Adm Policy Ment Health DOI 10.1007/s10488-015-0668-3

ORIGINAL ARTICLE

The Healthy Immigrant Effect on Mental Health: Determinants and Implications for Mental Health Policy in Spain Berta Rivera1 • Bruno Casal1,2 • Luis Currais3

Ó Springer Science+Business Media New York 2015

Abstract Since the mid-1990s, Spain has started to receive a great number of migrant populations. The migration process can have a significantly negative impact on mental health of immigrant population and, consequently, generate implications for the delivery of mental health services. The aim of this article is to provide empirical evidence to demonstrate that the mental health of immigrants in Spain deteriorates the longer they are resident in the country. An empirical approach to this relationship is carried out with data from the National Survey of Health of Spain 2011–2012 and poisson and negative binomial models. Results show that immigrants who reside \10 years in Spain appear to be in a better state of mental health than that observed for the national population. Studying health disparities in the foreign population and its evolution are relevant to ensure the population’s access to health services and care. The need for further research is especially true in the case of the immigrant population’s mental health in Spain because there is scant evidence available on their situation.

& Berta Rivera [email protected] 1

Department of Applied Economics, Faculty of Economics and Business, University of A Corun˜a, Campus de Elvin˜a, 15071 A Corun˜a, Spain

2

University College of Labour Relations, University of A Corun˜a, A Corun˜a, Spain

3

Department of Economic Analysis and Business Administration, Faculty of Economics and Business, University of A Corun˜a, A Corun˜a, Spain

Keywords Mental health
Immigration
Healthy immigrant effect
Spanish mental health service
Social capital

Introduction The scale of migratory movements between countries, regions, and continents has significantly increased in recent decades. Between 1990 and 2013 the number of people who decided to emigrate rose to almost 77 million. In 69 % of these migrations, the destination is somewhere in the developed world. En 2013, the number of migrants went up to 232 million (UN 2014). Beyond these figures, immigration is especially relevant in social and political terms for countries like Spain, for whom this has been a relatively recent phenomenon. In 2013 foreign residents represented 11.73 % of the total population. In contrast, this group only made up 1.37 % of the total in 1996. In general, the immigrant profile could be described as young, of working age, and ethnically diverse. In 2013, 48 % of foreigners were in the 25–45 age bracket; 26 % came from Latin American countries, 17 % from Africa, and 46 % from the European Union (EU) (Instituto Nacional de Estadı´stica, INE, several years). The migration process can have a significant negative impact on mental health (Bhugra and Jones 2001). As with all individuals, there are personality traits and specific psychological resources that will determine an immigrant’s vulnerability to mental health problems. Additional factors, such as a lack of social and economic integration, cultural changes inherent to the migration process, limited resources and family support, discrimination in terms of resources and opportunities, and success or failure at work- determine how these individuals’ state of mental health evolves and how

123

Adm Policy Ment Health

likely they are to suffer from anxiety and depression (Lou and Beaujot 2005; Stillman et al. 2009). The phenomenon of migration has important implications for the host country in terms of its health services. Policy makers have to become better informed about the specific characteristics of immigrants to safeguard this group´s access to primary and specialist care (Cantarero and Pascual 2008). It is therefore necessary to study the health of this part of the population in order to deal with its needs and to set priority benchmarks for its health care. In Spain, there have recently been a growing number of studies on this collective’s state of health and how its members gain access to and use the health services. This group presents a higher risk of suffering from mental health problems than their national counterparts do. Nevertheless, there is still a dearth of studies that focus on immigrants’ mental health and its determinants. Literature has addressed the amount of time immigrants reside in the destination country as one of the determinants of this population’s state of health. The effect, known as the Healthy Immigrant Effect (HIE), explains how newly arrived immigrants are healthier compared to locals with similar socio-demographic characteristics. Moreover, the longer they stay, the more their health will resemble that of the national population. In terms of general health, the HIE is a phenomenon that has been widely studied in countries with a long history of immigration, such as the US, Canada, or Australia. However, for countries like Spain, large-scale immigration is more recent and the HIE has been largely overlooked. Scientific literature in this field is scarce mostly because there is no longitudinal data about this group with specific information as to periods of residence dating back to when migration began. Before 2011, the main source of information for studying immigrant population health, the Spanish National Health Survey (SNHS), failed to gather data on how long immigrants had resided in the country. However, in 2011–2012, the SNHS adult questionnaire did collect these data, making a different approach possible. Health indicators can now be adjusted by the number of years since the individual left his/her country of origin. The main aim of this article is to analyze the immigrant populations mental health in relation to their length of stay in Spain and the implications for mental health policy. Data from the 2011–2012 SNHS and the model type poisson and negative binomial were used for the empirical analysis. The relevant variable for the mental health state study was the GHQ indicator score as an indicator of psychological well-being. A series of variables from the literature were also included. They are revealed as determinants in the immigrant population’s state of mental health. Among other factors, there are the region of origin, an individual’s work situation, marital status, the level of education he or she has reached and a variable that covers an individual´s social support.

123

The article is divided into five sections. First, there is an overview of the most relevant literature on the immigrant population’s mental health and the specific case of HIE. The following section briefly describes how Spain’s mental health services are organized and structured. It also touches on the immigrant population’s rights to health care. The data and econometric methodology used in the empirical analysis are then presented and the most important estimated results are shown. A discussion of the study’s main conclusions is found in the final section.

Previous Literature Organisms like the EU and the World Health Organization (WHO) recognize that, as a group, the immigrant population is especially at risk of suffering from mental health problems. Therefore, public health policies (European Observatory on Health Systems and Policies 2011) place this group near the top of their lists of priorities when it comes to care. As they migrate and then integrate into the host society, members of this group face a series of losses and cultural, social, linguistic, and climate changes. These make immigrants more vulnerable to mental health problems (Fossion et al. 2004; Gru¨sser et al. 2005; Carta et al. 2007; Bergeron et al. 2009). A study was developed for six European countries (France, Belgium, Italy, Spain, the Netherlands and Germany). Its aim was to compare the presence of mental health problems between the national and foreign populations. Its main findings were that migrants are 2.52 times more likely to develop mental disorders than the native population (Health and Consumer Protection Directorate-General 2004). More recently, Straiton et al. (2014) analyze the differences in mental health between Australian-born and foreign-born individuals living in South Australia, considering the sociodemographic characteristics of both samples. Results show that men from non-English speaking backgrounds have an increased risk of mental health problems. Employment and general health are important protectors of mental health. As far as how immigrants gain access to and use the mental health services, it is widely agreed in the literature that immigrants and ethnic minorities generally find themselves under-represented in the health systems. They are also less inclined to use health services. However, it is possible to detect a degree of variability between studies. The main reason for this is that there are differences in factors like the structure of the health systems in the host country, the individuals’ origins, the range of health services provided, and the immigrants’ legal situation (Oppedal et al. 2004; Chen and Vargas 2011; Chen et al. 2008). Kirmayer et al. (2007) shows how immigrant status is associated with lower rates of use of mental health services. In general terms, this

Adm Policy Ment Health

figure may be explained by language and cultural barriers. For instance, an immigrant may not know about the health system. When mental health care is compared to how other health services are used, it becomes obvious that good communication between patient and doctor is even more vital in this field. For this reason, language serves as an obstacle, partly explaining why mental health services are less frequently used. This is even more the case when individuals are older and in a worse economic situation (Yeo 2004). As for the type of mental health service, Lindert et al. (2008) argue that the immigrant population in Europe makes a differential use of these services; they visit psychiatric emergency care with greater frequency. Rehabilitation and psychotherapy are less used by migrants than by natives. Findings for psychiatric admissions generally show lower admission rates for migrants (Lay et al. 2006). In Spain, the literature that focuses on how the immigrant population uses health services presents results in accordance with four basic blocks: primary health care, hospitalization, emergency care, and specialized care (see, for example: Herna´ndez and Jimenez 2009; Rivera et al. 2008; Regidor et al. 2009). The review of literature carried out by LlopGirone´s et al. (2014) draws the conclusion that there is a dearth of studies on how the foreign population uses mental health care services. The surveys that are used in these studies do not distinguish between types of specialization. Therefore one cannot compare, for instance, the usage rates for psychiatric units between national and foreign populations. Some studies do use the admissions registers from mental health units, although the results cannot be extrapolated to the entire immigrant population that has settled in Spain. Among these studies, Gutierrez (2002) presents as his main finding that mental disorders appear to be the second reason immigrants consult the health service. In terms of how this collective uses the mental health care services, studies seem to point towards a lower usage rate of mental health services when compared with that of the national population (Regidor et al. 2009). It is also worth noting that, along with immigrant population using the mental health care services less, immigrants tend not to comply with treatment programs when they do go for help (Gotor and Gonza´lez-Jua´rez 2004). A variety of clinical and cultural factors may influence the therapeutic relationship, compliance with treatment, or whether they abandon treatment entirely. A number of studies in Spain have observed that certain immigrant groups are more likely than native ones to abandon psychological and psychiatric treatment (Baca-Garcı´a et al. 2005). Much of the literature on the HIE has obtained consistent results about the existence of HIE for countries with long histories of receiving immigrants. Among these countries are the USA, Canada, the UK, and Australia

(Biddle et al. 2007; Chen et al. 1996; Newbold and Danforth 2003; Perez 2002; Stephen et al. 1994; McDonald and Kennedy 2004; Antecol and Bedard 2005). Nevertheless, there are a few studies that have analyzed the HIE in countries like Spain, where the phenomenon of large-scale immigration is relatively recent. In Spain, Rivera et al. (2013) examined the dynamics of the overall health for the immigrant population with the 2011–2012 SNHS and obtained empirical evidence in favor of HIE. Different, complementary explanations for the HIE are provided in the literature. One of the main arguments is that positive selection in terms of health (HS) accounts for health patterns in this population (Marmot et al. 1984; McDonald and Kennedy 2004; Jasso et al. 2004). Thus, healthier individuals are better able to cope with migration, both physically and financially. At the same time, less healthy immigrants are more likely to return to their country of origin (Palloni and Arias 2003; Palloni and Morenoff 2001). For example, Marmot et al. (1984) show that immigrants that have settled in the UK have standardized rates of mortality below the rates attributed to others who remain in their countries of origin. Authors, such as Jasso et al. (2004) and McDonald and Kennedy (2004), explain that the way in which members of the foreign population perceive their health status can vary with the length of time they have been resident in that country. Another point to consider is the influence of certain socioeconomic conditions on health, such as levels of education, employment status, and genetic type conditions (Go´mez et al. 2004; Marmot and Syme 1976; Marmot et al. 1984). Most immigrants arriving in the destination country have levels of income and employment rates below those of the national population. As they stay longer in the destination country, the health levels of these individuals will also tend to improve (Sorlie et al. 1995). This increase is due to assimilation in terms of income and economic convergence with the national population. It should be pointed out that health is positively related to level of income. International literature provides limited evidence to analyze the relationship between mental health and length of residence in the destination country of the immigrant population. Most of these studies have focused on Canadian residents. Ali (2002) uses data from the 2000/2001 Canadian Community Health Survey (CCHS) to compare the prevalence of rates of depression and alcohol dependence among immigrants and nationals. The study finds that these rates develop as the time of residence increases. Compared to their national counterparts, the immigrant population has lower levels in these types of health problems. The HIE is higher for immigrants who have spent up to 10 years living in the destination country. The same is true for those from Africa and Asia. On the other hand,

123

Adm Policy Ment Health

immigrants who have spent more than 10 years in Canada have similar rates to those of the Canadian population as a whole. These immigrants are mostly from Europe. Wu and Schimmele (2005) studied the relationship between the duration of residence and episodes of depression in the immigrant population in Canada through the National Population Health Survey (NPHS) from 1996 to 1997. Compared to the national population, immigrants have fewer symptoms of depression. However, the period of time they reside in the destination country is a determinant in the way in which this converges with national health trends. In this study, social support is included as a determining factor in mental health. As a control variable, two factors are used: perceived social support index and a social contact networks, or the number of contacts they have. Both variables present a negative relationship with respect to the variables that come into play as the immigrant population’s mental health develops over time. Similar results are obtained by Lou and Beaujot (2005) using data from the CCHS to analyze the declared state of mental health in the immigrant population when compared to that of the national population. The study found that recent immigrants to Canada (0–9 years of residence in the country) are 57 % less likely than nationals to report that their mental health as ‘‘regular—bad’’, compared with immigrants who have resided there for more than 10 years and have mental health status similar to those of the nationals. There is also evidence that social support and self-related mental health are positively related. The advantage is greater for the immigrant population’s mental health when this population receives the same intensity of social support given to the national population. Aglipay et al. (2013) turns to the CCHS (2007–2008) to study the presence of anxiety disorders in immigrants who had lived there for between zero and 9 years and those who had been in that country for over 10 years. About 6.4 % of the non-immigrant population present anxiety disorder, in comparison with 1.85 % of immigrants who had been resident for \10 years and 3.95 % of immigrants who had been there over 10 years. Studies carried out at the mental health centers within hospitalization units of Spain find that, the longer immigrants reside in the country, the more their social-demographic characteristics are similar to those of the national population No demand is produced by the collective of immigrants who have recently arrived or find themselves in precarious situations in terms of their residence. These patients use hospital resources as a first line of health care, in contrast with the non-foreign population. Moreover, they present a high frequency of first psychiatric pathologies; this perhaps can be explained by the fact that the population who emigrates tends to be young and healthy. This affirmation is based on the low rate of previous psychiatric episodes found in the population

123

under treatment and an average age that is lower than the one for the entire population in psychiatric hospitals. The average amount of time they stay in the hospital is higher in the case of the immigrant population. This seems to indicate greater difficulty in being released from hospital owing to social support problems (Ochoa et al. 2004). Stoyanova and Dı´az-Serrano (2009) have entered uncharted territory by studying the relationship between mental health, social capital, and immigration. To this end, they have used data from the Health Survey for Catalonia database (2006). Their main finding is that social capital has a positive effect on the mental health of those who reside in that region. In the case of the immigrant population, it was shown that social capital had a differential effect on the mental health in accordance with how long someone had been resident in Spain. Years of residence has a positive effect on the accumulation of social capital stock. However, this factor, years of residence, does not have statistically significant effects on the risk of poor mental health.

Mental Health Care in Spain Each of the 17 Autonomous Communities (regions) in Spain is responsible for running its own mental health care services. Competences for this field have been transferred to these regions, a process that began in 1981 and finished in 2002. These regions can create a legal framework to regulate how public health care services are provided. Between the different territories, there are differences in the content of services, process and rights. A gradual trend in mental health care has been to move away from the traditional ways of providing care, like admitting patients into psychiatric hospitals. Instead mental health care concerns have been redirected to centers that are associated to the general health care system. Mental health care teams form part of primary care; they are the entry point to specialist care networks (Ministry of Health and Consumer Affairs 2007). Within the central government, a ministry called the Ministry of Health, Social Policy and Equality or Ministerio de Sanidad, Polı´ticas Sociales e Igualdad (MSPSI), coordinates regional services. It is guided by the general lines and strategies for promoting mental and psychological wellbeing, preventing mental illness and providing mental health education. All the Autonomous Communities have currently incorporated awareness programs into their mental health care plans. However they have yet to follow a generalized approach and there is great diversity in the way these ideas are put in practice (Ministerio de Sanidad, Polı´ticas Sociales e Igualdad 2014). The next step is to look at the way in which Autonomous Communities work in areas where there is danger of social

Adm Policy Ment Health

exclusion or marginality. Most regions take these areas into account in their mental health plans. However, when they themselves assess their own performance, it is revealed that programs aimed at the most vulnerable sectors remain underdeveloped. Another unresolved issue in Spain’s mental health care provision is the need for greater coordination of and cooperation between social services, primary providers, specialist care, and the programs that assist the patients’ treatment and re-insertion into society. Mental health care must meet its own challenges given the highly complex interplay between its various services. These difficulties are aggravated by the extreme lack of uniformity among the systems of care. Moreover mental health care is fragmented across various sectors, involving health, social, educational, and legal entities as well as the workplace. Secondary health care networks are a labyrinth and care is divided into sectors with specific services for the young, the elderly, substance abusers, and those who are disabled. In terms of how the immigrant population gains access to public health care, since 2000 all migrants in Spain have been entitled to the same health care coverage as nationals (Organic Law 8/2000). However, to get an individual health card, one had to be on the local civil registry, although children and pregnant women were exempt from this requirement. In the registration process, a valid passport and proof of habitual residence were needed. Therefore a number of undocumented migrants were unable to obtain health cards because they could not comply with the registration requirements, particularly when it came to providing proof of habitual residence. In response, some regions had developed more welcoming systems, in which undocumented migrants would be provided with health cards without being on the civil register lists. A step in a very different direction was then taken by the Spanish Government (Royal Decree 16/2012). Under this more recent law, only those foreigners who hold permanent residence in Spain have the right to gain access to complete health care. Not only must individuals have full legal status to be entitled to health care; members of their immediate family must do so as well. Those whose status has not been legalized can only go to emergency rooms, maternity units, and pediatric centers, the three services to which everyone is entitled. According to statistics from the Ministry of Labor, up to half a million people may find themselves adversely affected by the new law.

Methods Sample The data that were used came from the 2011 to 2012 SNHS (INE 2013), which was carried out between July, 2011 and

June, 2012. This survey collects information on health and lifestyle behavior including alcohol consumption, smoking, physical exercise, and nutrition, as well as demographic and socio-economic characteristics. The SNSH also includes data on frequency and use of health care services. Over 26,502 individuals were surveyed, but only those who were 15 years of age or over, a total of 21,007 individuals, were taken into account. The survey also identifies whether the adult respondents were born in Spain or abroad, and for the first time, the SNSH shows how long they have been living in this country. In the 2011–2012 survey, a total of 1717 individuals reported that they had been born abroad. According to previous literature, 239 individuals who arrived in Spain before the age of 15 years were excluded from the analysis (Nolan 2012). It was felt that they probably had similar experiences to members of the native population, in terms of cultural, social, and environmental habits, as well as in terms of access to health services. Finally, the study contained a total of 1478 individuals who were born abroad and had come to Spain when they were 15 years of age or older. Study Variables The dependent variable for this study was the GHQ indicator score, which was calculated using the General Household Questionnaire (Goldberg and Williams 1988). It was developed to detect if a healthy person is unable to carry out normal, everyday activities. Emerging anxiogenic phenomena or psychiatric disorders are also detected. The questionnaire was originally a 60-item instrument. In recent years, however, a range of shortened versions have become available, including the GHQ-30, GHQ-28, GHQ-20, and GHQ-12. The scale indicates whether the respondent has recently experienced a particular symptom or behavior. Each item relates to a four-point scale: less than usual, no more than usual, rather more than usual, or much more than usual. The SNHS incorporates the GHQ-12 questionnaire as an indicator of psychological well-being. The questionnaire consists of 12 questions to which the respondent answers whether he or she has experienced certain symptoms or behavioral changes in the weeks immediately prior to being surveyed. As usual, the types of scores used are a bimodal scale (0–0–1–1) and a 4-point Likert-type scale (0–1–2–3). The total score ranges from 0 to 12 points, from the best to the worst state of mental health. In addition to being a general measure of psychiatric well-being, the questionnaire is the most extensively used instrument for measuring common mental disorders. Its application in research settings as a screening tool is well documented in empirical and theoretical studies. Moreover, it has been studied in various countries and with various

123

Adm Policy Ment Health Table 1 Mental health state factors for native and immigrant populations (GHQ indicator). Aged adjusted

National

Immigrants less than 10 years

Immigrants more than 10 years

All

1.71 (2.92)

1.34 (2.40)

1.79 (2.88)

Men

1.31 (2.53)

1.10 (2.22)

1.64 (2.84)

Women

2.02 (3.15)

1.52 (2.51)

1.94 (2.92)

Age structure of the entire sample is used to estimate the age-adjusted rates (standard age distribution). The total score of the GHZ indicator ranges from 0 to 12 points, from the best to the worst state of mental health. Standard Deviations in brackets Table 2 The state of the immigrant population’s health by regions of origin Region

%

Mental health indicator

Latin

46.29

2.02 (2.93)

EU

29.40

1.00 (2.09)

Africa

16.23

1.50 (2.55)

Asia

4.63

1.22 (2.55)

Europe

3.45

1.05 (2.02)

Northern American immigrants were not included since they were considered to be a non-significant proportion of the sample (five observations). Standard Deviations in brackets

types of population (Goldberg et al. 1997; Pevalin 2000; Hoeymans et al. 2004; Costa et al. 2006). The indicator has also been validated for the Spanish population by Sa´nchez and Dresch (2008), justifying its efficacy in assessing people´s overall the psychological well-being and detecting non-psychotic psychiatric problems. In this study, the main independent variable is time of residence in the destination country (Nolan 2012; Wu and Schimmele 2005). Following the lines of Lou and Beaujot (2005), Bergeron et al. (2009), and Aglipay et al. (2013), a variable was used to consider if immigrants residing in the destination country had been living there for \10 years. Table 1 shows the mean values observed for the indicator of the national and immigrant populations, the latter according to the number of years of residence in the country. As can be seen, the state of mental health differs depending on the number of years since migration. On average, immigrants who have spent \10 years in Spain report better mental health than the national population. The level of mental health declines for immigrants who have spent more than 10 years in the country. For foreign males the level is even worse than that reported by nationals. The main independent variable is constructed in the model as an interaction term between the variables ‘‘immigrant’’ and ‘‘\10 years’’. The base group corresponds to the group of immigrants who have resided in Spain for more than 10 years (Krueger 1993). Therefore, the dichotomous variable includes those ‘‘born outside the destination country and living there for \10 years’’. Among the other independent variables used, the region within the immigrant’s native country was considered. A

123

variable with five categories was constructed. Birthplace can be a determinant of the individual’s state of health. It includes no observed differences in prenatal, neonatal, and child care; environmental factors; and social and cultural attitudes towards health-related behavior or the use of health services (McDonald and Kennedy 2004). As shown in Table 2, the largest group is from Latin America, representing nearly half of all geographical areas. The next largest is from the EU and Africa. The smallest proportion of immigrants comes from other European countries outside the EU. With regard to the mental health indicator, there were differences according to the immigrant’s region of origin. Foreign nationals from the EU have better levels of mental health when compared with other regions. Africans and Latin Americans, on the other hand, tend to have worse mental health. As mentioned earlier, literature on the state of the immigrant population’s mental health indicates there is an inverse relation between cognitive social capital and common mental disorders. The most widely accepted definition of social capital comes from Putnam (1993): ‘features of social organizations, such as networks, norms, and trust, that facilitate action and cooperation for mutual benefit’. Social capital must be understood as a multidimensional concept that embraces aspects like social participation and a relationship with networks of family and friends. In most studies, an individual’s social capital social is estimated through a series of questions. The aim is to determine the individual’s position in social relationships and how he or she perceives the quality of those relationships. In this particular study, the variable for the models that are presented is obtained from the Duke-UNC social functional support questionnaire included in the ENSE (Broadhead et al. 1988). This tool measures the interviewee’s perceptions when he or she is faced with the diverse situations of affective or personal support that occur in everyday life. The questionnaire was validated for the general Spanish population by Bello´n et al. (1996). It measures qualitative and functional aspects of social support—that is, confidential and affective support—in a scale of 11 items. Each item admits five possible responses in a Likert scale. The final points system for the variable is established between 11 and 55 points, from less to more functional social support.

Adm Policy Ment Health

Method Representing a recount of the number of symptoms or the behavior that determines an inability to carry out normal psychological activities and/or the occurrence of episodes of distress, the score obtained in the GHQ takes positive entire values (0–12). A natural choice for modeling the variables, therefore, was to use count data specifications (Cameron and Trivedi 2010; Greene 2011). The starting point for the count data regression is the Poisson distribution. In Poisson’s regression model, the property of equidispersion assumes that a single parameter k presents equal means and variance. This makes the model too restrictive, since, in practice, most variables show over-dispersion. To express this in another way, the means observed in the variable are less than the variance. A generalization of the Poisson model is the negative binomial model (NB model), in which the variance/mean ratio is linear with respect to the latter. It is more flexible than the Poisson model, and relaxes the assumption of equi-dispersion. In accordance with the GHQ distribution, Fig. 1 shows that a negative binomial distribution fits the data better than a Poisson distribution in that it allows for an over-dispersion variable. The variance is far in excess of the average (7.64 vs. 1.59). For comparison purposes, the next section also shows the results obtained from the Poisson estimates, although these are rejected in favor of the ones obtained using the NB model.

Results The socio-demographic characteristics of the immigrant population also differed with respect to age, sex, education levels, employment status, and type of work undertaken, or the level of qualifications and skills required for the same .6

.4

.2

0 0

2

4

6

8

k observed proportion poisson prob

Fig. 1 Distribution of the GHQ indicator

neg binom prob

10

kind of job. All of these variables have been considered independent. Table 3 shows the descriptive statistics for the variables used in the regressions developed in this study. Immigrants are, on average, younger, more highly educated, and in formal employment, but tend to perform less skilled work. Table 4 shows the estimated coefficients and the standard errors for the indicator of mental health through a Poisson and negative binomial regression. To interpret the quantitative implications of the results, average effects are given in adjacent columns. As mentioned in the previous section, the variable of interest shows a high number of observations with a value of zero (59 %). This means that the conditional mean of the data is not equal to the conditional variance. As a result, it will be necessary to apply specifications to make this overdispersion possible, along the lines of the NB model. The alpha parameter, which is included in the NB model, estimates the degree to which the data are over-dispersed. The observed value for this parameter (3.079), and its significance, is sufficient to reject the Poisson model. However, when comparing the results obtained for the two models, the coefficients maintain the signs and only minimal changes are observed in their magnitudes. As for the variable that reflects the immigrant’s condition, the results obtained using the NB model confirm that the length of stay influences the mental health of this population. Thus, a period of under 10 years residing in Spain is associated with a reduction of 0.22 symptoms or types of behavior that determine an inability to carry out normal psychological activities and/or episodes of distress, with respect to those immigrants who have spent longer periods in the country. In general, the rest of the explanatory variables taken into account in the analysis exhibit the same behavior as that expected for the whole of the sample. Social support has great significance in both models. A higher amount of social support leads to fewer symptoms associated with mental health problems, as expressed by the indicator under consideration. These results confirm what the literature has indicated: there is an inverse relationship between cognitive social capital and common mental disorders, or the general state of health, as mentioned earlier. Variables representing the individual’s age are all significant. They reflect a progressive deterioration in mental health while the individual is of working age, and a slight improvement in the indicator for the last two age ranges. In terms of employment status, having a job is associated with a reduction in 0.85 symptoms related to mental health. This result is in line with studies that examine the socioeconomic gradient and the individual’s state of health. They find that higher income levels are associated with better health (Smith 2004; Adams et al. 2003).

123

Adm Policy Ment Health Table 3 Variables and descriptive statistics Variable

Definition

Native

Immigrant

1.59

1.54

Dependent variables Mental health

Rating CHQ. between 0 and 12 points, from best to worst mental health

Independent variablesa Immigrant

1 if born abroad, 0 if born in Spain

–

\10 years

1, \10 years living in Spain, 0 otherwise

–

100.0

Social support

From 11 to 55 points, from less to more functional social support

50.00

48.00

Age 2

1, between 25 and 34 years old, 0 otherwise

11.98

27.78

Age 3

1, between 35 and 44 years old, 0 otherwise

17.88

30.2

Age 4

1, between 45 y 54 years old, 0 otherwise

16.87

19.35

Age 5

1, between 55 and 64 years old, 0 otherwise

15.71

9.77

Age 6 Male

1, 65 or more years old, 0 otherwise 1, if is male, 0 otherwise

30.06 45.94

6.64 46.10

Married

1, if he is married, 0 otherwise

52.44

54.19

Separated

1, if he is separated, 0 otherwise

6.3

8.38

54.21

Widower

1, if he is widower, 0 otherwise

13.96

3.71

Edu 1

1, if primary education not completed, 0 otherwise

15.34

6.90

Edu 2

1, if primary education completed, 0 otherwise

13.36

5.81

Edu 3

1, if first stage of secondary or intermediate level of VT completed, 0 otherwise

40.36

36.59

Edu 4

1, if high school or higher level VT completed, 0 otherwise

30.94

50.7

Edu 5

1, if college completed, 0 otherwise

14.87

16.92

Works

1, with work contract, 0 otherwise

40.55

53.7

Type 1

1, an unskilled worker, 0 otherwise

13.87

28.68

Town

1, if the residence is in a town of less than 10,000 inhabitant, 0 otherwise

24.63

15.84

Latin America

1, if birth country is in Latin America, 0 otherwise

–

45.40

European Union

1, if birth country belongs to the EU-27, 0 otherwise

–

29.31

Europe

1, if birth country belongs to a European country outside the EU, 0 otherwise

–

3.45

Asia

1, if birth country is in Asia, 0 otherwise

–

4.73

Sample size: 20.459 individuals a

The reference categories are: Spanish-born, age 15–24 years, female, never married, primary level education not completed, non-working, skilled worker, living in a town of more than 10,000 inhabitants, birth country is Africa

Educational attainment is sometimes also considered to be a determinant to an individual’s health (Grossman 2000; Smith 2004). From the results obtained, it would seem that education promotes mental health. This is true right across the board; all educational levels, when compared to the lowest of these, have a positive effect on health. There was also an observable educational gradient with respect to the first three variables considered. Mental health improves as the education level increases. This is true up to university education, when the gradient disappears, although the relationship remains significant. Moreover, the mental health of men seems to be better than that of women, and married individuals also tend to have better mental health. The results also show that individuals who live in municipalities with fewer than 10,000 inhabitants seem to have better mental health.

123

The variables regarding the origin of the immigrant population point towards significant values for individuals from Latin America and the EU; the former tend to have worse mental health and the latter, better. The effects are non significant for individuals from European countries non members of the UE and from Asia.

Discussion The main aim of this article was to analyze the immigrant population’s mental health in relation to their length of stay in Spain. Moreover, the study also try to provide greater knowledge of this collective’s characteristics and how these factors had an influence on their state of mental health. The analysis verifies the HIE, which explains how

Adm Policy Ment Health Table 4 Basic specifications for the state of mental health in relation to immigrant status and length of residence in Spain

NB regression Coefficient (SE)

Marginal effects (SE)

Age 2

0.619*** (0.095)

0.981*** (0.109)

Age 3

0.800*** (0.065)

1.268*** (0.107)

Age 4

0.860*** (0.066)

1.363*** (0.109)

Age 5

0.780*** (0.086)

1.236*** (0.108)

Age 6

0.535*** (0.064)

0.848*** (0.103)

Male

-0.308*** (0.027)

-0.488*** (0.047)

Married

-0.222*** (0.029)

-0.352*** (0.046)

Working

-0.541*** (0.034)

-0.858*** (0.057)

Edu 2

-0.116*** (0.052)

-0.184*** (0.083)

Edu 3

-0.173*** (0.046)

-0.275*** (0.074)

Edu 4 Edu 5

-0.336*** (0.049) -0.078*** (0.022)

-0.533*** (0.088) -0.123*** (0.078)

Town

-0.038*** (0.323)

-0.060*** (0.051)

Latin America European Union

0.381*** (0.090)

0.605*** (0.145)

-0.287*** (0.110)

-0.455*** (0.175)

-0.220 (0.262)

-0.349 (0.447)

Europe Asia

0.055 (0.241)

0.008 (0.380)

Social support

-0.008*** (0.0009)

-0.013*** (0.0001)

Inmigrant and residence \10 years

-0.140*** (0.095)

-0.223*** (0.150)

/lnalpha

1.114 (0.016)

alpha

3.047 (0.051)

N

20.383

Log-L

-32,053.36

Pseudo R2

0.014

Levels * 1 %, ** 5 %, *** 10 % Likelihood ratio test of alpha = 0: chibar 2(01) = 3.2e ? 0.4 Prob Cchibar2 = 0.000 dy/dx is for discrete change of dummy variable from 0 to 1

the immigrants’ state of mental health deteriorates the longer they stay in the host country. The state of their mental health tends to converge with that of the national population. The empirical analysis is developed with the data from the last SNHS, which includes questions about the length of stay of individuals who reported being born outside Spain. This variable is related to the mental health of individuals measured in terms of a GHQ score. The relationship between length of stay and mental health is examined using count data models. Results confirmed that the length of stay in the destination country is a determinant in the foreign population’s mental health status. Therefore, for a residence period of under 10 years in Spain, there is a reduction of 0.26 symptoms or types of behavior that determine an inability to carry out normal psychological activities, and/or the occurrence of episodes of distress when compared to immigrants who have lived there for over 10 years.

The literature points to other variables as determinants in the foreign population’s state of mental health. When the estimates were being made, another factor taken into consideration was how the individual perceived the social support he or she received. Results were obtained that confirm a positive relationship with the mental health indicator. The expected effects were achieved by the factors that other studies felt would protect immigrants’ mental health. In this sense, there are better levels of mental health among those who are married and have a work contract in the host country. Limitations This study makes it easier to understand how the immigrant population’s mental health evolves depending on how long they have been resident in the host country. However, it has its limitations. Firstly, the study uses cross-sectional data, which are focus on one point in time and give no indication

123

Adm Policy Ment Health

of the sequence of events. In this sense, it is impossible to consider certain unobservable characteristics, which may vary among immigrants who have arrived at different times. A longitudinal study on how an individual’s state of health evolves would be heightened if the transitions between states of health could be modeled as discrete changes of state. The fundamental advantage of panel data set over a cross section is that they provide great flexibility in modeling differences in behavior across individuals, unobservable in cross sections or aggregate time series. Unfortunately, no surveys are available that make it possible to produce panel data to follow an individual’s behavior over time. Secondly, other HIE determinants would have been identified had it been possible to rely on specific information pre-dating the migration process and the immigrant’s arrival in the destination country. In particular, data were needed on their state of health, socio-economic situation, or access to health care. What is certainly true is that the decrease in immigrant mental health levels over time in the new country of residence is due to a combination of factors. These factors include cultural acclimatization and increased health awareness, as well as a wider diagnosis of health problems. Implications for Future Research and Health Policy As mentioned earlier, there is a dearth of studies on the mental state of the immigrant population in Spain, particularly in terms of how this group gains access to and uses the specific health services. Although this collective is obviously complex, there is a need for a more extensive and better knowledge of the reality of immigrant health. To this end, progress should be made in designing surveys specifically for them. Alternatively, already existing surveys could be adapted to provide detailed information about this group. In any case, the interview would need to be in the language of the interviewees so that the response rate is improved and bias is reduced. From a health policy perspective, an essential step would be to address differences in the health of foreign nationals and how these evolve over time. It would therefore be possible to meet their health care needs, which vary during their stay and depend on certain factors, such as the individual socio-economic status of those immigrants. Traditionally, recommendations for immigrant health focus on the period they first arrive to their host country, bearing in mind that the process of migration itself is a traumatic experience. Nevertheless, in light of the results obtained, it is felt necessary to implement measures for promoting the health of immigrants who have been resident over a longer period of time, even though these immigrants appear to be integrated into the society that has taken them in.

123

Mental health care has two dimensions. On the one hand, it has something in common with other health services, which have to provide care and prevention to communities at greatest risk. Immigrants are among those communities. On the other, mental health care in particular must be promoted in itself. To this end, the health services have to collaborate with other sectors to create conditions that facilitate their adaptation to the country of destination. With this double focus in mind, mental health care should be more concerned with prevention and with greater collaboration among entities in the case of primary care. Specialist care, in turn, has to reach out to help individuals and their families. The results highlight the importance of the social support network for the immigrants’ mental health and the need to promote policies that facilitate that group’s integration into the host society. Social capital is also a relevant variable; it is one of the main sources of support alongside other, more official programs or services. Conclusions can be drawn from previous studies. It is necessary to make it easier for this population to gain access to health services. Another measure is to gather more information on how the health system is accessed and used when patients first make contact with providers. The aim here is to ensure these patients start and follow through with treatment (Sanz et al. 2007). To achieve these aims, mental health care professionals must be made aware of the cultural factors influencing immigrants and ethnic minorities. An official cultural mediator could make it easier to take into account the diverse realities of the immigrant population. Acknowledgments The authors would like to acknowledge the support received from the research project ECON2013-48217-C2-2R ‘‘Impacto econo´mico, sanitario y social de las enfermedades y los problemas de salud: informacio´n y herramientas para la evaluacio´n de polı´ticas pu´blicas’’.

References Adams, P., Hurd, M. D., Mcfadden, D., Merrill, A., & Ribeiro, T. (2003). Healthy, wealthy and wise? Tests for direct causal paths between health and socioeconomic status. Journal of Econometrics, 112, 3–56. Aglipay, M., Colman, I., & Chen, Y. (2013). Does the healthy immigrant effect extend to anxiety disorders? Evidence from a nationally representative study. Journal of Immigrant and Minority Health, 15(5), 851–857. Ali, J. (2002). Mental health of Canada’s immigrants. Health Reports, 13, 101–113. Antecol, H., & Bedard, K. (2005). Unhealthy assimilation: Why do immigrants converge to American health status levels?. IZA Discussion Paper, 1654. Bonn: IZA. Baca-Garcı´a, E., Pe´rez, M., Quintero, F. J., Martı´nez, M., Basurte, I., Sevilla-Vicente, J., et al. (2005). Acceso, itinerarios y utilizacio´n de los servicios psiquia´tricos en la poblacio´n inmigrante. Monografı´as de Psiquiatrı´a, 17(4), 11–17.

Adm Policy Ment Health Bello´n, J. A., Delgado, A., De Dios, J., & Lardelli, P. (1996). Validez y fiabilidad del cuestionario de apoyo social funcional DukeUNC-11. Atencio´n Primaria, 18, 153–163. Bergeron, P., Auger, N., & Hamel, D. (2009). Weight, general health and mental health: status of diverse subgroups of immigrants in Canada. Canadian Journal of Public Health, 100, 215–220. Bhugra, D., & Jones, P. (2001). Migration and mental illness. Advances in Psychiatric Treatment, 7, 216–233. Biddle, N., Kennedy, S., & McDonald, J. T. (2007). Health assimilation patterns amongst Australian immigrants. Economic Record, 83(260), 16–30. Broadhead, W. B., Gehlbach, S. H., de Gruy, F. V., & Kaplan, B. H. (1988). The Duke-UNC functional social support questionnaire: measurement of social support in family medicine patients. Medical Care, 26(7), 709–723. Cameron, A. C., & Trivedi, P. K. (2010). Microeconometrics using stata. Revised edition. College Station: Stata Press. Cantarero, D., & Pascual, M. (2008). Salud y utilizacio´n en la poblacio´n inmigrante: una revisio´n del caso espan˜ol. Atencio´n Sanitaria y Nuevas Necesidades Poblacionales: Inmigracio´n y Demanda. Santiago de Compostela: FEGAS. Carta, M. G., Bernal, M., Hardoy, M. C., & Haro-Abad, J. M. (2007). Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1). Clinical Practice and Epidemiology in Mental Health, 1, 13. Chen, J., Edward, N. G., & Russell, W. (1996). The Health of Canada’s Immigrants in 1994–95. Health Reports, 7(4), 33–45. Chen, A. W., Kazanjian, A., & Wong, H. (2008). Determinants of mental health consultations among recent Chinese immigrants in British Columbia, Canada: implications for mental health risk and access to services. Journal of Immigrant and Minority Health, 10, 529–540. Chen, J., & Vargas-Bustamante, A. (2011). Estimating the effects of immigration status on mental health care utilizations in the United States. Journal of Immigrant and Minority Health, 13(4), 671–680. doi:10.1007/s10903-011-9445-x. Costa, E., Barreto, S. M., Uchoa, E., Firma, J. O., Lima-Costa, M. F., & Prince, M. (2006). Is the GDS-30 better than the GHQ-12 for screening depression in elderly people in the community? The Bambui health aging study (BHAS). International Psychogeriatrics, 18, 493–503. European observatory on health systems and policies. (2011). Migration and health in the European Union. New York: Open University Press/McGraw-Hill. Fossion, P., Servais, L., Rejas, M. C., Ledoux, Y., Pelc, I., & Minner, P. (2004). Psychosis, migration and social environment: an age-andgender controlled study. European Psychiatry, 19(6), 338–343. ¨ stu¨n, T. B., Piccinelli, M., Goldberg, D. P., Gater, R., Satorius, N., U Gureje, O., & Rutter, M. (1997). The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychological Medicine, 27, 191–197. Goldberg, D., & Williams, P. (1988). A user’s guide to the general health questionnaire. Windsor: Nfer-Nelson. Go´mez, S. L., Kelsey, J. L., Glaser, S. L., Lee, M. M., & Sidney, S. (2004). Immigration and acculturation in relation to health and health-related risk factors among specific Asian subgroups in a health maintenance organisation. American Journal of Public Health, 94(11), 1977–1984. Gotor, L., & Gonza´lez-Jua´rez, C. (2004). Psychiatric hospitalization and continuity of care in inmigrants treated in Madrid. Social Psychiatry and Pychiatric Epidemiology, 39, 560–568. Greene, W. H. (2011). Econometric analysis. New Jersey: Prentice Hall. Grossman, M. (2000). The human capital model. In A. J. Culyer & J. P. Newhouse (Eds.), Handbook of health economics (pp. 347–408). Amsterdam: Elsevier.

Gru¨sser, S. M., Wo¨lfling, K., Mo¨rsen, C. P., Albrecht, U., & Heinz, A. (2005). Immigration-associated variables and substance dependence. Journal of Studies on Alcohol and Drugs, 66(1), 98–104. Gutie´rrez, M. D. (2002). Trastornos mentales en minorı´as e´tnicas: >un tema para investigar en atencio´n primaria? Atencio´n Primaria, 29, 6–13. Health & Consumer Protection Directorate-General. (2004). The state of mental health in Europe. Luxembourg: European Commission. Herna´ndez-Quevedo, C., & Jime´nez-Rubio, D. (2009). A comparison of the health status and health care utilisation patterns between foreigners and the national population in Spain: new evidence from the Spanish national health survey. Social Science and Medicine, 69, 370–378. Hoeymans, N., Garssen, A., Westert, G., & Verhaak, P. (2004). Measuring mental health of the Dutch population: a comparison of the GHQ-12 and the MHI-5. Health Quality Life Outcomes, 2, 13–23. Instituto Nacional de Estadı´stica. (2013). Encuesta Nacional de Salud 2011–2012. Madrid: Instituto Nacional de Estadı´stica. Jasso, G., Massey, D., Rosenzweig, M., & Smith, J. (2004). Immigrant health: selectivity and acculturation. IFS Working Paper, 04/23. London: Institute for Fiscal Studies. Kirmayer, L. J., Weinfeld, M., Burgos, G., du Fort, G. G., Lasry, J. C., & Young, A. (2007). Use of health care services for psychological distress by immigrants in an urban multicultural milieu. Canadian Journal of Psychiatry, 52(5), 295–304. Krueger, A. B. (1993). How computers have changed the wage structure: Evidence from microdata 1984–1989. Quaterly Journal of Economics, CVIII, 33–60. Lay, B., Lauber, C., Nordt, C., & Ro¨ssler, W. (2006). Patterns of inpatient care for immigrants in Switzerland: A case control study. Social Psychiatry and Psychiatric Epidemiology, 41(3), 199–207. Lindert, J., Schouler-Ocak, M., Heinz, A., & Priebe, S. (2008). Mental health, health care utilisation of migrants in Europe. European Psychiatry, 23(1), 14–20. doi:10.1016/S0924-9338(08)70057-9. Llop-Girone´s, A., Vargas, I., Garcia-Subirats, I., Aller, M. B., & Va´zquez, M. L. (2014). Acceso a los servicios de salud de la poblacio´n inmigrante en Espan˜a. Revista Espan˜ola de Salud Pu´blica, 88(6), 715–734. doi:10.4321/S1135-57272014000600005. Lou, Y., & Beaujot, R. (2005). What happens to the ‘Healthy Immigrant Effect’: The mental health of immigrants to Canada. PSC Discussion Papers Series, 19(15), article 1. London/Canada: Population Studies Centre, University of Western Ontario. Marmot, M. G., Adelstein, A. M., & Bulusu, L. (1984). Lessons from the study of immigrant mortality. Lancet, 1(8392), 1455–1457. Marmot, M. G., & Syme, S. L. (1976). Acculturation and coronary heart disease in Japanese–Americans. American Journal of Epidemiology, 104(3), 225–247. Mcdonald, J. T., & Kennedy, S. (2004). Insights into the ‘healthy immigrant effect’: health status and health service use of immigrants to Canada. Social Science and Medicine, 59, 1613–1627. Ministerio de Sanidad, Servicios Sociales e Igualdad. (2014). Transversalidad y Continuidad Asistencial en Salud Mental. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad. Ministry of Health and Consumer Affaire. (2007). Summary of the strategy in mental health of the national health system. Madrid: Ministry of Health and Consumer Affairs. Newbold, B., & Danforth, J. (2003). Health status and Canada’s immigrant population. Social Science and Medicine, 57, 1981–1995. Nolan, A. (2012). The’healthy immigrant’ effect: initial evidence for Ireland. Health Economics, Policy and Law, 7, 343–362. Ochoa, E., Vicente, N., & Dı´az, H. (2004). Asistencia psiquia´trica a inmigrantes: Demanda en un centro de salud mental y hospitalizacio´n. Psiquiatria, 8(3), 1–10.

123

Adm Policy Ment Health Oppedal, B., Røysamb, E., & Lackland, D. (2004). The effect of acculturation and social support on change in mental health among young immigrants. International Journal of Behavioral Development, 28(6), 481–494. doi:10.1080/01650250444000126. Palloni, A., & Arias, E. (2003). A re-examination of the hispanic mortality paradox. Center for Demography and Ecology Working Paper, 2003–01. University of Wisconsin: Madison. Palloni, A., & Morenoff, J. (2001). Interpreting the paradoxical in the ‘hispanic paradox’: Demographic and epidemiological approaches. In M. Weinstein, A. Hermalin, & M. Stoto (Eds.), Population health and aging (pp. 140–174). New York: New York Academy of Sciences. Perez, C. (2002). Health status and health behaviour among immigrants. Health Reports, 13. Ottawa: Statistics Canada. Pevalin, D. J. (2000). Multiple applications of the GHQ-12 in a general population sample: An investigation of long-term retest effects. Social Psychiatry and Psychiatric Epidemiology, 35(11), 508–512. Putnam, R. (1993). Making democracy work. Civic traditions in modern Italy. Princeton: Princeton University Press. Regidor, E., Sanz, B., Pascual, C., Lostao, L., Sa´nchez, E., & Dı´az, J. M. (2009). La utilizacio´n de los servicios sanitarios por la poblacio´n inmigrante en Espan˜a. Gaceta Sanitaria, 23(1), 4–11. Rivera, B., Casal, B., Cantarero, D., & Pascual, M. (2008). Adaptacio´n de los servicios de salud a las caracterı´sticas especı´ficas y de utilizacio´n de los nuevos espan˜oles. Gaceta Sanitaria, 22(1), 86–95. Rivera, B., Casal, B., & Currais, L. (2013). Healthy immigrant effect: trayectoria de salud de la poblacio´n inmigrante a partir de la ENSE 2011-2012. Estudios de Economı´a Aplicada, 31(2), 339–358. Sa´nchez-Lo´pez, M. P., & Dresch, V. (2008). The 12-item general health questionnaire (GHQ-12): Reliability, external validity and factor structure in the Spanish population. Psicothema, 20(4), 839–843.

123

Sanz, L. J., Elustondo, I., Valverde, M., Montilla, J., & Miralles, M. (2007). Salud mental e inmigracio´n: adhesio´n al tratamiento ambulatorio. Revista de la Asociacio´n Espan˜ola de Neouropsiquatrı´a, 27(100), 281–291. Smith, J. P. (2004). Unravelling the SES health connection. The Institute for Fiscal Studies Working Paper, 04-02. Londres: The Institute for Fiscal Studies. Sorlie, P. D., Backlund, E., & Keller, J. (1995). U.S. mortality by economic, demographic, and social characteristics: The national longitudinal mortality study. American Journal of Public Health, 85, 949–956. Stephen, E. H., Foote, K., Hendershot, G. E., & Schoenborn, C. A. (1994). Health of the foreign-born population. Advance Data from Vital and Health Statistics, 241, 1–10. Stillman, S., Mckenzie, D., & Gibson, J. (2009). Migration and mental health: Evidence from a natural experiment. Journal of Health Economics, 28, 677–687. Stoyanova, A., & Diaz-Serrano, L. (2009). El impacto diferencial del capital social sobre la salud mental de la poblacio´n auto´ctona y los inmigrantes residentes en Catalun˜a. Gaceta Sanitaria, 23(1), 93–99. Straiton, M., Grant, J. F., Winefield, H. R., & Taylor, A. (2014). Mental health in immigrant men and women in Australia: The North West Adelaide health study. BMC Public Health, 14, 1–15. United Nations. (2014). International migration report 2013. New York: United Nations. Wu, Z., & Schimmele, Ch. (2005). The healthy migrant effect on depression: Variation over time? Canadian Studies in Population, 32(2), 271–295. Instituto Nacional de Estadı´stica (several years). Padro´n Municipal: Explotacio´n Estadı´stica. Madrid: Instituto Nacional de Estadı´stica. Yeo, S. (2004). Language barriers and access to care. Annual Review of Nursing Research, 22, 59–73.