Mental health in immigrant men and women in Australia: the North West Adelaide health study

In many countries, there has been an increased focus on equal access to health care services across all social groups, including immigrants [1]. Research suggests that foreign born individuals (FBs) may use mental health services less than the rest of the population [2]. While it is recognised that many experience barriers to accessing care [3], there is also the suggestion that FBs experience better mental health [4]. This is known as the healthy migrant effect, where those who (voluntarily) move are assumed to be healthier and more resourceful than those who remain in their home country, upon migration. It is now widely acknowledged that this advantage deteriorates over time [5].

There is conflicting evidence for the healthy migrant effect with respect to mental health [4, 6]. This may be somewhat dependent on the FB population of interest, the host country and the way in which mental health is defined. The current study investigates differences in mental health service use and in mental health between Australian-born (AB) and FB individuals living in South Australia. It also looks at differences and similarities in the socio-demographic factors associated with mental health and service use for AB and FB men and women.

In Australia, around 27.7% of the population are estimated to be FB [7]. The largest groups are from the United Kingdom and New Zealand, but the majority come from non-English speaking backgrounds (NESBs). Recent years have seen a substantial increase in migrants from Asia; with nine of the top ten groups coming from Asian countries from 2007 onwards [8]. In earlier years, European migrants predominated. The largest NESBs groups are from India and China. Despite the large FB population, and the cultural, linguistic and religious diversity within Australia, there is limited research concerning the prevalence of mental health problems and service use in FB populations [2].

The North West Adelaide Health Study (NWAHS) is a representative biomedical cohort study with a focus on chronic disease and is a collaboration between The University of Adelaide, the South Australian Department for Health and Ageing, the University of South Australia, The Queen Elizabeth and Lyell McEwin Hospitals, and South Australia Pathology (Institute of Medical & Veterinary Science). Ethical approval for this study was sought and granted from the North Western Adelaide Health Service – Ethics of Human Research Committee.

In the initial stage of NWAHS, conducted between 1999 and 2003, all households with a telephone in the north-western area of Adelaide, South Australia, were eligible for selection. Within each contacted household, the person who last had their birthday and who was aged 18+ years was invited to participate. No substitutions for refusal were permitted. Of the original 8213 people who were contacted, 4056 participated, giving an overall response rate of 49.4%. The second wave, conducted between 2004 and 2006 was the first to include several measures of mental health. Data collection for both stages included a telephone interview using Computer Assisted Telephone Interview technology, a self-completed questionnaire and a clinical assessment. The current study uses data from the Stage 2 telephone interview and the questionnaire which includes a total of 3259 participants (80% of initial sample). Socio-demographic factors may have a different relationship with mental health post and pre-retirement age. Thus, in this study, we focus only on adults who were under 65 years at time of data collection (n = 2609). We were missing information on country of birth for 4 individuals. Analyses were therefore based on a total of 2605 individuals. All data collection was conducted in English. Full details of the NWAHS study and data collection procedures have been extensively described elsewhere [27, 28].

We found no interactions between English-speaking background and any of the variables in the final models for either men or women, suggesting that these variables did not relate to mental health measures in significantly different ways for ESB-FB and NESB-FBs.

This study aimed to investigate differences in mental health and service use between AB and FBs living in South Australia. As hypothesised, there were no differences between ABs and ESB-FBs on any of our measures. While we expected that NESB-FBs might have lower rates of diagnosed disorders, consultations and medication, we hypothesised that rates of current depression would be higher. This was only partially supported; higher rates of depression were observed among NESB-FB men but not among NESB-FB women. Contrary to expectations, diagnoses were also higher among NESB-FB men compared with AB men, although general health partially explained this difference. In line with recent research, we found no evidence of the healthy migrant effect for mental health in this study [15, 16]. The majority of participants in the current study were however, well-established in Australia; only 3% had lived in Australia less than 10 years. Any initial health benefits in the current sample may have deteriorated, though other recent research found no effect among FBs with shorter length of stays either [15].

In contrast to previous studies suggesting that NESB-FBs may utilise mental health services to a lesser extent than ABs [2], we found no differences between ABs and FBs’ consultation rates. Because NESB-FB men were more likely to have poorer mental health, it may suggest that men in this group do not access treatment equally according to need. Men are often reluctant to seek help for mental health problems [32] and foreign-born report a number of barriers to care including language difficulties [3, 33]. NESB-FB men may therefore need to overcome greater hurdles to access care compared with the other groups. Consideration should be given to ways of making mental health care more accessible for foreign-born men in particular.

Due to the secondary nature of this study, we were limited in the explanatory factors we could adjust for and as a result, the reasons why NESB-FB men are at heightened risk of poor mental health compared with ABs are not clear from this study. Previous research however, has linked to poor mental health among FB men in Australia to factors such as discrimination, pre-migration experiences and social support [16, 20]. It should also be noted that the NESB-FB group is very heterogeneous, coming from a range of different countries and cultures. There is likely to be large within group variation but we lacked the power to investigate differences by country or world region.

For women, there were no differences in mental health status or treatment rates, suggesting that FB women have similar levels of access to care as ABs according to need. This finding is encouraging, although may only be applicable to those with longer lengths of stay. Further, all were proficient enough in English to participate in the study; those who may experience the greatest barriers to care and the poorest mental health may have been excluded. Nonetheless, an interpreter service is available through the Australian health care system.

Although not statistically significant, NESB-FB women were less than half as likely to be on medication as AB women. Lower rates of anti-depressants have been found among immigrants compared with natives in other countries [34]. Mental health problems can be perceived differently across cultures, which can lead to varying ideas about the type of treatments, if any, that are appropriate [35]. Some NESB-FB women may prefer to seek other ways of dealing with mental health conditions.

Women typically report more distress than men [18] and our findings for ABs and ESB-FBs confirmed this. However, in this study, foreign-born men from a non-English-speaking background had notably similar rates of depression as their female counterparts and even higher rates of diagnosis. We did not directly investigate these gender differences and so can only speculate as to the reasons for this difference. NESB-FB men in this sample were less likely to be married than NESB-FB women. Further, marriage and living with others were important protective factors for FB men but not FB women. In general, women more often report friends and relatives as sources of support, while men more often report their spouses as their main source [36]. Upon migration, immigrants experience significant social disruption, loss of social network and often, extended family [37]. Support from one’s spouse may therefore become even more paramount. Mental health promotion campaigns which improve immigrant men’s social networks may be beneficial. For all groups, we found that those with fair or poor general health were more likely to report current depression compared with those with better health. General health also related to a mental health diagnosis among AB men and women in the same way. This consistent association is unsurprising as co-morbidity between general health and mental health is well-documented [38, 39]. NESB-FB men’s poorer general health status relative to AB men’s explained some of the difference in diagnosis. Although the causality is not known, it is conceivable that interventions aiming to improve the general health of NESB-FB men could also improve their mental health.

Being unemployed (or ‘other’) also had a strong association with mental health for AB and FB men and women. Unemployment has long been associated with poor mental health [40]. As with all other associations reported, the causal direction cannot be determined due to the cross-sectional nature of the study, though it is thought to be bidirectional [41, 42]. Unemployment is typically found to have more adverse effects on men’s than women’s mental health [42] but associations were strong among both men and women in the current study. However, we also observed that not being in the workforce was associated with higher odds of depression for AB men. This may relate to conventional gender roles: men who are not in employment may experience a loss of status and greater social stigma due to societies’ expectations. Stay-at-home men who otherwise closely adhere to the traditional masculine gender role may be at heighted risk of poor mental health [43].

As well as employment, this study benefited from the inclusion of income and education as measures of SES. Income appeared to be an important variable for ABs but the relationship was weaker and less consistent for FBs. This may be because foreign-borns, particularly those with a non-English speaking background may predominate in low paid jobs and can experience difficulties in obtaining jobs that match their level of qualification [44]. Yet, education was not strongly related to the measures of mental health for FBs either; it was associated only with having diagnosis for FB women and consultations for FB men. These findings confirm the complexity of the relationship between SES and mental health among FBs [22, 23, 25].

In addition to the sampling limitations mentioned above, this study also excluded people without a telephone or who were not listed in the White pages. However, since 97% of households in the study region have telephones, this is not likely to have significantly affected the representativeness [45]. While the attrition rate of around 10% from stage 1 of recruitment to stage 2 of the study may be a concern, since those with poorer mental health may have been more likely to drop out, there was little difference in attrition rates across the three groups (AB, ESB-FBs and NESB-FB). The validity of the comparisons made in this study is therefore unlikely to have been significantly compromised. All variables of interest were self-reported, which may be vulnerable to socially-desirable responding. This may be heighted among FBs, who may worry that reporting poor mental health will affect their residency status. However, most FBs in this sample were already well-established in Australia so this may be less of an issue.

The study benefits from using multiple measures of mental health, which has allowed us to explore differences in AB and FBs’ mental health status and treatment, as well as identify different variables that relate to different measures. Unlike other Australian studies, it also investigates men and women separately. The weightings applied in the study should make the results generalizable to the wider population in urban South Australia.

In general, the findings are positive in that FBs appear to access mental health services to a similar degree as ABs. NESB-FB men in this study, however, are at increased risk of mental health problems but do not have higher levels of treatment than AB men. Thus, there may be a need to increase the awareness of mental health problems and help-seeking among this group, particularly among unmarried, unemployed NESB-FB men who live alone. These risk factors also suggest the importance of social support in protecting against mental health problems for NESB-FB men in particular.