ALTHOUGH the United States is home to more than 3 million immigrants from the Middle East,1,2 they have received little attention in public health research.* The few studies conducted on this population have focused mainly on their physical health rather than psychological health.2–4 Middle Eastern (ME) immigrants experience unique challenges acculturating to the US mainstream society, including diverse cultural backgrounds and discrimination related to the September 11 events, which have been shown to significantly influence their psychological well-being.5,6 The relatively few studies that examine psychological health outcomes of ME immigrants show that they are at risk of psychological health problems.6–10
Recent research on the health of other US immigrant groups suggests that immigrants tend to arrive to the United States healthier than their US-born counterparts, a phenomenon known as “healthy immigrant effect.” Researchers speculate that the initial health advantage of immigrants is due to positive selection of healthy migrants, “cultural buffering,” and healthier lifestyles from their homeland.11–13 However, immigrant health deteriorates and converges to US-born levels the longer they stay in the United States, indicating a duration effect. Yet, this pattern has been less clear in the area of mental health. Studies have shown a high prevalence of serious psychological distress (SPD), anxiety, and depression among immigrants, particularly women,13–17 as well as shown a strong association between increasing length of stay in the United States and these same psychological health outcomes.18–21 Despite a few exceptions,7,8,22 these studies have focused mainly on larger immigrant groups, such as Latinos and Asians, ignoring ME immigrants. Further research is needed to tease out the role of duration of stay and sex in mental health among this population.
Thus, the current study contributes to the literature in the following ways: (1) it is the first to investigate the association between duration of stay in the United States and SPD among ME immigrants; and (2) it is the first to examine whether this relationship varies by sex using nationally representative data from the 2002-2012 National Health Interview Surveys (NHIS). To better understand SPD among ME immigrants, this study addresses the following questions: (1) Does the SPD of ME immigrants differ significantly from that of US-born whites? (2) Does the SPD of ME immigrants differ from that of US-born whites when taking their duration of stay in the United States into account? (3) Do ME female and male immigrants differ significantly in SPD compared with US-born white females and males? (4) Does the SPD of ME female and male immigrants vary from that US-born white females and males when taking their duration into account?
Psychological health outcomes among immigrants in the United States
A wealth of research has examined racial and ethnic differences in psychological health.8,13,14,16,17,23,24 For example, Bratter and Eschbach13 demonstrated that Hispanics and African Americans experienced less psychological distress (PD) than non-Hispanic whites. Among Hispanics, whereas Mexicans reported lower odds of PD, Puerto Ricans reported the highest levels of PD. Several factors, including shifting economic, political, and social realities, influence variations in psychological problems across race and ethnicity. These factors may also impact use of mental health services and expression of psychological problems among these populations.25
Yet, findings have been inconsistent on how immigrants fare on this issue. For example, some studies show that Hispanic immigrants have higher odds of reporting PD than whites and African Americans.17,25–27 In contrast, other studies show that Hispanic immigrants have either lower or similar levels of PD compared with non-Hispanic whites.23,24 While studies show that, as a whole, Asian immigrants experience better mental health outcomes than non-Hispanic whites,28 these experiences may vary widely by country of origin. For example, Koreans tend to have higher rates of severe depression than Filipino, Japanese, and Chinese immigrants16,21 and higher rates of PD than whites.29
Despite the rapid rise in ME immigrants in the United States, there are few nationally representative studies that explore their psychological health. Multiple community-based studies, however, demonstrate that ME immigrants are at risk of mental disorders. For example, Amer and Hovey7 revealed that 50% of their nonprobability sample of 601 ME immigrants experienced depression whereas 25% of the sample reported moderate to severe anxiety. In addition, examining Iraqi refugees in the United States, Jamil and colleagues9 found that almost half (49%) of their sample suffered from depression. In related work, ME individuals reported higher rate of depression (23.2%) than African Americans (15%).10 The authors attributed the high rates of depression among ME individuals to several factors such as poor health, discrimination, fear of backlash after September 11, and the immigration process itself.
The only nationally representative study of ME immigrants' SPD has displayed similar findings.8 The authors found that ME immigrants reported higher odds of SPD than US-born whites. They were twice as likely to report SPD compared with European immigrants and 3 times more likely than Russian immigrants to report SPD. The aforementioned studies highlight the increased risk of psychological health problems in the ME population in the United States.
Duration of stay in the United States and psychological health
Prior studies have shown the negative impact of length of stay in the United States on various stress-related psychosocial outcomes such as distress, depression, and anxiety among various immigrant groups.8,20,21 For example, Cook et al30 found that longer duration in the United States is related to a higher risk of psychiatric disorders among Latino immigrants. However, non-Hispanic white immigrants living in the United States for 5 years or more were less likely to report SPD than more recent immigrants. Not surprisingly, the association between duration of stay in the United States and mental health among ME immigrants has been understudied. Recent findings have suggested that length of stay in the host country might be a risk factor for ME immigrants' psychological health.8 Given that an association between duration of stay in the United States and mental health among ME immigrants exists, it is surprising that scholars of immigrant health have not sincerely explored this relationship and whether it differs by sex.
Sex differences and psychological health among US immigrants
Sex has been reported to have a strong relationship with psychological health and well-being, especially among recent immigrants.15,16,19 The immigration process is characterized by an experience of the continuous tension that results from entering a new culture. This tension impacts the mental health of all immigrants, although women's experiences are more acute.31 Often, this tension is reflected in symptoms of depression, stress, and anxiety among immigrant women.
Examining mental health of 8 racial/ethnic groups in the United States, Bratter and Eschbach13 found that women tended to report high levels of distress. Likewise, Franks and Faux15 found high levels of depression among Chinese, Vietnamese, Portuguese, and Latin American immigrant women. Female immigrants from the Former Soviet Union and from Korea also tend to report high rates of depression than other immigrant groups and their male counterparts.32,33 These findings can be explained by an argument in prior research that holds that women who live between 2 cultures are more vulnerable to psychological health problems because of conflicts among the many roles they attempt to fill.31
A handful of community-based studies examined psychological health outcomes of ME immigrant women in the United States, although they yielded inconsistent findings. On the one hand, some studies suggested that ME women are at increased risk of psychological health problems such as loneliness, sadness, emotional distress, and anxiety.31,34 On the other hand, other studies found no statistically significant differences between ME female and male individuals with regard to depression, acculturative stress, and level of happiness.6,7 To date, no nationally representative studies have differentiated between psychological health outcomes of ME immigrant men and women.
This research suggests a gap in empirical studies that explore the relationship between duration of stay in the United States, sex, and psychological health outcomes among ME immigrants. Drawing from literature that suggest an immigrant health advantage in the area of mental health as well as variations by sex, we predicted that ME immigrants would experience increased SPD compared with non-Hispanic whites, although this relationship would vary by duration of stay in the United States and sex.
DATA AND METHOD
To test the link between duration and SPD, we used pooled data from the 2002-2012 NHIS, a multipurpose health survey conducted annually by the National Center for Health Statistics and Centers for Disease Control and Prevention and administered by the US Census Bureau. The NHIS is a multistage, stratified cluster sample that is designed to collect information on the noninstitutionalized, civilian population in the United States. Using face-to-face interviews, data on health and other characteristics are collected for all individuals of sample households.
Starting in 2000, the NHIS included a question about global region of birth. This, in turn, helps distinguish the ME immigrant population. Because of the small number of ME immigrants interviewed in any given year, we combined data from 2002 to 2012. Analyses mainly draw data from the sample adult files of individuals 18 years and older. We also linked these files with their corresponding personal, household, and family files, when necessary. The analyses are based on US-born, non-Hispanic whites (n = 157 028) and ME immigrants (n = 893), for a total sample size of 157 921.
Serious psychological distress
SPD includes “mental health problems severe enough to cause moderate-to-serious impairment in social, occupational, or school functioning and to require treatment.”35(p.2) SPD is assessed with the Kessler (K6) scale, a validated population screening tool addressing nonspecific PD. It consists of 6 items.† Respondents were asked how often, during the last 30 days, they felt: “so bad that nothing could cheer them up,” “nervous,” “restless or fidgety,” “hopeless,” “that everything was an effort, and “worthless.” Respondents answered, based on a 5-point Likert-type scale: “none of the time,” “a little of the time,” “some of the time,” “most of the time,” or “all of the time.” Item responses are coded from 0 to 4, yielding a total score on the scale from 0 to 24. Similar to prior studies,8,17,35 we use the cutoff of 13 or greater to distinguish individuals with SPD.‡
The key independent variables are ethnicity and duration. Individuals born in the United States, non-Hispanic, and white are classified US-born whites (reference category). Those who reported being born in the Middle East are classified ME immigrants (coded 1). Duration is measured by length of stay in the United States. The NHIS asked foreign-born respondents to report their length of residence into 5 categories. Similar to Lopez-Gonzalez and colleagues,12 we created a binary variable where those who have been in the United States for less than 10 years are coded as “0” and those who have been in the United States for 10+ years are coded as “1.” We then constructed a new variable of 3 categories: ME immigrants who have been in the United States for less than 10 years (coded 1; shorter duration), ME immigrants who have been in the United States for 10+ years (coded 2; longer duration), and US-born non-Hispanic whites as the reference category. In addition, we controlled for citizenship status (noncitizen = 0).
We also controlled for other factors shown to be associated with duration and SPD, including health behavior, body mass index (BMI), health care utilization, as well as socioeconomic and demographic variables. Health behavior was measured using smoking status (do not smoke = 0 and current smoker = 1) and BMI (underweight and healthy weight [BMI < 25 = 0], overweight [25 ≤ BMI < 30 = 1], and obese [BMI ≥ 30 = 2]). Health care utilization was measured using health insurance coverage (covered = 1) and having a usual place to go to when you feel sick (yes = 1). Socioeconomic status (SES) is operationalized as family income (≤$34 999 = 0; $35 000-$74 999 = 1; $75 000 and above = 2), homeownership (own their home = 1), and education (less than high school/no diploma = 0; high school graduation/some college = 1; college and advanced degree = 2). Finally, we controlled for demographic variables including respondent's age (in years), sex (female = 1), marital status (married = 1), family size, and region of residence in the United States (Northeast = 0, Midwest = 1, South = 2, and West = 3).
The analysis is divided into 4 parts. We first present bivariate percentage distributions and 2-tailed χ2 tests showing variations in each variable by nativity/race—US-born whites versus ME immigrants (Table 1). Table 2 presents a series of binomial logistic regressions§ to model the association between duration and SPD among ME immigrants, comparing them with US-born whites. Table 3 shows a descriptive analysis of basic sex differences with regard to SPD differences by nativity. To assess whether the association between duration and SPD varies by sex, we offered separate models stratified by sex, followed by a pooled model with interaction terms for duration and sex (Table 4). The analyses are adjusted for a sampling design that includes using the weighted estimates and taking strata and clusters into account to calculate standard errors. Data analyses were conducted in SAS 9.3. We used listwise deletion to deal with the missing values.¶
Table 1 represents the χ2 tests of independence for US-born whites and ME immigrants. Compared with US-born whites, ME immigrants are slightly (but not statistically significant) more likely to report SPD. Compared with US-born whites, ME immigrants tend to be younger, have more children, and are more likely to be married, live in the Western region of the United States, and have a college or an advanced degree compared with US-born whites. However, they report lower income on average and lower homeownership. In addition, compared with US-born whites, ME immigrants are less likely to be obese, current smokers, have health insurance, and have a usual place to seek medical care. Finally, the majority of ME immigrants have resided in the United States for 10+ years (70%) and are naturalized citizens (62.93%).
Duration of stay in the United States and SPD
Table 2 shows a series of binary logistic regression models estimating SPD. In model 1, we compare ME immigrants as a group to US-born whites, without taking duration into account. This model shows that ME immigrants have 40% higher odds of reporting SPD compared with US-born whites when adjusting for basic demographic variables. Yet, a different story emerges in model 2 when taking duration status into consideration. ME immigrants who have been in the United States for <10 years have lower odds of reporting SPD compared with US-born whites. In contrast, ME immigrants who have resided in the United States for 10+ years have 80% higher odds of reporting SPD compared with US-born whites, controlling for the same variables as model 1. Results from model 2 imply that the significant difference between the 2 groups in model 1 is, in fact, due to the difference between the ME immigrant with longer duration and US-born whites.
Adjusting for SES and education in model 3 results in substantive changes, with ME immigrants with shorter duration exhibiting 61% lower odds of SPD than US-born whites. The odds ratio for ME immigrants with 10+ years duration is reduced by 27%. These findings highlight the substantial influence of SES and education on SPD and suggest that SES variables mediate the relationship between duration and SPD.
When introducing health behavior and health care utilization variables in model 4, the significant difference between ME immigrants with less than 10 years' duration and US-born whites diminishes and the odds ratio of SPD for ME immigrants with 10+ years duration increases by 19%. These findings suggest that both smoking and having an unhealthy BMI are highly associated with an elevated risk of SPD. Results also show that while individuals with health care coverage are less likely to report SPD, those who have places to go for care are significantly more likely to report SPD than their counterparts. Findings from model 4 suggest that health behavior variables mediate the relationship between duration and SPD.
Taken together, these results show that ME immigrants have higher odds of SPD than US-born whites. Also, longer duration of stay in the United States of ME immigrants is associated with higher odds of reporting SPD than US-born whites.
Descriptive analysis by sex
Table 3 highlights key differences between US-born whites and ME immigrants by sex. Women in both groups are significantly more likely to report SPD than their male counterparts. The sex gap for SPD is clearly much wider for ME immigrants than for US-born whites. On average, women in both groups are older and significantly more likely to be married than their male counterparts. While ME men are significantly more likely to have a higher educational degree than ME women, there is no significant difference between the 2 groups with regard to their SES. Although ME women are less likely to fall into the overweight BMI category, they are more likely to be obese than their male counterparts. ME immigrant women are more likely to have resided in the United States for 10+ years and to be naturalized citizens than their male counterparts.
Taken as a whole, these findings suggest that there are large sex differences among ME immigrants, with men tending to be psychologically healthier than their female counterparts. These sex differences suggest that ME men and women might respond differently to immigration's challenges.
Duration of stay in the United States and SPD by sex
Table 4 shows the odds ratios of predicting SPD comparing ME immigrant women with US-born white women and ME immigrant men with US-born white men, following the same model sequence as Table 2. In addition, this table uses the interaction term between duration status and female to determine whether the relationship between duration and SPD varies by sex. Indeed, this table provides a substantially different picture than Table 2. As shown in model 1, although the odds of SPD for ME immigrant men do not statistically differ from their US-born counterparts, ME female immigrants report significantly higher odds of SPD than US-born white females.
However, in model 2, when looking at differences by duration status, the results change substantively. For instance, SPD of ME immigrant men, regardless of their duration status, do not differ significantly from that of US-born males In contrast, ME females with 10+ years duration have significantly higher odds of reporting SPD than US-born white women.
Table 4 also shows that sex differences among ME immigrants and their US-born counterparts with respect to SPD persist across the 3 models (models 2-4). For example, after controlling for SES and education in model 3, the association between ME immigrant men with shorter duration and US-born white men becomes marginally significant (P = .09) and the odds ratio for ME immigrant women with longer duration is reduced by 20%.
In addition, introducing health behavior and health utilization variables in model 4, slightly increases the odds ratios of SPD for ME males and considerably increases the odds ratios of SPD for ME females. Nonetheless, only ME female immigrants with 10+ years' duration are significantly more likely to report SPD than US-born white females. Findings from models 3 and 4 suggest that SES and health behavior variables mediate the association between duration and SPD.
The final model of Table 4, the interactive model, tests whether the large differences in the odds ratios between male and female groups is statistically significant. Although the odds ratios for the interaction term of ME female immigrants with less than 10 years' duration attain no statistical significance, the odds ratios of the interaction term of ME female immigrants with longer duration attain crucial statistical significance. These findings suggest that the relationship between duration and SPD diverges by sex. The Figure displays these results graphically in the form of predicted probabilities.
Overall, findings from Table 4 show that results from Table 2 are deceptive and that the significant difference among ME individuals with longer duration and their US-born counterparts is in fact due to the differences between ME immigrant women with longer duration and US-born white women.
DISCUSSION AND CONCLUSION
Using nationally representative data from the 2002-2012 NHIS, the current study is the first to examine the association between duration of stay in the United States and SPD among ME immigrants and assess whether this relationship varies by sex. Results from the current study support previous research findings that show women are more likely to report psychological health problems than their male counterparts26,35 and US-born whites.13,15,16,32,33
Importantly, we find evidence of a negative duration effect on SPD among ME immigrants. That is, whereas ME immigrants with short duration are less likely to report SPD, ME immigrants with longer duration are more likely to report SPD than US-born whites. This aligns with studies on the healthy immigrant effect, where immigrants tend to arrive to the United States healthier, although deterioration occurs over time spent in the United States.11,12 Broken down by sex, we find that ME immigrant women report higher odds of SPD than their male counterparts. Particularly, we find clear duration differences among female immigrants, with ME immigrant women who have been in the United States for less than 10 years are less likely to report SPD than US-born whites whereas ME immigrant women who have been in the United States for 10+ years are significantly more likely to report SPD than US-born whites. Among men, the relationship between duration of stay in the United States and SPD, compared with US-born whites, is not statistically significant. In conclusion, these results are in accordance with previous studies that point to the importance of considering sex differences when assessing for psychological health outcomes.13
What explains the higher odds of SPD among ME immigrant women with longer duration? These patterns may be due to “the stigma associated with having a mental illness in the ME culture” particularly among women.8(p1927) ME immigrants are significantly less likely to report visiting a mental health professional in the last 12 months than US-born whites (results not shown). Another explanation could be that the discrimination that some ME immigrant women face in the US society—most ME immigrants are identifiable by their names and appearance (wearing veil/head cover and conservative clothes)—may have a negative influence on their psychological health. A final and major explanation could be the role overload that ME immigrant women have as mothers, wives, and sometimes employees, which puts more burden on ME women and elevates their levels of stress and psychological problems.31
Despite the significance of the abovementioned findings, the current study has several limitations. Most imperative is that the NHIS is a cross-sectional survey, meaning that it does not allow for causal inferences. As such, it cannot be concluded that the duration status of ME immigrants in the United States causes SPD. Although the current study reveals an association between duration and SPD among ME immigrants in the United States, we cannot determine whether or not this relationship changes over time. Another potential limitation is the measurement of SPD and the low levels of SPD in our sample. Nonetheless, the prevalence of reporting SPD was comparable with findings in previous studies among the US population.14,17 Furthermore, prior research highlights the association between discrimination and high rates of psychological health problems among ME immigrants, but the NHIS does not include measures of discrimination. Thus, the relationship between post-September 11 discrimination and psychological health among ME immigrants is unknown. Finally, because of NHIS confidentiality, we could not differentiate ME immigrants by country of origin, which would have been beneficial in these analyses, given the heterogeneity of this population.
Regardless of these limitations, this study has many strengths. The findings are unique because they draw from multiple years of a nationally representative sample to tease out disparities among a group that has been neglected in the immigrant health literature for decades. The findings reveal that important implications for policy makers and social service providers create programs and/or policies that improve health outcomes among this population.37 Specifically, these findings address the importance of considering and evaluating the role of duration of stay in the United States when counseling ME immigrant women on their psychological health.38
Although the current study significantly expands the literature on immigrant psychological health, additional research is needed to explain the relatively high rate of SPD among ME immigrant women with longer duration in the United States, including structural, cultural, and discriminatory factors. Finally, more theoretical and empirical studies should examine the effect of the physical health of ME immigrants on their psychological well-being. Such studies will provide researchers and service providers with much-needed information concerning the psychological health of ME women in the United States.
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* The National Health Interview Survey (NHIS) refers to Middle Easterners as those who trace their ancestry to Aden, Arab Palestine, Arabia, Bahrain, Gaza Strip, Iraq, Jordan, Kuwait, Syria, Lebanon, “Middle East,” Oman, Palestine, Qatar, Saudi Arabia, Syria, United Arab Emirates, West Bank, Yemen, Armenia, Cyprus, Iran, Israel, Persia, and Turkey.
† In 1994, Kessler and his colleagues designed and validated the K6 scale to measure nonspecific psychological distress (NSPD) over the past 30 days. The K6 has been included in the NHIS core sample adult questionnaire since 1997. Several other national surveys such as the annual National Household Survey on Drug Abuse and World Mental Health (WMH) include Kessler's K6 scale to measure NSPD (see Kessler et al, 2003).36
‡ “The optimal cut point on the K6 to equalize false-positive and false-negative results in the weighted sample was 0 to 12 versus 13 or more (coding in the responses 0-4 and summing items to yield a scale with a 0-24 range). At this cut point, sensitivity (SE) was 0.36 (0.08), specificity was 0.96 (0.02), and total classification accuracy was 0.92 (0.02).” See Kessler et al (2003:p188) for more details.
§ We also ran sensitivity analyses using multiple regression model techniques to examine the relationship between duration status and NSPD, a summative measure that ranges from 0 (none of the time) to 24 (all the time). In addition, we examined whether this relationship varies by sex. Using the same models, results were similar to those presented in this study. Thus, we opted to present results using binary logistic regressions.
¶ It is arguable that listwise deletion affects statistical power of the tests conducted. Accordingly, for robustness, we computed the same series of models using multiple imputation procedures in SAS, which yielded similar substantive results.
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved
duration of stay in the United States; Middle Eastern immigrants; serious psychological distress; sex