J Immigrant Minority Health DOI 10.1007/s10903-015-0203-3
ORIGINAL PAPER
Turkish and Moroccan Young Adults in the Netherlands: The Relationship Between Acculturation and Psychological Problems ¨ zbek1 • Ilja L. Bongers2,3 • Jill Lobbestael4 • Chijs van Nieuwenhuizen2,3 Emel O
Ó Springer Science+Business Media New York 2015
Abstract This study investigated the relationship between acculturation and psychological problems in Turkish and Moroccan young adults living in the Netherlands. A sample of 131 healthy young adults aged between 18 and 24 years old, with a Turkish or Moroccan background was recruited using snowball sampling. Data on acculturation, internalizing and externalizing problems, beliefs about psychological problems, attributions of psychological problems and barriers to care were collected and analyzed using Latent Class Analysis and multinomial logistic regression. Three acculturation classes were identified in moderately to highly educated, healthy Turkish or Moroccan young adults: integration, separation and diffusion. None of the participants in the sample were marginalized or assimilated. Young adults reporting diffuse acculturation reported more internalizing and externalizing problems than those who were integrated or separated. Separated young adults reported experiencing more practical barriers to care than integrated young adults. Further
¨ zbek & Emel O [email protected]; [email protected] & Chijs van Nieuwenhuizen [email protected] 1
GGzE, Idiomes, PO Box 909, 5600 AX Eindhoven, The Netherlands
2
GGzE Centre for Child and Adolescent Psychiatry, PO Box 909, 5600 AX Eindhoven, The Netherlands
3
Tranzo - Scientific Centre for Care and Welfare, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
4
Department of Clinical Psychological Science, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
research with a larger sample, including young adult migrants using mental health services, is required to improve our understanding of acculturation, psychological problems and barriers to care in this population. Including experiences of discrimination in the model might improve our understanding of the relationship between different forms of acculturation and psychological problems. Keywords Acculturation Young adult migrants Internalizing problems Externalizing problems Psychological problems
Introduction Most research on acculturation and psychological problems has been conducted on adult migrants or children and there is limited evidence on acculturation and psychological problems in young adult migrants. Young migrants use outpatient mental health services less than natives, although they are overrepresented in the population of users of specialized and forensic mental health services [1– 4]. Currently 11 % of the population of the Netherlands is non-Western migrants; Turks (total = 392.923, 25.7 % young adults) and Moroccans (total = 362.954, 23.6 % young adults) are the largest national groups [5]. Turkish and Moroccan young adults undergo a process of acculturation involving both cultural and psychological change as a result of their contact with other cultural groups. Both migrants and natives play an important role in the acculturation process; however changes in cultural orientation are typically confined to the minority culture [6]. The most widely used model for the acculturation process is Berry’s bi-dimensional model [6] which implies that acculturation is a process of two independent dimensions; maintenance
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of heritage, culture and identity, and involvement with or identification with mainstream society. Berry conceptualized four acculturation strategies: integration—identification with one’s own ethnic group as well with mainstream society; assimilation—identification with mainstream society at the cost of identification with one’s own ethnic group; separation—identification with one’s own ethnic group while identification with rejection of mainstream society; marginalization–rejection of one’s own ethnic group as well as with mainstream society [6]. Previous research has suggested that not all individuals’ experiences can be described in terms of these four strategies, and that inconsistencies in acculturation processes may be an indicator of a diffuse or ambivalent acculturation strategy [7, 8]. Studies have also shown that integrated young people have fewer psychological problems and higher self-esteem than young people who are marginalized or separated [7, 9–12]. Assimilation has been associated with delinquent behavior [13, 14]. In addition, Moroccan adolescent females ambivalent to acculturation experienced more internalizing and externalizing problems than integrated or separated Moroccan adolescent females [15]. However other studies reported no associations between acculturation and problem behavior or psychological problems [15, 16]. Previous studies have reported that certain ethnic groups are more prone to psychological problems regardless of their acculturation strategy [17–20]. For instance, Turkish migrants in the Netherlands have a higher incidence of psychological problems than native Dutch citizens; similarly Turkish females living in the Netherlands are at greater risk of developing anxiety and mood disorders than native Dutch females [21, 22]. Furthermore, externalizing problems are more prevalent in Turkish and Moroccan adolescents living in the Netherlands than in native Dutch adolescents, and more prevalent in male Moroccan migrants than their female counterparts [17, 23]. Although young migrants are reported to experience more psychological problems than natives they appear to under-use outpatient mental health services [1–4]. Migrants in the Netherlands who are more orientated to Dutch culture are more likely to use mental health services than migrants whose primary orientation is to a minority culture [24, 25]. For migrants, self-reliance, low expectations of mental health service providers and lack of knowledge of mental health services are barriers to seeking help with mental health problems [26]. Verhulp et al. [2] argued that a failure to identify emotional problems by migrant adolescents self and their parents is responsible for their underuse of mental health services. Young migrants’ negative attitudes to psychological treatment and the belief that mental health problems do not have intra psychic causes
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may be other factors in their under-use of mental health services [27]. To the best of our knowledge there has been no combined research pertaining to acculturation, psychological problems and barriers to care in Turkish and Moroccan young adults. The results of previous research on the relationship between acculturation and mental health are inconsistent [7, 9–13, 15, 16]. Our first objective was to derive acculturation profiles from our data using latent class analysis and assess the distribution of psychological problems in this group of young adults. Our second objective was to examine how acculturation strategies were related to externalizing and internalizing problems, and to beliefs about mental health and barriers to seeking help with mental health problems in this group of young adults.
Methods Sampling and Recruitment The sample consisted of 131 healthy Turkish and Moroccan young adults aged 18–24 years old who were not in receipt of mental health services. Participants were recruited using snowball sampling [28–30]. The researcher (EO) recruited key persons with a Turkish or Moroccan background from her own social network. These key persons then recruited participants, who in turn recruited additional participants from their own social networks. Seven key persons with a Turkish or Moroccan background and varying levels of education (two Turkish men; one Moroccan man; two Turkish women; two Moroccan women) participated. The researcher gave the key persons information about the purpose of the study and the inclusion criteria. Key persons were compensated for their assistance with cinema vouchers worth ten Euros. Participants received an envelope containing information about the study objectives, instructions, a consent form, questionnaires and return envelopes. Two hundred and forty-seven questionnaires were distributed and 131 were returned, a return rate of 53 %. Participants completed the questionnaires without the help of the key persons in order to ensure that their responses remained private. Participants returned the questionnaires and the form indicating their informed consent to participation in separate envelopes, either to one of the key persons or by post to the researcher. Participation was entirely voluntary and participants’ anonymity was guaranteed. The questionnaire included a question asking if the respondent had received professional mental health services in the last 12 months. Participants who responded positively were excluded from further analysis.
J Immigrant Minority Health
The Science Commission of the Institute for Mental Health Services, Eindhoven judged that the study design and sampling procedure did not require ethical approval from a national medical ethics committee on the basis of the Medical Research Involving Human Subjects Act (WMO). The study was conducted in accordance with the ethical standards set out in the 1964 Declaration of Helsinki and its later amendments. Measures Socio-Demographic Characteristics The socio-demographic variables investigated were: gender, age, ethnicity, educational level and daily occupation. There were three categories of educational level: low education (no education, primary education, lower vocational education or lower secondary education), moderate education (intermediate vocational education or higher secondary education) and high education (higher vocational education or university). Acculturation Acculturation was measured with the Psychological Acculturation Scale (PAS) [31]. The PAS was developed to measure the individual degree of emotional bonding, sense of belonging to a group and understanding of one’s own minority ethnic culture and the majority culture. Stevens et al. [8] adapted and validated the PAS for measurement of acculturation strategies in Moroccan youth. Van Oort et al. [17] successfully used this adapted version of the PAS in a sample of Turkish youth. In this study we used the adapted version of the PAS developed by Stevens et al. [8] and Van Oort et al. [17]. The PAS consists of two subscales, each containing six items; one subscale is used to assess identification with the majority culture (in this instance Dutch culture) and the other to assess identification with the minority culture (Turkish or Moroccan culture). All 12 items are rated on a five-point scale ranging from 0 = ‘strongly disagree’ to 4 = ‘strongly agree’. Items include ‘I have a lot in common with Dutch people and Turkish/Moroccan people’ and ‘I am proud of Dutch culture and Turkish/Moroccan culture’. The PAS has good reliability and validity [8, 16]. In our sample, Cronbach’s alpha ranged from 0.84 to 0.91. Internalizing and Externalizing Problems Emotional and behavioral problems in the past 6 months were measured with the Adult Self-Report (ASR) [32]. Internalizing problems were indicated by the sum of scores for items relevant to the following profiles: Anxious/
Depressed (e.g. ‘I am too fearful or anxious’), Withdrawn (e.g. ‘I would rather be alone than with others’) and Somatic Complaints (e.g. ‘Heart pounding or racing’). Externalizing problems were indicated by the sum of scores on items in the following syndrome profiles: Rule-breaking Behavior (e.g. ‘I do things that may get me into trouble with the law’), Intrusive Behavior (e.g. ‘I try to get a lot of attention’) and Aggressive Behavior (e.g. ‘I get in a many fights’). Higher scores were taken as an indication of greater emotional and behavioral problems. Score for internalizing problems and externalizing problems were dichotomized: participants with scores above the average for the non-referred norm group (see Appendix C, Achenbach and Rescorla [32]) were assigned the score ‘0’ and participant with scores below the average of the non-referred norm group were assigned ‘1’. Although recoding the data as a binary variable causes loss of information, it makes analysis simpler as an odds ratio indicates the likelihood that young adults with above-average experience of emotional or behavioral problems will be assigned to the acculturation reference category rather than the non-reference categories. Good reliability and validity have been reported for the ASR [32]. In our sample, Cronbach’s alpha ranged from 0.89 to 0.92. Barriers to Care Barriers to seeking professional help were measured using the Barriers to Care Checklist (BTCC) [33–35]. The checklist begins with the question ‘Have you received professional help for mental health problems in the last 12 months?’ Participants who responded positively to this question were excluded from further analysis. Participants rated 18 items using a binary yes/no scale. The items can be grouped into two subscales: Psychological barriers (barriers related to fear, stigma or perceived helpfulness of treatment, e.g. ‘I did not think treatment would help’) and Practical barriers (barriers related to cost, geographical availability or time, e.g. ‘I did not know how to get help’) [27]. Beliefs and Causal Attributions Beliefs about mental illnesses were measured with the Illness Perception Questionnaire-Revised (IPQ-R) [36, 37]. The IPQ-R was emended for this study by replacing the word ‘illness’ with ‘psychological problems’. The IPQ-R consists of 38 items describing psychological problems, which are rated on five-point scales ranging from 0 = ‘strongly disagree’ to 4 = ‘strongly agree’. Four of the IPQ-R subscales were used in this study: Personal Control (e.g. ‘I have the power to influence my mental health problems’), Consequences (e.g. ‘My mental health
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problems have major consequences on my life’), Chronic Timeline (e.g. ‘My mental health problems will last a long time) and Cyclic Timeline (e.g. ‘My mental health problems come and go in cycles’). Good reliability and validity have been reported for the IPQ-R [36, 37]. In our sample Cronbach’s alpha was between 0.72 and 0.85. Causal attributions of psychological problems were measured using Faller’s self-report questionnaire for causal attributions (CAQ) [38]. A list of 22 possible causes of psychological problems were rated on a five-point scale ranging from 0 = ‘strongly disagree’ to 4 = ‘strongly agree’. These 22 items can be grouped into five subscales: Interpersonal causes (e.g. ‘problems in with a partner or with family’), Social causes (e.g. ‘difficulties at work or school’), Intra-psychic causes (e.g. ‘low self-esteem’), Biographical causes (e.g. ‘difficult childhood’), and Somatic causes (e.g. ‘physical illnesses’). This questionnaire has good validity and reliability [27, 38]. In our sample Cronbach’s alpha was between 0.78 and 0.86. Statistical Analysis Descriptive and multinomial logistic regression analyses were performed using SPSS and Latent Class Analysis (LCA) [39] with M-Plus [40]. Group differences were analyzed with ANOVAs or Chi square tests (v2), applying the Fisher exact correction. Attrition analyses were performed by comparing the analyzed subsample for a particular measure with the whole sample (used in analysis of acculturation strategies, internalizing and externalizing problems) using a one-way ANOVA. LCA was used to identify acculturation subgroups on the basis of responses to the 12 PAS items. The primary goal of LCA is to find the smallest number of relatively homogeneous classes into which a sample can be decomposed. Various LCA solutions were compared using model fit indices. The Bayesian information criterion (BIC) is a relative indicator of model fit, with lower values indicating better fit of the model to the data [41]. The Vuong–Lo– Mendell–Rubin likelihood ratio (VLMR) was used to assess whether a model with k classes fitted significantly better than a model with k-1 classes [42]. LCA estimates the probability of class membership for each participant and participants are assigned to the class in which their posterior probability of membership was highest. Separate multinomial logistic regression analyses were used to determine associations between acculturation (dependent variable) and internalizing or externalizing problems (independent variables; scores above and below the average for the non-referred norm group were coded 0 and 1 respectively), controlling for potential effects of gender (male = 0, female = 1) and ethnicity (Moroccan = 0, Turkish = 1). The reference category was ‘above-average
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experience of psychological problems’. The sample size for the multinomial logistic regression analyses was n = 81 owing to removal of questionnaire data which showed evidence of pattern-based responding. Analyses were conducted in a stepwise manner. In the first block the socio-demographic variables gender and ethnicity were entered. In the second block internalizing problems (Model 1) or externalizing problems (Model 2) or both internalizing and externalizing problems (Model 3) were added. Finally, in the third block the scores on the IPQ-R, CAQ and BTCC were added in a forward, stepwise manner. We report significant odds ratios, v2 test and the Nagelkerke R2 for the model. There was no evidence of multicollinearity among the predictor variables using a tolerance criterion of 0.10. Attrition Analysis All questionnaires were scanned for patterned responding (defined as responding ‘no’ or ‘totally disagree’ to all items on a questionnaire) and any which showed evidence of patterned responding were removed from further analysis to avoid biasing the results. Patterned responding was found in the following questionnaires: ASR (n = 6), IPQ-R (n = 22), CAQ (n = 39), BTCC (n = 17) and PAS (n = 5). The group exhibiting patterned responding had a lower mean score for internalizing and externalizing problems than the group which did not show patterned responding.
Results Study Sample The participants were healthy Turkish and Moroccan young adults between the ages of 18–24 years, who were not receiving mental health services. Individuals who were born in the Netherlands but had at least one parent born in Turkey or Morocco were considered Turkish or Moroccan [43]. All the participants in our sample were born in the Netherlands. Table 1 gives details of the sample. A total of 131 young adults (males: n = 54, 41.2 %; females: n = 77, 58.8 %) participated in the study, 64 (48.9 %) were Turkish and 67 (51.1 %) were Moroccan. The Moroccan subsample included significantly more females than males [v2(1) = 3.98, p = 0.046; females: n = 45, 67.2 %; males: n = 22, 32.8 %]. The average age was 21 years (SD = 1.97; range = 18–24 years) and the majority had completed intermediate vocational education (n = 100, 76.3 %) or higher secondary education (n = 20, 15.3 %). There were no systematic differences between Turks and Moroccans in terms
J Immigrant Minority Health Table 1 Socio-demographic characteristics of the sample Age (years)
Total (N = 131) Mean (SD)
Turkish (n = 64) Mean (SD)
Moroccan (n = 67) Mean (SD)
21 (1.96)
21.5 (1.89)
20.76 (2.05)
%
%
%
41.2
50.0
32.8*
Low
8.4
6.3
10.4
Moderate
76.3
78.1
74.6
High
15.3
15.6
14.9
75.4
81.0
76.1
Males Educational level (completed)
Daily occupation Student
Group differences were investigated using t tests for continuous variables and Chi square tests for categorical variables * p \ 0.05
Table 2 Means and standard deviations for questionnaire scores and gender and ethnicity effects in the overall sample and in Turkish and Moroccan subgroups
ASR
Total Mean (SD)
Turkish Mean (SD)
Moroccan Mean (SD) n = 61
Gender F
Ethnicity gP
2
F
gP2
N = 125
n = 64
Internalizing problems
12.52 (9.92)
13.25 (10.77)
11.75 (8.93)
0.64
0.00
0.97
0.01
Externalizing problems
9.27 (7.76)
9.26 (7.24)
9.28 (8.33)
4.52*
0.04
0.21
0.00
CAQ
n = 109
n = 60
n = 49
Internal causes
5.70 (3.36)
5.70 (3.28)
5.69 (3.50)
4.21*
0.04
0.17
0.00
Social causes
6.39 (3.66)
6.32 (3.68)
6.47 (3.67)
3.88*
0.04
0.03
0.00
Interpersonal causes
3.52 (2.26)
3.73 (2.34)
3.27 (2.17)
2.82
0.03
1.94
0.02
Somatic causes
4.92 (4.12)
5.18 (4.00)
4.59 (4.28)
0.03
0.00
0.49
0.05
4.84*
0.04
1.91
0.02
0.53 8.66**
0.01 0.09
0.39 0.03
0.00 0.00
Biographical causes IPQ-R Personal control Consequences
4.41 (3.08)
4.67 (3.15)
4.10 (2.99)
n = 92
n = 48
n = 44
9.57 (3.77) 7.03 (5.10)
9.75 (3.61) 6.81 (5.29)
9.36 (3.97) 7.27 (4.93)
Cyclic timeline
6.88 (3.79)
6.76 (3.53)
7.00 (4.09)
2.97
0.03
0.00
0.00
Chronic timeline
3.36 (5.10)
3.29 (3.24)
3.43 (2.95)
5.64*
0.06
0.07
0.00
Gender and ethnic group differences were assessed using ANOVAs ASR Adult Self-Report, CAQ Faller’s self-report causal attribution questionnaire, IPQ-R Illness Perception Questionnaire-Revised * p \ 0.05; ** p \ 0.01, g2p = effect size
of age or educational level [age: t(129) = -1.42, p = 0.16; vocational education: v2(1) = 0.75, p = 0.69; secondary education: v2(2) = 1.80, p = 0.41]. None of the participants reported clinically significant internalizing or externalizing problems on the ASR. There were no gender or ethnic differences in experience of psychological barriers and practical barriers to accessing mental health services. The mean ASR scores for the sample were comparable to the means for the non-referred norm group [32] (Table 2).
Acculturation was assessed by performing a LCA on the 12 PAS items. BIC values decreased as the number of classes was increased from two (BIC = 1484.99; VLMR test = 0.00), to three (BIC = 1389.79; VLMR test = 0.01) and then four (BIC = 1375.73; VLMR test = 0.25). The VLMR test suggested that a four-class solution overfitted the data (p = 0.25). On the basis of our interpretation of the classes identified and the reported fit indices we concluded that acculturation was best represented by a three-class solution (Fig. 1).
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J Immigrant Minority Health Fig. 1 Three classes of acculturation based on the Psychological Acculturation Scale
Table 3 Gender and ethnicity distributions for the three classes of acculturation (N = 126) Class 1 Integration N (%)
Class 2 Separation N (%)
Class 3 Diffusion N (%)
Gender
v2 test
0.00 (p = 0.99)
Male
29 (58.0)
11 (22.0)
10 (20.0)
Female
44 (57.9)
17 (22.4)
15 (19.7)
Turkish
39 (61.9)
13 (20.6)
11 (17.5)
Moroccan
34 (54.6)
15 (23.8)
14 (22.2)
Ethnicity
0.84 (p = 0.65)
Participants in Class 1 (n = 73, 58 %) were integrated young adults who were highly attached to their minority ethnic group and culture but also moderately to highly attached to Dutch people and culture (Fig. 1). Class 2 (n = 28, 22 %) consisted of separated participants who were highly attached to their minority ethnic group and culture and had little attachment to Dutch people and culture. Finally, Class 3 (n = 25, 20 %) consisted of participants showing diffuse acculturation, i.e. they had a moderate attachment to both their minority ethnic group and culture and to Dutch people and culture. Gender and ethnicity distributions were similar in all acculturation classes (Table 3). Multinomial logistic regression revealed associations involving acculturation, barriers to care and internalizing problems (Model 1) and externalizing problems (Model 2) (Table 4). Scores on the IPQ-R and CAQ were not associated with acculturation. Model 1 [v2(8) = 15.51;
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p \ 0.05] indicated that participants with above-average internalizing problems were more likely to be assigned to Class 3 (diffusion) than Class 1 (integration) (OR 3.70, 95 % CI 1.03–13.31) or Class 2 (separation) (OR 5.82, 95 % CI 1.20–28.34). Model 1 also indicated that participants who reported more practical barriers to accessing mental health services were more likely to be assigned to Class 2 (separation) than Class 1 (integration) (OR 5.62, 95 % CI 1.38–22.84). In Model 2 [v2(6) = 9.85; p = 0.13], participants with an above-average scores for externalizing problems were more likely to be assigned to Class 3 (diffuse acculturation) than Class 1 (integration) (OR 5.67, 95 % CI 1.78–18.02). In Model 3, which included both internalizing problems and externalizing problems as independent variables we found an association between externalizing problems and acculturation [v2(8) = 13.21, p = 0.11; Nagelkerke R2 = 0.18] (Table 4). Participants reporting above-average externalizing problems were more likely to be assigned to Class 3 (diffuse acculturation) than Class 1 (integration) (OR 3.61, 95 % CI 1.02–12.72).
Discussion We believe that this is the first study to investigate the relationship between acculturation and psychological problems in healthy Turkish and Moroccan young adults in a sample for which data on barriers to care or beliefs about psychological problems were also available.
J Immigrant Minority Health Table 4 Relationship between acculturation and internalizing and externalizing problems (n = 81)
Model 1
v2 test
Nagelkerke R2
15.51
0.20
Class 1 versus Class 2 OR (95 % CI)
Class 1 versus Class 3 OR (95 % CI)
Class 2 versus Class 3 OR (95 % CI)
Internalizing problems
0.64 (0.17–2.39)
3.70 (1.03–13.31)
5.82 (1.20–28.34)
Practical barriers
5.62 (1.38–22.84)
2.15 (0.60–7.75)
0.38 (0.07–2.07)
2.21 (0.64–7.62)
5.67 (1.78–18.02)
2.57 (0.63–10.41)
0.82 (0.21–3.16) 2.42 (0.61–9.63)
2.99 (0.81–11.03) 3.61 (1.02–12.72)
3.63 (0.72–18.25) 1.49 (0.31–7.17)
Model 2
9.85
0.13
13.21
0.18
Externalizing problems Model 3 Internalizing problems Externalizing problems
Class 1: Integration (n = 47); Class 2: Separation (n = 15); Class 3: Diffuse acculturation (n = 19). Model 1 is a multinomial logistic regression model with internalizing problems as the independent variable; Model 2 is a multinomial logistic regression with externalizing problems as the independent variable; Model 3 is a multinomial logistic regression with both internalizing and externalizing problems as the independent variables. In all models scores on Faller’s causal attribution questionnaire, the Illness Perception Questionnaire-Revised and Barriers to Care Checklist were added as covariates and the dependent variable was acculturation. All models controlled for potential effects of ethnicity and gender. The reference category for internalizing and externalizing problems was above-average problems
Two of the forms of acculturation which emerged from LCA in this study seem to fit Berry’s bi-dimensional acculturation model [6]. More than half of the young adults in our sample were classified as integrated, implying that they had a strong attachment to their minority ethnic culture and a strong to moderate attachment to Dutch society. Berry defines separated individuals (22 % of this sample) as having a strong attachment to their minority ethnic culture and little attachment to the host culture or society (Dutch, in this sample). In this study, a third class representing participants who displayed diffuse acculturation i.e. had moderate attachment to both Dutch and Turkish or Moroccan people and culture. This form of acculturation corresponds to what Berry and colleagues described as ‘diffuse acculturation’ and what Stevens et al. [7, 8, 44] referred to as ‘ambivalent acculturation’ in their research on migrant adolescents. Diffuse acculturation can be characterized as the lack of a clear sense of identification with either a minority ethnic culture of origin or a host culture, in this case Dutch culture. Stevens et al. [44] suggest that this form of acculturation might be associated with a sense of discomfort and lack of clarity about one’s cultural orientation. Unlike the study on which the acculturation model was based [6], our sample did not include any participants who could be described as assimilated or marginalized; this is consistent with an earlier study of Dutch migrants [8]. The absence of assimilated young adults from our sample might be due to the sampling method used; it is possible that the social networks of the key persons who recruited participants did not include any assimilated individuals. Marginalization, however, is rare according to Berry [6], who argued that it was a consequence of failed compulsory
assimilation combined with forced exclusion by the major society. This suggests that the absence of marginalized participants from our sample may be due to the migration policy of the Netherlands which is not based on compulsory assimilation and forced exclusion. Different forms of acculturation were associated with different psychological problems in our sample of young adult migrants. Young adults showing diffuse acculturation reported more internalizing and externalizing problems than integrated or separated participants, which is consistent with other studies [7, 9–12, 44, 45]. Young adults in the diffuse acculturation class responded ‘neither agree nor disagree’ to most of the PAS items. This pattern of responding may reflect a lack of a sense of belonging, or an uncertainty about one’s cultural identity. Belonging to a social group is important in young adulthood and so it is possible that the lack of a clear cultural identity, and the associated feeling of confusion, affects identity development, resulting in more externalizing and internalizing problems [46]. Practical barriers (e.g. not knowing where to get help, travel difficulties) but not psychological barriers were independently associated with acculturation. Separated young adults reported more practical barriers to care than integrated young adults. It is possible that separated young adults are less knowledgeable about sources of help because they are relatively detached from Dutch society. We also found an independent association between externalizing problems and acculturation; young adults who showed diffuse acculturation had more externalizing problems than integrated young adults. The mechanism underlying this association remains unclear, although it is known that discrimination—which was not investigated in
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this study—has a negative impact on psychological adaptation [47–49]. It is possible that young adults showing diffuse acculturation have experienced more discrimination, and that this is responsible for the higher incidence of externalizing problems in this group. Strengths and Limitations An important strength of this study is that it represents an attempt to improve our understanding of mental health knowledge, acculturation and barriers to using mental health services in a group about which we know rather little. Migrants and young adults are considered ‘hard to reach’ and they do not often participate in research voluntarily [50]. The recruitment strategy used in this study, working with key persons to recruit participants from the populations of interest, had the advantage of being cost effective in terms of both time and money; it also resulted in a return rate of 53 %, which is high for migrant research in the Netherlands. Another positive aspect of this study was that among moderate to high-educated Turkish and Moroccan young adults, specific patterns of acculturation and mental health were found. It should however be noted that our sample may not be representative of the population of Turkish and Moroccan young adults in the Netherlands, more specifically it seems likely that our sample contained a disproportionate number of highly educated participants. In addition, the sample size was too small for a stratified analysis of gender and ethnic differences. The small sample was a limitation. Questionnaires which showed evidence of systematic responding were excluded from analysis to avoid biasing the results, however this meant that the sample size was smaller than anticipated and it reduced the power of the analysis. Berry’s acculturation model [6] is widely-used in acculturation research, but it has limitations. The model appears to imply that migrants consciously or freely choose an acculturation ‘strategy’ and does not recognize that the host or majority society can hinder or promote acculturation and may have more influence on acculturation processes than individual migrant variables [51]. Another criticism of the bi-dimensional model of acculturation and instruments based on it is that it does not differentiate between public and private domains. It is likely that migrants’ acculturation takes different forms in different contexts. In addition Bhatia and Ram [52] argued for a more dynamic model of acculturation instead of a series of stable outcomes. Implications Our findings have several implications for assessment and treatment of psychological problems. First, taking account of acculturation—by discussing relevant processes and
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issues with patients—might lead to improvements in understanding of migrant clients and to tailored treatment plans. Second, mental health services should consider improving access to care by providing clear information about how to reach these services. Finally, even moderately or highly educated young adult migrants do not necessarily understand research material like the self-report questionnaires used in this study, some psychological concepts used in self-report questionnaires might be difficult to understand for non-Western migrants. Especially in assessment with self-report questionnaires among migrants, it is important to try to ensure that respondents have understood the items and to look for systematic patterns of responding. In a clinical context failure to do this could result in misdiagnosis and inappropriate treatment or lack of treatment. New Contributions to the Literature Three classes of acculturation were identified in a sample of moderately to highly educated, healthy, Turkish and Moroccan young adults: integration, separation and diffuse acculturation. We failed, however, to identify any marginalized or assimilated young adults in this sample. Young adult migrants showing diffuse acculturation reported more internalizing and externalizing problems than those who were integrated with or separated from Dutch culture. Separated young adults experience more practical barriers to accessing mental health services than their integrated peers. Further research in a larger sample which includes young adult migrants who are receiving mental health services is required to improve our understanding of acculturation, mental health and barriers to use of mental health services. Extending models of acculturation to include discrimination experiences might improve our understanding of the relationship between acculturation and psychological problems. Conflict of interest of interest.
The authors declare that they have no conflict
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ORIGINAL PAPER
Turkish and Moroccan Young Adults in the Netherlands: The Relationship Between Acculturation and Psychological Problems ¨ zbek1 • Ilja L. Bongers2,3 • Jill Lobbestael4 • Chijs van Nieuwenhuizen2,3 Emel O
Ó Springer Science+Business Media New York 2015
Abstract This study investigated the relationship between acculturation and psychological problems in Turkish and Moroccan young adults living in the Netherlands. A sample of 131 healthy young adults aged between 18 and 24 years old, with a Turkish or Moroccan background was recruited using snowball sampling. Data on acculturation, internalizing and externalizing problems, beliefs about psychological problems, attributions of psychological problems and barriers to care were collected and analyzed using Latent Class Analysis and multinomial logistic regression. Three acculturation classes were identified in moderately to highly educated, healthy Turkish or Moroccan young adults: integration, separation and diffusion. None of the participants in the sample were marginalized or assimilated. Young adults reporting diffuse acculturation reported more internalizing and externalizing problems than those who were integrated or separated. Separated young adults reported experiencing more practical barriers to care than integrated young adults. Further
¨ zbek & Emel O [email protected]; [email protected] & Chijs van Nieuwenhuizen [email protected] 1
GGzE, Idiomes, PO Box 909, 5600 AX Eindhoven, The Netherlands
2
GGzE Centre for Child and Adolescent Psychiatry, PO Box 909, 5600 AX Eindhoven, The Netherlands
3
Tranzo - Scientific Centre for Care and Welfare, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
4
Department of Clinical Psychological Science, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
research with a larger sample, including young adult migrants using mental health services, is required to improve our understanding of acculturation, psychological problems and barriers to care in this population. Including experiences of discrimination in the model might improve our understanding of the relationship between different forms of acculturation and psychological problems. Keywords Acculturation Young adult migrants Internalizing problems Externalizing problems Psychological problems
Introduction Most research on acculturation and psychological problems has been conducted on adult migrants or children and there is limited evidence on acculturation and psychological problems in young adult migrants. Young migrants use outpatient mental health services less than natives, although they are overrepresented in the population of users of specialized and forensic mental health services [1– 4]. Currently 11 % of the population of the Netherlands is non-Western migrants; Turks (total = 392.923, 25.7 % young adults) and Moroccans (total = 362.954, 23.6 % young adults) are the largest national groups [5]. Turkish and Moroccan young adults undergo a process of acculturation involving both cultural and psychological change as a result of their contact with other cultural groups. Both migrants and natives play an important role in the acculturation process; however changes in cultural orientation are typically confined to the minority culture [6]. The most widely used model for the acculturation process is Berry’s bi-dimensional model [6] which implies that acculturation is a process of two independent dimensions; maintenance
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of heritage, culture and identity, and involvement with or identification with mainstream society. Berry conceptualized four acculturation strategies: integration—identification with one’s own ethnic group as well with mainstream society; assimilation—identification with mainstream society at the cost of identification with one’s own ethnic group; separation—identification with one’s own ethnic group while identification with rejection of mainstream society; marginalization–rejection of one’s own ethnic group as well as with mainstream society [6]. Previous research has suggested that not all individuals’ experiences can be described in terms of these four strategies, and that inconsistencies in acculturation processes may be an indicator of a diffuse or ambivalent acculturation strategy [7, 8]. Studies have also shown that integrated young people have fewer psychological problems and higher self-esteem than young people who are marginalized or separated [7, 9–12]. Assimilation has been associated with delinquent behavior [13, 14]. In addition, Moroccan adolescent females ambivalent to acculturation experienced more internalizing and externalizing problems than integrated or separated Moroccan adolescent females [15]. However other studies reported no associations between acculturation and problem behavior or psychological problems [15, 16]. Previous studies have reported that certain ethnic groups are more prone to psychological problems regardless of their acculturation strategy [17–20]. For instance, Turkish migrants in the Netherlands have a higher incidence of psychological problems than native Dutch citizens; similarly Turkish females living in the Netherlands are at greater risk of developing anxiety and mood disorders than native Dutch females [21, 22]. Furthermore, externalizing problems are more prevalent in Turkish and Moroccan adolescents living in the Netherlands than in native Dutch adolescents, and more prevalent in male Moroccan migrants than their female counterparts [17, 23]. Although young migrants are reported to experience more psychological problems than natives they appear to under-use outpatient mental health services [1–4]. Migrants in the Netherlands who are more orientated to Dutch culture are more likely to use mental health services than migrants whose primary orientation is to a minority culture [24, 25]. For migrants, self-reliance, low expectations of mental health service providers and lack of knowledge of mental health services are barriers to seeking help with mental health problems [26]. Verhulp et al. [2] argued that a failure to identify emotional problems by migrant adolescents self and their parents is responsible for their underuse of mental health services. Young migrants’ negative attitudes to psychological treatment and the belief that mental health problems do not have intra psychic causes
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may be other factors in their under-use of mental health services [27]. To the best of our knowledge there has been no combined research pertaining to acculturation, psychological problems and barriers to care in Turkish and Moroccan young adults. The results of previous research on the relationship between acculturation and mental health are inconsistent [7, 9–13, 15, 16]. Our first objective was to derive acculturation profiles from our data using latent class analysis and assess the distribution of psychological problems in this group of young adults. Our second objective was to examine how acculturation strategies were related to externalizing and internalizing problems, and to beliefs about mental health and barriers to seeking help with mental health problems in this group of young adults.
Methods Sampling and Recruitment The sample consisted of 131 healthy Turkish and Moroccan young adults aged 18–24 years old who were not in receipt of mental health services. Participants were recruited using snowball sampling [28–30]. The researcher (EO) recruited key persons with a Turkish or Moroccan background from her own social network. These key persons then recruited participants, who in turn recruited additional participants from their own social networks. Seven key persons with a Turkish or Moroccan background and varying levels of education (two Turkish men; one Moroccan man; two Turkish women; two Moroccan women) participated. The researcher gave the key persons information about the purpose of the study and the inclusion criteria. Key persons were compensated for their assistance with cinema vouchers worth ten Euros. Participants received an envelope containing information about the study objectives, instructions, a consent form, questionnaires and return envelopes. Two hundred and forty-seven questionnaires were distributed and 131 were returned, a return rate of 53 %. Participants completed the questionnaires without the help of the key persons in order to ensure that their responses remained private. Participants returned the questionnaires and the form indicating their informed consent to participation in separate envelopes, either to one of the key persons or by post to the researcher. Participation was entirely voluntary and participants’ anonymity was guaranteed. The questionnaire included a question asking if the respondent had received professional mental health services in the last 12 months. Participants who responded positively were excluded from further analysis.
J Immigrant Minority Health
The Science Commission of the Institute for Mental Health Services, Eindhoven judged that the study design and sampling procedure did not require ethical approval from a national medical ethics committee on the basis of the Medical Research Involving Human Subjects Act (WMO). The study was conducted in accordance with the ethical standards set out in the 1964 Declaration of Helsinki and its later amendments. Measures Socio-Demographic Characteristics The socio-demographic variables investigated were: gender, age, ethnicity, educational level and daily occupation. There were three categories of educational level: low education (no education, primary education, lower vocational education or lower secondary education), moderate education (intermediate vocational education or higher secondary education) and high education (higher vocational education or university). Acculturation Acculturation was measured with the Psychological Acculturation Scale (PAS) [31]. The PAS was developed to measure the individual degree of emotional bonding, sense of belonging to a group and understanding of one’s own minority ethnic culture and the majority culture. Stevens et al. [8] adapted and validated the PAS for measurement of acculturation strategies in Moroccan youth. Van Oort et al. [17] successfully used this adapted version of the PAS in a sample of Turkish youth. In this study we used the adapted version of the PAS developed by Stevens et al. [8] and Van Oort et al. [17]. The PAS consists of two subscales, each containing six items; one subscale is used to assess identification with the majority culture (in this instance Dutch culture) and the other to assess identification with the minority culture (Turkish or Moroccan culture). All 12 items are rated on a five-point scale ranging from 0 = ‘strongly disagree’ to 4 = ‘strongly agree’. Items include ‘I have a lot in common with Dutch people and Turkish/Moroccan people’ and ‘I am proud of Dutch culture and Turkish/Moroccan culture’. The PAS has good reliability and validity [8, 16]. In our sample, Cronbach’s alpha ranged from 0.84 to 0.91. Internalizing and Externalizing Problems Emotional and behavioral problems in the past 6 months were measured with the Adult Self-Report (ASR) [32]. Internalizing problems were indicated by the sum of scores for items relevant to the following profiles: Anxious/
Depressed (e.g. ‘I am too fearful or anxious’), Withdrawn (e.g. ‘I would rather be alone than with others’) and Somatic Complaints (e.g. ‘Heart pounding or racing’). Externalizing problems were indicated by the sum of scores on items in the following syndrome profiles: Rule-breaking Behavior (e.g. ‘I do things that may get me into trouble with the law’), Intrusive Behavior (e.g. ‘I try to get a lot of attention’) and Aggressive Behavior (e.g. ‘I get in a many fights’). Higher scores were taken as an indication of greater emotional and behavioral problems. Score for internalizing problems and externalizing problems were dichotomized: participants with scores above the average for the non-referred norm group (see Appendix C, Achenbach and Rescorla [32]) were assigned the score ‘0’ and participant with scores below the average of the non-referred norm group were assigned ‘1’. Although recoding the data as a binary variable causes loss of information, it makes analysis simpler as an odds ratio indicates the likelihood that young adults with above-average experience of emotional or behavioral problems will be assigned to the acculturation reference category rather than the non-reference categories. Good reliability and validity have been reported for the ASR [32]. In our sample, Cronbach’s alpha ranged from 0.89 to 0.92. Barriers to Care Barriers to seeking professional help were measured using the Barriers to Care Checklist (BTCC) [33–35]. The checklist begins with the question ‘Have you received professional help for mental health problems in the last 12 months?’ Participants who responded positively to this question were excluded from further analysis. Participants rated 18 items using a binary yes/no scale. The items can be grouped into two subscales: Psychological barriers (barriers related to fear, stigma or perceived helpfulness of treatment, e.g. ‘I did not think treatment would help’) and Practical barriers (barriers related to cost, geographical availability or time, e.g. ‘I did not know how to get help’) [27]. Beliefs and Causal Attributions Beliefs about mental illnesses were measured with the Illness Perception Questionnaire-Revised (IPQ-R) [36, 37]. The IPQ-R was emended for this study by replacing the word ‘illness’ with ‘psychological problems’. The IPQ-R consists of 38 items describing psychological problems, which are rated on five-point scales ranging from 0 = ‘strongly disagree’ to 4 = ‘strongly agree’. Four of the IPQ-R subscales were used in this study: Personal Control (e.g. ‘I have the power to influence my mental health problems’), Consequences (e.g. ‘My mental health
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problems have major consequences on my life’), Chronic Timeline (e.g. ‘My mental health problems will last a long time) and Cyclic Timeline (e.g. ‘My mental health problems come and go in cycles’). Good reliability and validity have been reported for the IPQ-R [36, 37]. In our sample Cronbach’s alpha was between 0.72 and 0.85. Causal attributions of psychological problems were measured using Faller’s self-report questionnaire for causal attributions (CAQ) [38]. A list of 22 possible causes of psychological problems were rated on a five-point scale ranging from 0 = ‘strongly disagree’ to 4 = ‘strongly agree’. These 22 items can be grouped into five subscales: Interpersonal causes (e.g. ‘problems in with a partner or with family’), Social causes (e.g. ‘difficulties at work or school’), Intra-psychic causes (e.g. ‘low self-esteem’), Biographical causes (e.g. ‘difficult childhood’), and Somatic causes (e.g. ‘physical illnesses’). This questionnaire has good validity and reliability [27, 38]. In our sample Cronbach’s alpha was between 0.78 and 0.86. Statistical Analysis Descriptive and multinomial logistic regression analyses were performed using SPSS and Latent Class Analysis (LCA) [39] with M-Plus [40]. Group differences were analyzed with ANOVAs or Chi square tests (v2), applying the Fisher exact correction. Attrition analyses were performed by comparing the analyzed subsample for a particular measure with the whole sample (used in analysis of acculturation strategies, internalizing and externalizing problems) using a one-way ANOVA. LCA was used to identify acculturation subgroups on the basis of responses to the 12 PAS items. The primary goal of LCA is to find the smallest number of relatively homogeneous classes into which a sample can be decomposed. Various LCA solutions were compared using model fit indices. The Bayesian information criterion (BIC) is a relative indicator of model fit, with lower values indicating better fit of the model to the data [41]. The Vuong–Lo– Mendell–Rubin likelihood ratio (VLMR) was used to assess whether a model with k classes fitted significantly better than a model with k-1 classes [42]. LCA estimates the probability of class membership for each participant and participants are assigned to the class in which their posterior probability of membership was highest. Separate multinomial logistic regression analyses were used to determine associations between acculturation (dependent variable) and internalizing or externalizing problems (independent variables; scores above and below the average for the non-referred norm group were coded 0 and 1 respectively), controlling for potential effects of gender (male = 0, female = 1) and ethnicity (Moroccan = 0, Turkish = 1). The reference category was ‘above-average
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experience of psychological problems’. The sample size for the multinomial logistic regression analyses was n = 81 owing to removal of questionnaire data which showed evidence of pattern-based responding. Analyses were conducted in a stepwise manner. In the first block the socio-demographic variables gender and ethnicity were entered. In the second block internalizing problems (Model 1) or externalizing problems (Model 2) or both internalizing and externalizing problems (Model 3) were added. Finally, in the third block the scores on the IPQ-R, CAQ and BTCC were added in a forward, stepwise manner. We report significant odds ratios, v2 test and the Nagelkerke R2 for the model. There was no evidence of multicollinearity among the predictor variables using a tolerance criterion of 0.10. Attrition Analysis All questionnaires were scanned for patterned responding (defined as responding ‘no’ or ‘totally disagree’ to all items on a questionnaire) and any which showed evidence of patterned responding were removed from further analysis to avoid biasing the results. Patterned responding was found in the following questionnaires: ASR (n = 6), IPQ-R (n = 22), CAQ (n = 39), BTCC (n = 17) and PAS (n = 5). The group exhibiting patterned responding had a lower mean score for internalizing and externalizing problems than the group which did not show patterned responding.
Results Study Sample The participants were healthy Turkish and Moroccan young adults between the ages of 18–24 years, who were not receiving mental health services. Individuals who were born in the Netherlands but had at least one parent born in Turkey or Morocco were considered Turkish or Moroccan [43]. All the participants in our sample were born in the Netherlands. Table 1 gives details of the sample. A total of 131 young adults (males: n = 54, 41.2 %; females: n = 77, 58.8 %) participated in the study, 64 (48.9 %) were Turkish and 67 (51.1 %) were Moroccan. The Moroccan subsample included significantly more females than males [v2(1) = 3.98, p = 0.046; females: n = 45, 67.2 %; males: n = 22, 32.8 %]. The average age was 21 years (SD = 1.97; range = 18–24 years) and the majority had completed intermediate vocational education (n = 100, 76.3 %) or higher secondary education (n = 20, 15.3 %). There were no systematic differences between Turks and Moroccans in terms
J Immigrant Minority Health Table 1 Socio-demographic characteristics of the sample Age (years)
Total (N = 131) Mean (SD)
Turkish (n = 64) Mean (SD)
Moroccan (n = 67) Mean (SD)
21 (1.96)
21.5 (1.89)
20.76 (2.05)
%
%
%
41.2
50.0
32.8*
Low
8.4
6.3
10.4
Moderate
76.3
78.1
74.6
High
15.3
15.6
14.9
75.4
81.0
76.1
Males Educational level (completed)
Daily occupation Student
Group differences were investigated using t tests for continuous variables and Chi square tests for categorical variables * p \ 0.05
Table 2 Means and standard deviations for questionnaire scores and gender and ethnicity effects in the overall sample and in Turkish and Moroccan subgroups
ASR
Total Mean (SD)
Turkish Mean (SD)
Moroccan Mean (SD) n = 61
Gender F
Ethnicity gP
2
F
gP2
N = 125
n = 64
Internalizing problems
12.52 (9.92)
13.25 (10.77)
11.75 (8.93)
0.64
0.00
0.97
0.01
Externalizing problems
9.27 (7.76)
9.26 (7.24)
9.28 (8.33)
4.52*
0.04
0.21
0.00
CAQ
n = 109
n = 60
n = 49
Internal causes
5.70 (3.36)
5.70 (3.28)
5.69 (3.50)
4.21*
0.04
0.17
0.00
Social causes
6.39 (3.66)
6.32 (3.68)
6.47 (3.67)
3.88*
0.04
0.03
0.00
Interpersonal causes
3.52 (2.26)
3.73 (2.34)
3.27 (2.17)
2.82
0.03
1.94
0.02
Somatic causes
4.92 (4.12)
5.18 (4.00)
4.59 (4.28)
0.03
0.00
0.49
0.05
4.84*
0.04
1.91
0.02
0.53 8.66**
0.01 0.09
0.39 0.03
0.00 0.00
Biographical causes IPQ-R Personal control Consequences
4.41 (3.08)
4.67 (3.15)
4.10 (2.99)
n = 92
n = 48
n = 44
9.57 (3.77) 7.03 (5.10)
9.75 (3.61) 6.81 (5.29)
9.36 (3.97) 7.27 (4.93)
Cyclic timeline
6.88 (3.79)
6.76 (3.53)
7.00 (4.09)
2.97
0.03
0.00
0.00
Chronic timeline
3.36 (5.10)
3.29 (3.24)
3.43 (2.95)
5.64*
0.06
0.07
0.00
Gender and ethnic group differences were assessed using ANOVAs ASR Adult Self-Report, CAQ Faller’s self-report causal attribution questionnaire, IPQ-R Illness Perception Questionnaire-Revised * p \ 0.05; ** p \ 0.01, g2p = effect size
of age or educational level [age: t(129) = -1.42, p = 0.16; vocational education: v2(1) = 0.75, p = 0.69; secondary education: v2(2) = 1.80, p = 0.41]. None of the participants reported clinically significant internalizing or externalizing problems on the ASR. There were no gender or ethnic differences in experience of psychological barriers and practical barriers to accessing mental health services. The mean ASR scores for the sample were comparable to the means for the non-referred norm group [32] (Table 2).
Acculturation was assessed by performing a LCA on the 12 PAS items. BIC values decreased as the number of classes was increased from two (BIC = 1484.99; VLMR test = 0.00), to three (BIC = 1389.79; VLMR test = 0.01) and then four (BIC = 1375.73; VLMR test = 0.25). The VLMR test suggested that a four-class solution overfitted the data (p = 0.25). On the basis of our interpretation of the classes identified and the reported fit indices we concluded that acculturation was best represented by a three-class solution (Fig. 1).
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J Immigrant Minority Health Fig. 1 Three classes of acculturation based on the Psychological Acculturation Scale
Table 3 Gender and ethnicity distributions for the three classes of acculturation (N = 126) Class 1 Integration N (%)
Class 2 Separation N (%)
Class 3 Diffusion N (%)
Gender
v2 test
0.00 (p = 0.99)
Male
29 (58.0)
11 (22.0)
10 (20.0)
Female
44 (57.9)
17 (22.4)
15 (19.7)
Turkish
39 (61.9)
13 (20.6)
11 (17.5)
Moroccan
34 (54.6)
15 (23.8)
14 (22.2)
Ethnicity
0.84 (p = 0.65)
Participants in Class 1 (n = 73, 58 %) were integrated young adults who were highly attached to their minority ethnic group and culture but also moderately to highly attached to Dutch people and culture (Fig. 1). Class 2 (n = 28, 22 %) consisted of separated participants who were highly attached to their minority ethnic group and culture and had little attachment to Dutch people and culture. Finally, Class 3 (n = 25, 20 %) consisted of participants showing diffuse acculturation, i.e. they had a moderate attachment to both their minority ethnic group and culture and to Dutch people and culture. Gender and ethnicity distributions were similar in all acculturation classes (Table 3). Multinomial logistic regression revealed associations involving acculturation, barriers to care and internalizing problems (Model 1) and externalizing problems (Model 2) (Table 4). Scores on the IPQ-R and CAQ were not associated with acculturation. Model 1 [v2(8) = 15.51;
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p \ 0.05] indicated that participants with above-average internalizing problems were more likely to be assigned to Class 3 (diffusion) than Class 1 (integration) (OR 3.70, 95 % CI 1.03–13.31) or Class 2 (separation) (OR 5.82, 95 % CI 1.20–28.34). Model 1 also indicated that participants who reported more practical barriers to accessing mental health services were more likely to be assigned to Class 2 (separation) than Class 1 (integration) (OR 5.62, 95 % CI 1.38–22.84). In Model 2 [v2(6) = 9.85; p = 0.13], participants with an above-average scores for externalizing problems were more likely to be assigned to Class 3 (diffuse acculturation) than Class 1 (integration) (OR 5.67, 95 % CI 1.78–18.02). In Model 3, which included both internalizing problems and externalizing problems as independent variables we found an association between externalizing problems and acculturation [v2(8) = 13.21, p = 0.11; Nagelkerke R2 = 0.18] (Table 4). Participants reporting above-average externalizing problems were more likely to be assigned to Class 3 (diffuse acculturation) than Class 1 (integration) (OR 3.61, 95 % CI 1.02–12.72).
Discussion We believe that this is the first study to investigate the relationship between acculturation and psychological problems in healthy Turkish and Moroccan young adults in a sample for which data on barriers to care or beliefs about psychological problems were also available.
J Immigrant Minority Health Table 4 Relationship between acculturation and internalizing and externalizing problems (n = 81)
Model 1
v2 test
Nagelkerke R2
15.51
0.20
Class 1 versus Class 2 OR (95 % CI)
Class 1 versus Class 3 OR (95 % CI)
Class 2 versus Class 3 OR (95 % CI)
Internalizing problems
0.64 (0.17–2.39)
3.70 (1.03–13.31)
5.82 (1.20–28.34)
Practical barriers
5.62 (1.38–22.84)
2.15 (0.60–7.75)
0.38 (0.07–2.07)
2.21 (0.64–7.62)
5.67 (1.78–18.02)
2.57 (0.63–10.41)
0.82 (0.21–3.16) 2.42 (0.61–9.63)
2.99 (0.81–11.03) 3.61 (1.02–12.72)
3.63 (0.72–18.25) 1.49 (0.31–7.17)
Model 2
9.85
0.13
13.21
0.18
Externalizing problems Model 3 Internalizing problems Externalizing problems
Class 1: Integration (n = 47); Class 2: Separation (n = 15); Class 3: Diffuse acculturation (n = 19). Model 1 is a multinomial logistic regression model with internalizing problems as the independent variable; Model 2 is a multinomial logistic regression with externalizing problems as the independent variable; Model 3 is a multinomial logistic regression with both internalizing and externalizing problems as the independent variables. In all models scores on Faller’s causal attribution questionnaire, the Illness Perception Questionnaire-Revised and Barriers to Care Checklist were added as covariates and the dependent variable was acculturation. All models controlled for potential effects of ethnicity and gender. The reference category for internalizing and externalizing problems was above-average problems
Two of the forms of acculturation which emerged from LCA in this study seem to fit Berry’s bi-dimensional acculturation model [6]. More than half of the young adults in our sample were classified as integrated, implying that they had a strong attachment to their minority ethnic culture and a strong to moderate attachment to Dutch society. Berry defines separated individuals (22 % of this sample) as having a strong attachment to their minority ethnic culture and little attachment to the host culture or society (Dutch, in this sample). In this study, a third class representing participants who displayed diffuse acculturation i.e. had moderate attachment to both Dutch and Turkish or Moroccan people and culture. This form of acculturation corresponds to what Berry and colleagues described as ‘diffuse acculturation’ and what Stevens et al. [7, 8, 44] referred to as ‘ambivalent acculturation’ in their research on migrant adolescents. Diffuse acculturation can be characterized as the lack of a clear sense of identification with either a minority ethnic culture of origin or a host culture, in this case Dutch culture. Stevens et al. [44] suggest that this form of acculturation might be associated with a sense of discomfort and lack of clarity about one’s cultural orientation. Unlike the study on which the acculturation model was based [6], our sample did not include any participants who could be described as assimilated or marginalized; this is consistent with an earlier study of Dutch migrants [8]. The absence of assimilated young adults from our sample might be due to the sampling method used; it is possible that the social networks of the key persons who recruited participants did not include any assimilated individuals. Marginalization, however, is rare according to Berry [6], who argued that it was a consequence of failed compulsory
assimilation combined with forced exclusion by the major society. This suggests that the absence of marginalized participants from our sample may be due to the migration policy of the Netherlands which is not based on compulsory assimilation and forced exclusion. Different forms of acculturation were associated with different psychological problems in our sample of young adult migrants. Young adults showing diffuse acculturation reported more internalizing and externalizing problems than integrated or separated participants, which is consistent with other studies [7, 9–12, 44, 45]. Young adults in the diffuse acculturation class responded ‘neither agree nor disagree’ to most of the PAS items. This pattern of responding may reflect a lack of a sense of belonging, or an uncertainty about one’s cultural identity. Belonging to a social group is important in young adulthood and so it is possible that the lack of a clear cultural identity, and the associated feeling of confusion, affects identity development, resulting in more externalizing and internalizing problems [46]. Practical barriers (e.g. not knowing where to get help, travel difficulties) but not psychological barriers were independently associated with acculturation. Separated young adults reported more practical barriers to care than integrated young adults. It is possible that separated young adults are less knowledgeable about sources of help because they are relatively detached from Dutch society. We also found an independent association between externalizing problems and acculturation; young adults who showed diffuse acculturation had more externalizing problems than integrated young adults. The mechanism underlying this association remains unclear, although it is known that discrimination—which was not investigated in
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this study—has a negative impact on psychological adaptation [47–49]. It is possible that young adults showing diffuse acculturation have experienced more discrimination, and that this is responsible for the higher incidence of externalizing problems in this group. Strengths and Limitations An important strength of this study is that it represents an attempt to improve our understanding of mental health knowledge, acculturation and barriers to using mental health services in a group about which we know rather little. Migrants and young adults are considered ‘hard to reach’ and they do not often participate in research voluntarily [50]. The recruitment strategy used in this study, working with key persons to recruit participants from the populations of interest, had the advantage of being cost effective in terms of both time and money; it also resulted in a return rate of 53 %, which is high for migrant research in the Netherlands. Another positive aspect of this study was that among moderate to high-educated Turkish and Moroccan young adults, specific patterns of acculturation and mental health were found. It should however be noted that our sample may not be representative of the population of Turkish and Moroccan young adults in the Netherlands, more specifically it seems likely that our sample contained a disproportionate number of highly educated participants. In addition, the sample size was too small for a stratified analysis of gender and ethnic differences. The small sample was a limitation. Questionnaires which showed evidence of systematic responding were excluded from analysis to avoid biasing the results, however this meant that the sample size was smaller than anticipated and it reduced the power of the analysis. Berry’s acculturation model [6] is widely-used in acculturation research, but it has limitations. The model appears to imply that migrants consciously or freely choose an acculturation ‘strategy’ and does not recognize that the host or majority society can hinder or promote acculturation and may have more influence on acculturation processes than individual migrant variables [51]. Another criticism of the bi-dimensional model of acculturation and instruments based on it is that it does not differentiate between public and private domains. It is likely that migrants’ acculturation takes different forms in different contexts. In addition Bhatia and Ram [52] argued for a more dynamic model of acculturation instead of a series of stable outcomes. Implications Our findings have several implications for assessment and treatment of psychological problems. First, taking account of acculturation—by discussing relevant processes and
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issues with patients—might lead to improvements in understanding of migrant clients and to tailored treatment plans. Second, mental health services should consider improving access to care by providing clear information about how to reach these services. Finally, even moderately or highly educated young adult migrants do not necessarily understand research material like the self-report questionnaires used in this study, some psychological concepts used in self-report questionnaires might be difficult to understand for non-Western migrants. Especially in assessment with self-report questionnaires among migrants, it is important to try to ensure that respondents have understood the items and to look for systematic patterns of responding. In a clinical context failure to do this could result in misdiagnosis and inappropriate treatment or lack of treatment. New Contributions to the Literature Three classes of acculturation were identified in a sample of moderately to highly educated, healthy, Turkish and Moroccan young adults: integration, separation and diffuse acculturation. We failed, however, to identify any marginalized or assimilated young adults in this sample. Young adult migrants showing diffuse acculturation reported more internalizing and externalizing problems than those who were integrated with or separated from Dutch culture. Separated young adults experience more practical barriers to accessing mental health services than their integrated peers. Further research in a larger sample which includes young adult migrants who are receiving mental health services is required to improve our understanding of acculturation, mental health and barriers to use of mental health services. Extending models of acculturation to include discrimination experiences might improve our understanding of the relationship between acculturation and psychological problems. Conflict of interest of interest.
The authors declare that they have no conflict
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