When Asian immigrant women speak: from mental health to strategies of being

Undiagnosed depression, persistent depressive symptoms and seeking mental health care: analysis of immigrant and non-immigrant participants of the Canadian Longitudinal Study of Aging

AIMS

Early diagnosis and treatment of depression are associated with better prognosis. We used baseline data of the Canadian Longitudinal Study on Aging (2012-2015; ages 45-85 years) to examine differences in prevalence and predictors of undiagnosed depression (UD) between immigrants and non-immigrants at baseline and persistent and/or emerging depressive symptoms (DS) 18 months later. At this second time point, we also examined if a mental health care professional (MHCP) had been consulted.

METHODS

We excluded individuals with any prior mood disorder and/or current anti-depressive medication use at baseline. UD was defined as the Center for Epidemiological Studies Depression 10 score ⩾10. DS at 18 months were defined as Kessler 10 score ⩾19. The associations of interest were examined in multivariate logistic regression models.

RESULTS

Our study included 4382 immigrants and 18 620 non-immigrants. The mean age (standard deviation) in immigrants was 63 (10.3) years v. 65 (10.7) years in non-immigrants and 52.1% v. 57.1% were male. Among immigrants, 12.2% had UD at baseline of whom 34.2% had persistent DS 18 months later v. 10.6% and 31.4%, respectively, among non-immigrants. Female immigrants were more likely to have UD than female non-immigrants (odds ratio 1.50, 95% confidence interval 1.25-1.80) but no difference observed for men. The risk of persistent DS and consulting an MHCP at 18 months did not differ between immigrants and non-immigrants.

CONCLUSIONS

Female immigrants may particularly benefit from depression screening. Seeking mental health care in the context of DS should be encouraged.

Understanding self-construction of health among the slum dwellers of India: a culture-centred approach

Disembarking from a traditional approach of narrow hazardous environmental and structural conditions in understanding urban slums' health problems and moving towards a new notion of what constitutes health for slum dwellers will open a new avenue to recognise whether and how health is being prioritised in disadvantaged settings. Drawing on in-depth semi-structured interviews with a total of 67 men and 68 women from Kolkata slums and 62 men and 48 women from Bangalore slums, this study explored how knowledge, social realities, material and symbolic drivers of a place interweave in shaping slum-dwellers' patterned way of understanding health, and the ways health and illnesses are managed. The current study adds to the growing evidence that ordinary members of the urban slums can articulate critical linkages between their everyday sociocultural realities and health conditions, which can support the design and delivery of interventions to promote wellbeing. The concept of health is not confined to an abstract idea but manifested in slum-dwellers' sporadic practices of preventive and curative care as well as everyday living arrangements, where a complex arrangement of physical, psychological, financial, sociocultural and environmental dimensions condition their body and wellbeing.

Healthful, Cultural Foods and Safety Net Use Among Cambodian and Brazilian Immigrant Communities in Massachusetts

Declining health and food security status among low-income immigrants in the U.S. may result from limited access to healthful, cultural foods and safety net programs. We held focus group discussions with low-income Cambodian and Brazilian immigrants (11 groups, n = 84) living in Massachusetts. Cambodians and Brazilians valued healthful, cultural foods, emphasizing their beliefs that cultural foods are healthier and beneficial for weight management and aging. Although both groups could access these foods, some individuals had difficulty affording them. Cambodians reported that food quality decreased over the month due to inadequate resources. Cambodians relied on SNAP, WIC, families, and food pantries; however, Brazilians generally did not participate in safety net programs. Barriers to accessing and using safety nets appear to limit diet quality for some immigrant families. Targeted nutrition interventions should build on current knowledge of and desire for healthful, cultural foods in the context of available safety nets.

Sociocultural Perceptions and Enablers to Seeking Mental Health Support Among Bhutanese Refugees in Western Massachusetts

This qualitative study aimed to identify cultural influences on seeking mental health support among Bhutanese refugees resettled in Western Massachusetts. Bhutanese refugees aged 18 years or older were recruited for eight focus group discussions, organized by age and gender ( N = 67, 49.3% female, mean age = 38, SD = 15.9). The PEN-3 cultural model was used as the theoretical framework to examine the roles of cultural perceptions that influence mental health-seeking behaviors. Focus group discussions were audio taped to facilitate the thematic-analysis. Younger participants (<35 years) reported experiencing stressors relating to economic hardships and difficulties in developing academic and social skills as they juggle breadwinner and care-giving responsibilities for their families. Older participants reported frustration with the difficulties in learning English and increased dependence on their children. Family members provided the initial frontline support to persons with mental health problems. If family support did not work, they consulted with their relatives and trustworthy community members for further assistance. Psychological factors such as fears of emotions, social norms, beliefs, and self-esteem associated with cultural norms and values influenced seeking mental health support. All participants expressed the need to have a culturally tailored intervention to develop acquired skills to improve their self-esteem and self-efficacy in order to integrate into their new social and cultural environment. Because family members make important decisions about seeking mental health support, involving family members in developing and delivering culturally appropriate skill development interventions could be a potential strategy to reduce their stress and increase resilience in this refugee community.

Characteristics of Successful and Unsuccessful Mental Health Referrals of Refugees

In this community based participatory research study, we explored key characteristics of mental health referrals of refugees using stories of providers collected through an on-line survey. Ten coders sorted 60 stories of successful referrals and 34 stories of unsuccessful referrals into domains using the critical incident technique. Principal components analysis yielded categories of successful referrals that included: active care coordination, establishing trust, proactive resolution of barriers, and culturally responsive care. Unsuccessful referrals were characterized by cultural barriers, lack of care coordination, refusal to see refugees, and system and language barriers. Recommendations for training and policy are discussed.

Accessibility and use of primary healthcare for immigrants living in the Niagara Region

Although the challenges of accessing and using primary healthcare for new immigrants to Canada have been fairly well documented, the focus has primarily been on large cities with significant immigrant populations. The experiences of immigrants living in smaller, less diverse urban centres remain largely unknown. The purpose of this study was to examine the lived experiences of immigrants living in a small urban centre with regards to the primary healthcare system. A total of 13 immigrants living in the Greater Niagara Region participated in semi-structured interviews. All interviews were recorded, transcribed, and then coded and analyzed for emergent themes using NVivo. Five factors were found to impact primary care access and use: lack of social contacts, lack of universal healthcare coverage during their initial arrival, language as a barrier, treatment preferences, and geographic distance to primary care. Overall findings suggest that immigrants moving to smaller areas such as the Niagara Region face similar barriers to primary care as those moving into large cities. Some barriers, however, appear to be specific to the context of smaller urban centres, further exacerbated by living in a small city due to a smaller immigrant population, fewer services for immigrants, and less diversity in practicing physicians. More research is required to understand the contextual factors inhibiting primary care access and use among immigrants moving to smaller urban centres, and determine effective strategies to overcome these barriers.

Social support, social conflict, and immigrant women's mental health in a Canadian context: a scoping review

ACCESSIBLE SUMMARY

Social support has positive and negative dimensions, each of which has been associated with mental health outcomes. Social networks can also serve as sources of distress and conflict. This paper reviews journal articles published during the last 24 years to provide a consolidated summary of the role of social support and social conflict on immigrant women's mental health. The review reveals that social support can help immigrant women adjust to the new country, prevent depression and psychological distress, and access care and services. When social support is lacking or social networks act as a source of conflict, it can have negative effects on immigrant women's mental health. It is crucial that interventions, programmes, and services incorporate strategies to both enhance social support as well as reduce social conflict, in order to improve mental health and well-being of immigrant women.

ABSTRACT

Researchers have documented the protective role of social support and the harmful consequences of social conflict on physical and mental health. However, consolidated information about social support, social conflict, and mental health of immigrant women in Canada is not available. This scoping review examined literature from the last 24 years to understand how social support and social conflict affect the mental health of immigrant women in Canada. We searched MEDLINE, PsycINFO, CINAHL, Healthstar, and EMBASE for peer-reviewed publications focusing on mental health among immigrant women in Canada. Thirty-four articles that met our inclusion criteria were reviewed, and are summarized under the following four headings: settlement challenges and the need for social support; social support and mental health outcomes; social conflict and reciprocity; and social support, social conflict, and mental health service use. The results revealed that social support can have a positive effect on immigrant women's mental health and well-being, and facilitate social inclusion and the use of health services. When social support is lacking or social networks act as a source of conflict, it can have negative effects on immigrant women's mental health. The results also highlighted the need for health services to be linguistically-appropriate and culturally-safe, and provide appropriate types of care and support in a timely manner in order to be helpful to immigrant women.

Immigrant Mental Health, A Public Health Issue: Looking Back and Moving Forward

The Mental Health Commission of Canada's (MHCC) strategy calls for promoting the health and wellbeing of all Canadians and to improve mental health outcomes. Each year, one in every five Canadians experiences one or more mental health problems, creating a significant cost to the health system. Mental health is pivotal to holistic health and wellbeing. This paper presents the key findings of a comprehensive literature review of Canadian research on the relationship between settlement experiences and the mental health and well-being of immigrants and refugees. A scoping review was conducted following a framework provided by Arskey and O'Malley (Int J Soc Res Methodol 8:19-32, 2005). Over two decades of relevant literature on immigrants' health in Canada was searched. These included English language peer-reviewed publications from relevant online databases Medline, Embase, PsycInfo, Healthstar, ERIC and CINAHL between 1990 and 2015. The findings revealed three important ways in which settlement affects the mental health of immigrants and refugees: through acculturation related stressors, economic uncertainty and ethnic discrimination. The recommendations for public health practice and policy are discussed.

Exploring the mental health effects of political trauma with newly arrived refugees

We explored the mental health effects of war trauma and torture as described by 111 refugees newly arrived in the United States. We used ethnocultural methodologies to inform 13 culture-specific focus groups with refugees from Bhutan (34), Burma (23), Ethiopia (27), and Somalia (27). Contrary to the belief that stigma prevents refugees from discussing mental health distress, participants readily described complex conceptualizations of degrees of mental health distress informed by political context, observation of symptoms, cultural idioms, and functional impairment. Recommendations for health care providers include assessment processes that inquire about symptoms in their political context, the degree of distress as it is culturally conceptualized, and its effect on functioning. Findings confirm the cross-cultural recognition of symptoms associated with posttraumatic stress disorder; however, refugees described significant cultural variation in expressions of distress, indicating the need for more research on culture-bound disorders and idioms of distress.

Service delivery on rusty health care wheels: implications for visible minority women

The primary purpose of this article is to demonstrate how immigrant/refugee women's access to health services is influenced by both immigration and health policies. The author argues that the wheel of health care must revolve along with the wheel of immigration. The application of health immigration policies that existed preconfederation, as well as health care interventions based on Eurocentric principles, limit minority women's accessibility to health services. An integrated dialogue between all levels of government, health care professionals, policy makers, researchers, and immigrant groups is critical to provide equitable access to health care to foster immigrant settlement in Canada's smaller communities and rural areas.

A study of Iranian immigrants' experiences of accessing Canadian health care services: a grounded theory

BACKGROUND

Immigration is not a new phenomenon but, rather, has deep roots in human history. Documents from every era detail individuals who left their homelands and struggled to reestablish their lives in other countries. The aim of this study was to explore and understand the experience of Iranian immigrants who accessed Canadian health care services. Research with immigrants is useful for learning about strategies that newcomers develop to access health care services.

METHODS

The research question guiding this study was, "What are the processes by which Iranian immigrants learn to access health care services in Canada?" To answer the question, a constructivist grounded theory approach was applied. Initially, unstructured interviews were conducted with 17 participants (11 women and six men) who were adults (at least 18 years old) and had immigrated to Canada within the past 15 years. Eight participants took part in a second interview, and four participants took part in a third interview.

RESULTS

Using a constructivist grounded theory approach, "tackling the stumbling blocks of access" emerged as the core category. The basic social process (BSP), becoming self-sufficient, was a transitional process and had five stages: becoming a stranger; feeling helpless; navigating/seeking information; employing strategies; and becoming integrated and self-sufficient. We found that "tackling the stumbling blocks of access" was the main struggle throughout this journey. Some of the immigrants were able to overcome these challenges and became proficient in accessing health care services, but others were unable to make the necessary changes and thus stayed in earlier stages/phases of transition, and sometimes returned to their country of origin.

CONCLUSION

During the course of this journey a substantive grounded theory was developed that revealed the challenges and issues confronted by this particular group of immigrants. This process explains why some Iranian immigrants are able to access Canadian health care effectively while others cannot. Many elements, including language proficiency, cultural differences, education, previous experiences, financial status, age, knowledge of the host country's health care services, and insider and outsider resources work synergistically in helping immigrants to access health care services effectively and appropriately.

Attitudes about depression and its treatment among mental health professionals, lay persons and immigrants and refugees in Norway

BACKGROUND

Internationally, depression is a common psychological disorder whose treatment depends upon its identification by treating professionals as well as patient utilization of mental health care systems; the latter often being hampered by cultural differences between patients and health professionals.

METHOD

The current study used vignettes of depressed patients which varied the culture and/or social circumstances of the patient to assess whether these variables influenced the conceptualization of depression and its treatment. Participants (N=722) included mental health professionals, lay people, immigrants, and refugees in Norway.

RESULTS

We found that immigrants and refugees, particularly those of non-western origin, endorsed different types of depression treatments from native Norwegians and mental health professionals, and judged who deserved treatment and who was overreacting based on the patient's culture and social circumstances, while native Norwegians did not.

LIMITATIONS

While widely used cross-culturally, vignette methodology is limited in its generalizability to real clinical situations. Acculturation was not evaluated, which may have influenced the results.

CONCLUSIONS

Findings support the integration of cultural competency ideals not only into treatment, but also into public health promotions of mental health services for lay people.

Cultural predictors of caregiving burden of Chinese-Canadian family caregivers

The growth of research knowledge on culturally diverse family caregivers for the aging population lags behind the increase of culturally diverse populations in Canada. This study examines the effects of culture, as manifested through cultural variables, on the caregiving burden of family caregivers in a Chinese-Canadian community. A random sample of 339 Chinese-Canadian caregivers for elderly relatives completed a telephone survey. Results of hierarchical stepwise multiple regression analysis reported the predicting effects of culture-related variables on caregiving burden. The findings indicated that being an immigrant, having a Western or non-Western religion as compared to having no religion, and having a lower level of filial piety, predicted a higher level of caregiving burden. Chinese tradition does not exempt the caregivers from being burdened. Policies and practices should address the needs of family caregivers according to the intra-cultural variations identified in this study.

"My health has improved because I always have everything I need here...": A qualitative exploration of health improvement and decline among immigrants

Immigrants in Canada constitute approximately 20% of the total population and will continue to account for a significant portion of the country's population in the future. Accordingly, a growing body of research has focused on examining the disparity in health status between the increasing foreign-born and the Canadian-born populations. The healthy immigrant effect, in particular, acknowledges that immigrants have better health status than their Canadian-born counterparts upon arrival in the country. However, studies have shown that over time the health of immigrants declines to a level on par with the Canadian-born population. There is much speculation as to the reasons for this decline including acculturation (i.e., uptake of unhealthy lifestyles) and a lack of access to health care. Yet, there have been few studies to examine possible reasons for potential declines in health, especially from the perspective of immigrants themselves. This study is one of the first to qualitatively examine perceived changes in health status and reasons for health status change among immigrants. The paper presents the results of 23 in-depth interviews with adults with recent (less than 3 years of residency), mid-term (3-10 years), and long-term (more than 10 years) immigrants living in the Greater Toronto Area. The results reveal that the majority of the participants believed their health had remained stable or even improved over time due to improved living standards and lifestyle behaviours in Canada. Those who perceived their health to have worsened over time attributed the change to the stress associated with migration, and the aging process rather than the adoption of an unhealthy lifestyle. Additionally, while the vast majority of participants reported improved access to resources upon migration, there were mixed reviews in terms of how beneficial these resources were or could be for health. The findings highlight the need for research to incorporate mental health into studies on changing immigrant health status and to focus on those factors contributing to high levels of stress among more recent immigrants.

A Qualitative Investigation of Korean Immigrant Women’s Lives

Postimmigration adjustment experiences of 10 Korean immigrant women were examined using the consensual qualitative research method. Seven domains emerged: general life conditions; gender role; changes in family dynamics; ethnic/national identity, cultural competency, and belongingness; value changes; racial relationships; and support systems and attitudes toward counseling. Participants reported English barriers as one of the biggest challenges. They appreciated a better educational environment for children; a sense of liberation from patriarchal, collectivistic pressures (e.g., demands by in-laws, comparison with others); and strengthened family ties. They highlighted Korean immigrant women’s strengths and adaptability for family survival in the new environment. Participants reported lacking cultural competency or a sense of belongingness in the mainstream society but expected their children to succeed and have voices in the mainstream society. All participants experienced racism and developed coping strategies such as verbal confrontation. Concern about gossips in the small ethnic community was a barrier to seeking counseling.

"I spent nine years looking for a doctor": exploring access to health care among immigrants in Mississauga, Ontario, Canada

There is a growing body of research in Canada and from other countries acknowledging that immigrants face barriers in accessing health care services. As immigrants make up an increasing percentage of the population in many developed nations, a better understanding and eliminating these barriers is a major priority. This research contributes to current understandings of access among immigrant populations in Canada by exploring perceptions of access to care through focus groups with a diverse group of immigrants living in a Mississauga, Ontario neighbourhood. The results of eight focus groups reveal that immigrants face geographic, socio-cultural and economic barriers when attempting to access health care services in their community. This paper provides policy recommendations relevant to the federal, provincial and local levels for eliminating these barriers.