
0.71, 2.96
1.30
0.21, 7.91
4.64**
1.49, 14.46
5 years and less
2.65
1.14, 6.17
1.40
0.75, 2.59
5.34*
1.24, 23.05
4.84**
1.50, 15.62
Ref 1.30
– 0.59, 2.91
Ref 0.79
– 0.45, 1.36
Ref 1.27
– 0.49, 3.32
Ref 0.79
– 0.40, 1.58
Family connectedness (0–1)
0.02***
0.003, 0.09
0.01***
0.004, 0.04
0.05**
0.01, 0.37
0.02***
0.004, 0.06
School connectedness (0–1)
0.02***
0.003, 0.12
0.02***
0.004, 0.07
0.13
0.01, 1.53
0.08**
0.014, 0.46
Cultural connectedness (0–1)
0.07**
0.01, 0.46
0.08***
0.02, 0.33
0.11*
0.01, 0.98
0.40
0.08, 2.10
Non-English language spoken at home Never or sometimes Most of the time Protective factors
Source: British Columbia Adolescent Survey, 2008, McCreary Centre Society. Results shown are weighted * p \ 0.05; ** p \ 0.01; *** p \ 0.001
Table 3 Odds ratios of self-reported extreme stress by acculturation and protective factors, stratified by gender Characteristics
Unadjusted OR
Adjusted OR
Southeast Asian young men
Southeast Asian Young women
Model 1 Southeast Asian young men Model v2 33.06, p \ 0.001
Model 2 Southeast Asian young women Model v2 69.91, p \ 0.001
OR
95 % CI
OR
95 % CI
OR
95 % CI
OR
95 % CI
Age
1.29**
1.10, 1.51
1.14*
1.03, 1.27
1.16
0.98, 1.38
1.088
0.96, 1.23
Immigrant status Canadian-born
Ref
–
Ref
–
Ref
–
Ref
–
Foreign-born
1.37
0.78, 2.43
0.81
0.53, 1.22
2.09
0.96, 4.55
0.60
0.29, 1.26
More than 10 years
Ref
–
Ref
–
Ref
–
Ref
–
6–10 years
0.52
0.18, 1.53
1.57
0.92, 2.68
0.39
0.12, 1.30
2.42*
1.09, 5.38
5 years and less
1.08
0.52, 2.24
0.61
0.34, 1.08
0.57
0.21, 1.54
0.99
0.41, 2.38
Length of residence
Non-English language spoken at home Never or sometimes
Ref
–
Ref
–
Ref
–
Ref
–
Most of the time
0.98
0.53, 1.80
0.73
0.47, 1.12
0.82
0.41, 1.65
0.71
0.43, 1.17
Family connectedness (0–1)
0.05***
0.02, 0.19
0.05***
0.02, 0.12
0.09**
0.02, 0.42
0.07***
0.02, 0.21
School connectedness (0–1)
0.07***
0.02, 0.28
0.03***
0.01, 0.10
0.17
0.03, 1.03
0.07***
0.02, 0.29
Cultural connectedness (0–1)
0.67
0.14, 3.17
0.71
0.23, 2.14
2.57
0.48, 13.86
4.15*
1.10, 15.72
Protective factors
Source: British Columbia Adolescent Survey, 2008, McCreary Centre Society. Results shown are weighted * p \ 0.05; ** p \ 0.01; *** p \ 0.001
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Emotional distress was assessed by gender and by immigrant status using modified Rao Scott Chi square tests. Multivariate logistic regression analyses adjusting for age were conducted to examine the relationships between social connectedness, migration and mental health. Analyses were stratified by gender and four regression models were conducted to examine potential gender-related differences in factors related to emotional distress.
Results Approximately 1 in 20 Southeast Asian youth participated in the 2008 BC AHS (5 % of survey sample; n = 1,225; population estimate = 14,283). Young women reported significantly higher rates of extreme levels of stress and despair compared to young men (see Table 1). There were no significant differences in mean levels of school or cultural connectedness by gender although young men reported higher family connectedness. Results from bivariate tests suggest that higher family and school connectedness are associated with lower odds of extreme stress and extreme despair, while higher cultural connectedness is related to lower odds of extreme despair. There were, however, no significant relationships between acculturation-related measures (foreign born status, time lived in Canada, language spoken at home) and emotional distress in bivariate analyses, even when examined by gender. In multivariate analyses, recent immigrant status was associated with five times higher odds of extreme despair among Southeast Asian youth (see Table 2). Being in Canada for more than five but less than 10 years was related to higher odds of extreme despair as well as extreme stress among young women (see Table 3). Higher cultural connectedness was associated with lower odds of extreme despair among young men (after adjusting for age and acculturation), yet was associated with higher odds of extreme stress among young women. Findings suggest gender-related patterns in protective factors for mental health. In terms of extreme despair, lower odds were associated with higher family and cultural connectedness in young men; while family and school connectedness were significant protective factors for extreme despair among young women. Among young men, family connectedness was the only significant protective factor against extreme stress. In contrast, connectedness to families and schools was associated with lower odds of reporting extreme stress among young women even though there were no significant gender-related differences in levels of school connectedness in bivariate analyses (p = 0.97). Although there was a significant relationship between school connectedness and
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extreme stress in bivariate analysis, school connectedness was not significantly associated with young men’s selfreported extreme stress in the final regression model.
Discussion Findings from this study suggest that emotional distress may be related to level of acculturation as measured by length of residence in Canada. In particular, extreme despair was found to be more likely among newcomer youth. Differences in the findings between the models for despair and stress suggest that these outcomes are experienced in distinct ways by Southeast Asian youth. Further, the concept of despair may be more related to experiences of acculturative stress than with notions of general stress and strain. Based on general stress and adaptation theories [30], acculturative stress can be understood as responses to events or changes in people’s lives that ‘‘challenge their cultural understandings about how to live’’ [31]. Within an acculturation framework, individual behavior and experiences interact with the contexts in which different cultures come into contact such as in migration. In this way, acculturative stress may be a stress response among young immigrants navigating the complex experience of psychological and social acculturation. While long-term effects associated with acculturative stress may range from adaptive to non-adaptive, findings from our study suggest that young immigrant men who have lived in Canada for more than five but less than 10 years (short-term immigrant) are no more likely to experience extreme stress or despair compared to their peers living in Canada for over 10 years. Among young women, however, short-term immigrant status was associated with higher odds of extreme stress and despair even after controlling for age and level of connectedness. Possible explanations for these findings might be that, in terms of extreme stress, young women may initially experience positive adaptation, but after the first 5 years face greater stressors. In terms of extreme despair, young women may face unique stressors that may persist for a longer period of time. Findings from this study do not support the ‘healthy immigrant effect’ phenomena in the mental health of Southeast Asian youth [15]. Rather, as hypothesized, findings from this study suggest higher odds of extreme despair among recent immigrant youth. These results are similar to findings from a previous school-based survey study in Canada that found higher symptoms of psychological distress among first-generation immigrant youth compared to subsequent generations [32]. However, in this study, extreme stress was not associated with level of acculturation in the same way that the latter was linked
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with extreme despair, suggesting that acculturative stress may be better captured in this population with the concept of despair. Findings from this study also highlight the protective role of social connectedness in experiences of emotional distress among Southeast Asian youth although these relationships may vary by gender and type of distress (despair versus stress). Family connectedness appeared to have the strongest protective effect against emotional distress, a finding consistent with previous adolescent health studies [17–20]. In contrast, higher school connectedness was protective only against emotional distress among young Southeast Asian women, suggesting gender-related differences in the ways that connectedness is linked to mental health. Some gender-related patterns of mental health observed in this study are consistent with other studies that suggest greater rates of depression among adolescent girls [33, 34]. Findings based on data from the Longitudinal Survey of Immigrants to Canada also show that immigrant women report higher rates of emotional problems compared to immigrant men [35], suggesting that gender differences in mental health may be salient in adolescence and potentially persist into adulthood. Another gender-based difference was related to the role of cultural or ethnic identity connectedness. The observed relationship between cultural connectedness and extreme stress among young Southeast Asian women was surprising given previous studies suggesting the protective role of ethnic identity on self-esteem and depressive symptoms, especially among ethnic minority groups [11, 36, 37]. It is possible that differences in study findings may be related in part to the particular indicators used for mental health, potential interaction effects between risk and protective factors or the role of other variables related to mental health such as physical and sexual abuse [38]. Additionally, these findings are limited by the unidimensional linear model of acculturation used in the study (e.g. length of residence) rather than complex multidimensional models of acculturation that can provide important information about acculturation strategies used by youth and their effect on health outcomes [12]. Another possible explanation is that ethnic identity may actually contribute to poorer mental health by exacerbating the negative effects of perceived racial discrimination on mental health. Some findings suggest that visible minorities and immigrants who experience discrimination are also more likely to report declines in self-assessed mental health status compared to other newcomers while perceptions of discrimination in neighborhood and school settings may affect youth’s sense of belonging, which in turn shapes their mental well-being [39, 40]. Alternately, a sense of belonging to a particular cultural community may create
greater stress or conflict for individuals if they do not perceive their social identity as favorable [41]. For instance, some findings suggest that, among Southeast Asian groups in Canada, experiences and perceptions of discrimination may marginalize individuals as ethnic minorities and increase risk for psychological distress [42]. Among newcomer families in Canada, perceived discrimination has been associated with various health problems in immigrant children and younger adolescents including aggression, hyperactivity, and emotional problems [43]. Conversely, cultural connectedness was a protective factor against extreme despair among young men in the final regression models. One possible explanation is that cultural connectedness may not be related to discrimination in Southeast Asian young men in the same way as for young women and may be linked to healthier acculturation strategies. Limitations There are several limitations to findings in this study. First, the 2008 BC AHS does not ask about generational status so it was not possible to examine differences in mental health status between foreign-born youth and second-generation youth born in Canada to immigrant parents. Second, the relationship between cultural connectedness and mental health may have been better examined using multidimensional measures of specific acculturation strategies [12]. Further, the study did not include a question on immigrant class, e.g. economic immigrant or government-assisted refugee, or a measure of socioeconomic status. Because it is conducted among youth aged 12–19 years, there is no robust measure for socioeconomic status or poverty in the BC AHS although recent statistics provide such estimates among newcomer families [3]. The emotional distress items used in the BC AHS were based on the general well-being scale and were not developed to specifically capture distress related to acculturation. Additionally, not all immigrants may experience acculturative stress or perceive migration experiences in terms of acculturation. While the measures of extreme stress and despair were drawn from the same scale, it is important to note that they are measuring distinct concepts. That we found differences in the relationships between acculturation and these two mental health outcomes suggests that the items are measuring unique concepts despite being dimensions of emotional distress. Other limitations include the administration of the survey in English, which may have affected the responses of youth who lacked the language or literacy skills to complete the questionnaire. Since the BC AHS was administered at school, this data cannot provide information on youth who are not in school or are in alternative education
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programs including those in government custody or streetinvolved youth. Lastly, there is the potential for the aggregation of data on ethnic or cultural backgrounds into the larger Southeast Asian category to mask possible differences between the groups in terms of mental health status and factors associated with emotional distress.
Conclusions Findings from this research contribute to current understandings about mental health and protective factors among Southeast Asian youth. Our results suggest that newcomers experience higher likelihood of extreme despair that, for young women, may persist up to 10 years following immigration. Health providers who work with immigrant youth may need to assess for potential emotional distress related to their experiences of migration and acculturation, especially among recent immigrants. Health providers and educators should promote family and school connectedness among Southeast Asian youth and help immigrant families to maintain caring family relationships. Tailored interventions may be needed to support immigrant youth in negotiating experiences of psychological and social acculturation, especially in the initial period after migration. It is evident that there is a need for gender considerations in mental health research that examine not only differences by gender but also potentially unique patterns in the factors that support immigrant youth’s health. Applying multidimensional acculturation models and concepts will also strengthen study designs with immigrant populations and help providers to understand how to best promote healthy acculturation and identity development. Lastly, qualitative research approaches are much needed to further understand the intricate relationships between mental health and protective factors such as cultural connectedness at the intersections of gender, adolescence and migration. Acknowledgments The authors would like to thank the reviewers for their thoughtful feedback. Conflict of interest
None.
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