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I Acculturation and Health Outcomes Among Vietnamese Immigrant Women In Taiwan Yung Mei Yang Queensland University of Technology School of Nursing
I
Acculturation and Health Outcomes Among Vietnamese Immigrant Women
In Taiwan
Yung Mei Yang
Queensland University of Technology School of Nursing
II
III
Queensland University of Technology
School of Nursing Faculty of Health
Institute of Health and Biomedical Innovation
Acculturation and Health Outcomes Among Vietnamese Immigrant Women
In Taiwan
Yung-Mei Yang
RN, BA, MS
This thesis is submitted to fulfil the requirements for
Degree of Doctor of Philosophy at the
Queensland University of Technology
2008
IV
Statement of Original Authorship
“The work contain in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To
the best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.”
Signature:……………………………………….
Date:……………………………………………..
V
Scholarships/ Awards
1. Research Scholarship, Grand-in Aid Scholarship for international conference(2007)
Queensland University of Technology, Australia.
2. Research Project Funding, National Science Council of Taiwan. (2007-2009)
Participatory action research of acculturation and health promotion strategies
among SEA new immigrant women in Taiwan.
3. Research Scholarship, Write up Publications Scholarship (QWU)(2008)
Queensland University of Technology, Australia.
4. Nominate “Outstanding Thesis Award” (2008) Queensland University of
Technology, Australia.
Publications for preparation (2008)
1. Yang, Y.M. Anderson, D., Wang, H.H., & Barr, J. (2008). Globalized vs.Marginalized
Women: The relationships between acculturation, socio-demographic factors, and
health-related quality of life among Vietnamese migrant brides in Taiwan. Journal of
Nursing Scholarship (SSCI,Impact Factor: 1.25 Journal citation reports 2007)
2. Yang, Y.M. Anderson, D., Wang, H.H., & Barr, J. (2008). Predicting psychological
distress among Vietnamese marriage migrant women in Taiwan: A classification
and regression trees (CART) model. International Journal of Nursing Studies.
(SSCI,Impact Factor - 1.07. Journal citation reports 2007).
3. Yang, Y.M. Anderson, D., Wang, H.H., & Dulp, R. (2008). Marriage Immigration: A
cross-cultural comparison of health related quality of life among Vietnamese
female immigrants and Taiwanese women. Quality of Life Research, SSCI
(SSCI,Impact Factor: 2.0 Journal citation reports 2007)
VI
Key Words
Acculturation
Immigrant women
Foreign brides
Women’s health
Short form 36 (SF-36)
Health Related Quality of Life (HRQOL) .
The Suinn-Lew Asian Self-Identity Acculturation Sca le (SL-ASIA).
The Demand of Immigration Specific Distress Scale ( DIS)
Classification and Regression Trees (CART)
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ACKNOWLEDGMENTS
My life experiences during these years in Australia are meaningful and
unforgettable. I would like to thank my supervisory team, Professor, Debra
Anderson, Dr.Jenniffer Barr, and Professor Hsiu-Hung Wang who formed the
foundation for which I dedicate my dissertation. Professor Debra Anderson has
been unfailingly patient, supportive, encouraging, and endlessly generous with
her knowledge and expertise in research. Her commitment to high standards
inspired me to put forth my best efforts, and her gifts as a teacher ensured that
every step of the process was a valuable learning experience. Dr.Jenniffer Barr
whose unique focus gave me the direction and encouragement to successfully
complete this endeavor. Her expertise in women’s health was valuable to my
research. Professor Hsiu-Hung Wang 王 秀 紅 was my external associate
supervisor who has been a mentor and a positive role model in my
professional pursuits since I began studying a master degree in Kaohsiung
Medical University. She generously provided the research resources in Taiwan
to further help my project.
I wish to express my deep gratitude to Professor 鍾信心 whose generosity in
providing the scholarship helped me to counter the economic difficulties and
encouraged me to complete my PhD study.
IX
This dissertation research could not have been completed without the
contributions of many people. I would like to thank my brilliant PhD colleagues
for their intellectual inspiration and thoughtful suggestions on the research
subjects from a cultural perspective; John Robertson correcting and directing
my writing. I would like to thank Dr. Ray Dulp for sharing his knowledge and
experience with statistical analysis. I sincerely extend my appreciation to
research participants for their enthusiastic assistance and coordination
throughout the data collection process without their assistance; this study could
not have been completed on time.
I wish to express my deep gratitude to my partner Peng Guan who has walked
this journey with me. His love and compassion sustained me when I felt low
and frustrated because of the demands of my study. I could not have reached
this goal nor endured the process without love and support of my families.
Thank you all for your patience and encouragement when I most needed it.
Especially my parents who took care my cherished children, Kevin, Esther, and
Moses with enduring love and compassion while I studied in Australia and
supported my academic dream coming true in my mid-life.
This study was supported by the following grants: a QUT PhD student support
grant; a QUT publication write-up grant; and grants from the National Science
Council of Taiwan (NSC 96 -26 28-B-037-041-MY2). The author appreciates
the help from the grants.
X
Acculturation and Health Outcomes Among Vietnamese Immigrant Women
In Taiwan
Abstract
Background Recently, Taiwan has been faced with the migration of numbers of women
from Southeast Asian (SEA) countries. It was estimated that the aggregate
number of SEA wives in Taiwan was more than 131,000 in 2007 (Ministry of
Foreign Affairs, 2006).These women are often colloquially called, “foreign
brides” or “alien brides”; most of them are seen as commodities of the marriage
trade, whose marriages are arranged by marriage brokers. Some women can
be regarded as being sold for profit by their families.
These young Vietnamese immigrant women come to Taiwan alone, often with
a single suitcase, and are culturally and geographically distinct from Taiwanese
peoples; the changes in culture, interpersonal relationships, personal roles,
language, value systems and attitudes exert many negative impacts on their
health, so greater levels of acculturation stress can be expected. This
particular group of immigrant women are highly susceptible and vulnerable to
health problems, due to language barriers, cultural conflicts, social and
interpersonal isolation, and lack of support systems. The aims of this study
were to examine the relationships between acculturation and immigrant-
specific distress and health outcomes among Vietnamese transnational
married women in Taiwan. This study focuses on Vietnamese intermarriage
immigrants, the largest immigrant group in the period from1994 through to
2007.
XI
Methodology
The quantitative study was divided into two phases: the first was a pilot study
and the second the main study. This study was conducted in a community-
based health centre in the south of Taiwan, targeting Taiwanese households
with Vietnamese wives, including the Tanam, Kaohsiung, and Pentong areas.
This involved convenience sampling with participants drawn from registration
records at the Public Health Centre of Kaohsiung and used the snowball
technique to recruit 213 participants. The instruments included the following
measures: (1) Socio-demographic information (2) Acculturation Scale (3)
Acculturative Distress Scale, and (4) HRQOL. Questions related to immigrant
women’s acculturation level and health status were modified. Quantitative data
was coded and entered into the SPSS and SAS program for statistical
analysis. The data analysis process involved descriptive, bivariate, multi-
variate multiple regression, and classification and regression trees (CART).
Results
Six hypotheses of this study were validated. Demographic data was presented
and it revealed that there are statically significant differences between levels of
acculturation and years of residency in Taiwan, number of children, marital
status, education, religion of spouse, employment status of spouse and
Chinese ethnic background by Pearson correlation and Kendall’s Tau-b or
Spearman test. The correlations of daily activity, language usage, social
interaction, ethnic identity, and total of acculturation score with DI tend to be
negatively significant. In addition, the result of the one-way ANOVA supported
the hypothesis that the different types of acculturation had a differential effect
on immigrant distress. The marginalized group showed a greater immigrant
distresses in comparison with the integrated group.
Furthermore, the comparison t-test revealed that the Vietnamese immigrant
women showed a lower score than Taiwanese women in HRQOL. The result
XII
showed higher acculturative stress associated with lower score of HRQOL on
bodily pain, vitality, social functioning, mental health, and mental component
summary. The CART procedure to the conclusion that the predictive variables
for the physical component of the SF-36 (PCS) were: alienation, occupation,
loss, language, and discrimination (predicted 28.8% of the total variance
explained). The predictive variables for the mental component of the SF-36
(MCS) were: alienation, occupation, loss, language, and novelty (predicted
28.4% of the total variance explained).
Conclusion
As these Vietnamese immigrant women become part of Taiwanese
communities and society, the need becomes apparent to understand how they
acculturate to Taiwan and to the health status they acquire. The findings have
implications for nursing practice, research, and will assist the Taiwanese
government to formulate appropriate immigrant health policies for these SEA
immigrant women. Finally, the application of this research will positively
contribute to the health and well being of thousands of immigrant women and
their families.
XIII
XIV
TABLE OF CONTENTS
CHAPTER 1 INTRODUCTION……………………………………………………1
INTRODUCTION .................................................................................................... 1
1.1 Background of the Study ............................................................................. 1
1.1.1 “Foreign Bride” Phenomena in Taiwan ................................................ 3
1.1.2 Health Issues among “Foreign Brides” in Taiwan ................................ 4
1.2 Purpose of this Study................................................................................... 6
1.2.1 Research Questions............................................................................ 6
1.2.2 Research Aims and Objectives ........................................................... 6
1.2.3 The Research Hypotheses.................................................................. 7
1.3. Research Framework ................................................................................. 9
1.4. Research Significance .............................................................................. 12
1.4.1 The Scope of Acculturation and Nursing Research ........................... 12
1.4.2 Research Outcomes and Contributions............................................. 14
1.5. Definition of Terms.................................................................................... 15
CHAPTER 2 LITERATURE REVIEW …………………………………………..17
INTRODUCTION .................................................................................................. 17
2.1 Migration and Women’s Health.................................................................. 17
2.1.1 Migration ........................................................................................... 17
2.1.2 Migration and Women’s Heath .......................................................... 18
2.1.3 Southeast Asian Foreign Brides in Taiwan........................................ 20
2.2 Acculturation.............................................................................................. 24
2.2.1 Definition of Acculturation.................................................................. 25
2.2.2 Acculturation Theories ...................................................................... 27
2.2.3 Psychological Acculturation............................................................... 28
2.2.4 Acculturative Stress .......................................................................... 30
2.2.5 Acculturative Stress and Psychological Health.................................. 30
2.2.6 Berry’s Acculturative Stress Model.................................................... 31
2.3 Factors Influencing Acculturation ............................................................... 35
2.3.1 Gender and Acculturation.................................................................. 35
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2.3.2 Socio-demographic Status ................................................................ 36
2.3.3 Length of Residence in the Host Country .......................................... 37
2.3.4 Characteristics of the Host Society.................................................... 37
2.3.5 Social Support................................................................................... 38
2.3.6 Language Proficiency........................................................................ 41
2.4 Acculturation and Health Outcomes........................................................... 42
2.5 Measurement of Acculturation ................................................................... 44
2.6 Measurement of Health Outcomes ............................................................ 47
2.6.1 Health Related Quality of Life (HRQOL)............................................ 48
2.6.2 Acculturative Distress........................................................................ 49
2.6.3 Psychological Well-being .................................................................. 51
2.7 Current Studies in Taiwan.......................................................................... 52
2.8 Summary ................................................................................................... 53
CHAPTER 3 METHODOLOGY………………………………………………….55
INTRODUCTION .................................................................................................. 55
3.1 Research Design ....................................................................................... 55
3.2 Sampling Recruitment and Sample Size.................................................... 56
3.2.1 Sample Recruitment.......................................................................... 56
3.2.2. Sample Size Estimation ................................................................... 57
3.3.3 The Participants ................................................................................ 57
3.3.4 Data Collection.................................................................................. 58
3.3 Instrumentation.......................................................................................... 58
3.3.1 Socio-demographic Information......................................................... 59
3.3.2 Acculturation Measurement............................................................... 59
3.3.3 Acculturative Stress Measurement.................................................... 61
3.3.4 Health Outcomes Measurement........................................................ 64
3.3.5 Instrument Translation ...................................................................... 69
3.4 Data Management ..................................................................................... 70
3.4.1 Data ManagementProcedures………………………………………..…..70
3.4.2 Data Analysis Procedures ................................................................. 70
3.5 Ethical Statement ...................................................................................... 74
3.6 Summary ................................................................................................... 75
CHAPTER 4 PILOT STUDY……………………………………………………..77
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Introduction...................................................................................................... 77
4.1 Phase 1 Study ........................................................................................... 77
4.1.1 Pilot Study......................................................................................... 78
4.1.2 Sample Recruitment Strategies & Procedure .................................... 78
4.1.3 Instrument Translation ...................................................................... 78
4.1.4 Face Validity of the Instruments ........................................................ 79
4.2 Results of Pilot Study................................................................................. 80
4.2.1 The Acculturation scale..................................................................... 82
4.2.3 The Demands of Immigrant Stress (DI )Scale ................................... 83
4.2.4 The Health Related Quality of Life (HRQOL)-The SF-36................... 85
4.3 Discussion ................................................................................................. 86
4.3 Summary ................................................................................................... 86
CHAPTER 5 RESULTS………………………………………………………………..87
INTRODUCTION ...............................................................................................…87
5.1 Descriptive Data Analysis .......................................................................... 87
5.1.1 Characteristic of the Participant......................................................... 87
5.1.2 Characteristic of the Spouse ............................................................. 91
5.2 Study Instrument ....................................................................................... 94
5.2.1 Acculturation Scale……………………………………… ...................... 96
5.2.2 Demand of Immigration Specific Distress Scale ............................... 97
5.2.3 Health Related Quality of Life – SF36 .............................................. 97
5.3 Result of the Hypothese ............................................................................ 98
5.3.1 Hypothesis..……..………………………………………………………….99
5.3.2 Hypothesis 2 ..................................................................................... 99
5.3.3 Hypothesis 3 .................................................................................... 98
5.3.4 Hypothesis 4………………………………………………………………106
5.3.5 Hypothesis 5 ....................................................................................111
5.3.6 Hypothesis 6 ....................................................................................115
5.4.Summary…………………………………………………………………………118
CHAPTER 6 DISCUSSION…………………………………………………………..121
INTRODUCTION .................................................................................................121
6.1 Characteristics of the sample....................................................................122
6.2 Discussion of Research Hypothesis One..................................................123
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6.3 Discussion of Research Hypothesis Two ..................................................125
6.4 Discussion of Research Hypothesis Three ...............................................129
6.5 Discussion of Research Hypothesis Four .................................................131
6.5.1 Acculturative Distress and HRQOL ..................................................133
6.5.2 Mental Health, Depression and Anxiety............................................133
6.5.3 Bodily Pain, Vitality, and Somatization .............................................135
6.5.4 Somatization ....................................................................................136
6.5.5 Cross-cultural Issues and Mental health...........................................137
6.5.6 Social Functioning and Social Isolation ............................................138
6.6 Discussion of Research Hypothesis Five: .................................................140
6.7 Discussion of Research Hypothesis Six....................................................143
6.7.1 Alienation .........................................................................................144
6.7.2 Language Accommodation and Health.............................................146
6.7.3 Occupational.Adjustment...................................................................147
6.7.4 Loss .................................................................................................149
6.7.5 Novelty.............................................................................................149
6.8 The Holistic View of Immigrant Women’s Health.......................................150
6.9 Conceptual Framework for Acculturation and Health ................................152
6.10 Summary ................................................................................................153
CHAPTER 7 CONCLUSION……………………………………………….……….155
INTRODUCTION .................................................................................................155
7.1 Advocacy for Immigrant Women’s Health .................................................155
7.1.1 Disadvantaged Population ...............................................................156
7.1.2 Health Advocacy for Disadvantaged Immigrant Women...................157
7.2 Implications and Recommendations .........................................................157
7.2.1. Nursing Practice..............................................................................157
7.2.2. Implications for Nursing Research...................................................162
7.2.3. Implications for Health Policy ..........................................................163
7.3 Suggestions for Future Research .............................................................164
7.4 Limitations of This Study...........................................................................168
7.5 Conclusion................................................................................................170
References ……………………………………………………………………………....172
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LIST OF FIGURES
Figure 1.1 Berry's acculturative stress model…………………………………………..9
Figure 1.2 The hypothesized model of this study……………………………………..11
Figure 2.1 The AISM model……………………………………………………………..33
Figure 3.1 SF-36 measurement model…………………………………………………66
Figure 4.1 Translation process of instruments………………………………………...79
Figure 4.2 Process for the Pilot study…………………………………………………..80
Figure 5.1 Histogram of three groups of acculturation………………………………..95
Figure 5.2 Histogram of three groups of acculturation………………………………104
Figure 5.3 Distributions of DI score across acculturative groups…………………..105
Figure 5.4 The mean Plot for degree of acculturation and mental health…………106
Figure 5.5 The SF-36 score of Vietnamese immigrant women.…………………….112
Figure 5.6 CART for identifying differential risks on mcs of SF-36…………………117
Figure 5.7 CART for identifying differential risks on pcs of SF-36………………….118
Figure 6.1 The conceptual framework of this study………………………………….153
Figure 7.1 Health promotion for immigrant women…………….………………….....161
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LIST OF TABLES
Table 3.1 Strategies for analysis of quantitative data for this study......................73
Table 4.1 Demographic characteristics of Vietnamese women…….…………..…81
Table 4.2 Socio-demographic variables of articipants…………………………..….81
Table 4.3 Internal consistency and reliability of scales.........................................82
Table 5.1 The means and SD of socio-demographic variables……………………88
Table 5.2 Frequency of socio-demographic variables of participants…………….89
Table 5.3 Frequency of socio-demographic variables of participants…………….90
Table 5.4 Frequencies of socio-demographic variables of spouse……………….92
Table 5.5 Internal consistency reliability of instruments (n=213)………………….94
Table 5.6 Means, standard deviations and ranges of Acculturation scales…......95
Table 5.7 Means, SD, ranges of DI scale……………………………………………96
Table 5.8 Means and standard deviation of Vietnamese SF-36 score…………...97
Table 5.9 Correlations of acculturation difference with socio-demographic
variables……………………………………………………………………101
Table 5.10 Bivariate correlations among acculturative distress…………………..102
Table 5.11 95% CI of pair-wise difference in mean change in DI Scale...............101
Table 5.12 Correlation matrix of level of acculturation and HRQOL………………104
Table 5.13 Correlation matrix of acculturation subscales and mental health…….108
Table 5.14 Correlation matrix of acculturative distress and HRQOL……………...109
Table 5.15 Regression analysis of acculturation and acculturative distress as
predictor for mental Health .................................................................112
Table 5.16 Comparison of mean scores for SF-36 by Taiwanese and
Vietnamese women……………………………………………………….116
Table 5.17 HRQOL in Vietnamese immigrant women and Taiwanese
women………………………………………………………………..……131
Table 5.18 HRQOL of Vietnamese immigrant women compared to
Taiwanese women, by age groups………………………….…………..114
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Appendices
Appendix 1: Ethical approval document
Appendix 2: Research agreement in Taiwan
Appendix 3: Informed consent
Appendix 4: Permission letter for using the SL-ASIA Scale
Appendix 5: Permission letter for using the DI Scale
Appendix 6: Permission letter for using the SF-36 survey
Appendix 7: Questionnaire (Vietnamese version)
Appendix 8: Questionnaire (Chinese version)
Appendix 9: Questionnaire (back translation)
Appendix 10: PhD time line
1
Chapter 1 Introduction
Introduction
Recently, Taiwan has been faced with the migration of numbers of women
from Southeast Asian (SEA) countries. These women are often colloquially
called, “foreign brides” or “alien brides”; most of them are seen as
commodities of the marriage trade, their marriages arranged by marriage
brokers. Some women can be regarded as being sold for profit by their
families; so their relationships with Taiwanese husbands are built on fragile
foundations. These immigrant women often face poverty, discrimination and
exploitation, alienation and a sense of anonymity, and have limited access to
social, education, and health services.
This particular group of immigrant women are highly susceptible and
vulnerable to health problems, due to language barriers, cultural conflicts,
social and interpersonal isolation, and lack of support systems. Those
immigrant women who are single and alone find themselves dealing with
economic struggle, hardship, and are marginalized in the Taiwanese society.
It is estimated that the aggregate number of SEA wives in Taiwan is more
than 131,000 in 2007. This is expected to rise in the future.
1.1 Background of the study
The importation of Southeast Asian brides started in 1987 in rural areas of
Taiwan (Hsia, 1997; 2000). This form of arranged transnational marriage has
created a special social phenomenon of “marriage trading” that is popular
among the lower middle classes in Taiwan, and especially in farming or
fishing villages. Arranged intermarriage is one kind of cross-border migration
2
flow for women, especially these coming to Taiwan from Vietnam, Indonesia,
Philippines, Thailand, Malaysia, and Cambodia. According to the Ministry of
Foreign Affairs (2005), there was a total of 131,000 such foreign female
spouses with valid resident permits, of which 85% came from Southeast Asia,
particularly Vietnam and Indonesia; of the total number of visas issued to
these brides, 69.34% were Vietnamese, 11.16% Indonesians and 7.10%
Filipinas. This study focuses on Vietnamese intermarriage immigrants, the
largest immigrant group in the period 1994 through 2007. The proportion of
undocumented SEA female residents is expected to rise in the future.
The literature indicates that immigration and acculturation are assumed to be
stressful experiences that may cause psychological distress in people's lives
(Berry & Kim, 1988). The common assumption that immigrant women are at
greater risk of psychological distress has been consistently confirmed in the
literature; immigrant women find themselves dealing with economic struggle
and hardship, and are marginalized in the new society (Meleis,1991; Frank &
Faux, 1990; Noh, Speechley, Kaspar & Zheng, 1992; Vega, Kolody, Valle &
Weir, 1991).
In Taiwan, the issue of transnational marriage, as with all international
migration, is about stresses in life (Yang & Wang, 2002). These young
Vietnamese immigrant women come to Taiwan alone, often with a single
suitcase, and are culturally and geographically distinct from Taiwanese
people; the changes in culture, interpersonal relationships, personal roles,
language, value systems and attitudes exert many negative impacts on their
health, so greater levels of acculturation stress can be expected. In addition, it
is common for them to get pregnant, and even give birth, before they are fully
adapted to the new environment, and to continue reproducing until the ideal
number of children expected by the family is reached. The need has become
apparent to understand how they assimilate to Taiwanese society and what
health problems they encounter.
3
However, there have been only a limited number of health-related studies on
Vietnamese immigrant women in Taiwan. Most of these studies on Southeast
Asian immigrant women in transnational marriages take a macro-sociological
approach, from the perspectives of sociology, capitalism, economic labour,
globalization and cultural diversification, in order to discuss their social
networks, family relationships and forms of marriage. Relatively little is known
about how the consequences of immigration influence the physical and
psychological health of immigrant women. Research in Taiwan designed to
investigate acculturation and health outcomes among these women is still
very limited.
In order to improve the health care of this increasingly vulnerable group and
their families, further research is required. The aim of this research is to
explore the physical and psychological impacts of the acculturation process
and to examine the relationships between acculturation and health outcomes
among Vietnamese women immigrating to Taiwan to get married.
1.1.1 “Foreign Bride” Phenomena in Taiwan
These Southeast Asian “foreign brides” usually marry a Taiwanese groom
with lower socioeconomic status, educational level and/or income, some of
them with physical or mental handicaps, whose chief purpose in marriage is to
continue the family bloodline (Liu, Chung & Hsu, 2001; Chang, 1999; Yang &
Wang, 2003). Taiwanese men, by arrangement with marriage brokers, take
travel packages to Southeast Asian countries and interview bridal candidates.
If satisfied, they pay an agreed sum to transport their brides home (Tang &
Tsai, 2000). In Taiwan, these SEA women are often colloquially called,
“foreign brides” or “alien brides”.
Obviously, most SEA foreign brides choose to marry Taiwanese men abroad
out of love. However, it is a fact that many of them decide to marry for
economic reasons, often hoping their spouses will give them a better life, and
4
in the expectation of sending remittances to their family in Vietnam (Tian &
Wang, 2006). These young Vietnamese immigrant women come to Taiwan
alone, and face a totally different environment, in terms of weather, lifestyle,
custom, culture, language, and family relationships, so starting the process of
immigrant adaptation can be extremely stressful.
Additionally, the nature of trans-national marriage and immigration to Taiwan
may be dramatically different from many other forms of immigration. Since
their marriages are primarily intended for extending a family line, bearing
children is their key mission in life (Liu, Chung & Hsu, 2001; Lin & Wang,
2007), and it is common for them to get pregnant, and even give birth, before
they are fully adapted to the new environment and then to continue
reproducing until the ideal number of children expected by the family is
reached (Wang & Yang, 2002). Thus, it is important that health professionals
should understand, promote and provide culturally sensitive and appropriate
healthcare for these women and their children.
1.1.2 Health Issues among “Foreign Brides” in Taiwa n
Immigrant adaptation refers to the physical, psychological, social and cultural
changes that immigrant women face, and their process of readjustment,
adaptation and acculturation. WHO (World Health Organization) (1997) has
stated that women are at a higher health risk, and that migrant women are
particularly prone to psychological problems, partly because of the precarious
conditions under which they started their journey of immigration.
Southeast Asian migrant women in Taiwan suffer from both immigration and
marriage-related pressures (Lee & Wang, 2005). In addition, the lower
education and language levels of some of these women have made health
issues even more diverse and complicated. The stresses related to language
barriers, socioeconomic status, and difficulties in adapting to a new
environment are all health-related factors. Immigrant women clearly feel
5
stressed during their first year in Taiwan; for example, Yang and Wang (2003)
found that those Indonesian brides who experienced the breaking of ties to
family and friends in their country of origin, had feelings of loss and loneliness,
social isolation, language inadequacy ethnic discrimination and cultural
prejudice.
The above types of experiences are encapsulated by the term “acculturative
stress”, which directly results from and has its source in the acculturative
process (Williams & Berry, 1991). In Taiwan, a qualitative study (Yang &
Wang, 2002) of transnationally-married women who self-reported their health
status, found that psychological health problems included emotional obstacles
posed by immigration-related stress (fatigue, loneliness, anxiety, depression,
worry, sadness and loss); self-withdrawal, shock at the gap between
expectations and reality; and marital adjustment problems related to disparity
between present conditions and premarital expectations. Based on their
descriptions of first-year experiences of adjustment, evidence of bodily
ailments like headache, loss of appetite, homesickness, crying at night,
insomnia, sleeping disorders and even psychosomatic complaints, could be
traced back to psychological anxiety and stress.
Although the number of intermarriages of women from Southeast Asia
countries is continuing to grow in Taiwan, and despite the fact that
Vietnamese immigrant women belong to the largest visible minority group in
Taiwan, there are few health-related studies that focus on this vulnerable
population, particularly in relation to their psychological, social-cultural
adaptation and health outcomes. The present study aims to bridge the
knowledge gap, by examining the relationships among acculturation variables,
socio-demographic characteristics, and Health-Related Quality of Life among
Vietnamese immigrant women in Taiwan.
6
1.2 Purpose of this study
1.2.1 Research Questions
1. What mode of acculturation do Vietnamese immigrant women use to
adapt to Taiwanese society?
2. What is the relationship between selected socio-demographic variables and
level of acculturation among Vietnamese immigrant women in Taiwan?
3. What is the relationship between level of acculturation and Health-Related
Quality of Life among Vietnamese immigrant women in Taiwan?
4. What is the relationship between acculturative distress and Health-Related
Quality of Life among Vietnamese immigrant women in Taiwan?
5. Is there a difference in Health-Related Quality of Life between Taiwanese
women and Vietnamese immigrant women in Taiwan?
6. What acculturation factors influence the Health-Related Quality of Life
among Vietnamese immigrant women in Taiwan?
1.2.2 Research Aims and Objectives
The aims of this study were to examine the relationships between
acculturation and socio-demographic variables, acculturative distress and
health outcomes among Vietnamese transnational-married women in Taiwan.
This quantitative study was divided into two phases: phase one was a pilot
study and the second phase the main study.
7
The objectives of these two phases were:
Phase one study: Pilot study
1. To obtain permission to produce a Vietnamese version of the Acculturation
scale, the DI scale and the SF-36 scale.
2. To translate and validate the research instruments.
3. To test protocols, data collection and sample recruitment strategies.
4. To conduct a pilot study to test the reliability and validity of the revised
survey instruments.
Phase two study: Main survey
1. To utilise the revised scales to identify the acculturation mode used by
Vietnamese immigrant women in Taiwan.
2. To examine the relationships between acculturation and demographic
factors, acculturative distress, and health outcomes among Vietnamese
immigrant women in Taiwan
3. To identify acculturation impact factors on health outcomes among
Vietnamese immigrant women in Taiwan.
8
1.2.3 The Research Hypotheses
Hypothesis 1
“Integration” is the mode of acculturation most often used by Vietnamese
immigrant women to adapt to Taiwanese society.
Hypothesis 2
Social-demographic variables (age, marital status, years of residence in
Taiwan, Chinese generation background, number of children, education level,
spouse’s educational level, religion and employment status) will demonstrate
significantly different effects on level of acculturation among Vietnamese
immigrant women in Taiwan.
Hypothesis 3
A significant interaction between the levels of acculturation and acculturative
distress and health outcomes will be seen among Vietnamese immigrant
women in Taiwan.
Hypothesis 4
Acculturative distress is positively associated with decrease in psychological
health among Vietnamese immigrant women in Taiwan.
Hypothesis 5
Vietnamese immigrant women will report lower scores of Health-Related
Quality of Life, as measured by SF-36 (HRQOL), than Taiwanese women.
Hypothesis 6
Acculturation factors will impact on the Health-Related Quality of Life, as
measured by SF-36 (HRQOL), among Vietnamese immigrant women in
Taiwan.
9
1.3. Conceptual Framework
The conceptual framework used in this research is based on Berry’s
Acculturative Stress Model (1987). The concept of acculturation has been
broadly discussed and applied in a range of sociology and cross-cultural
psychology research. One of the key theorists in the field is John Berry who
has offered a comprehensive conceptual framework for the study of
immigration, acculturation, and adaptation. Berry and Kim (1998) identify the
cultural and psychological factors that govern the relationship between
acculturation and mental health. They have concluded that mental health
problems often do arise during acculturation. Berry’s acculturative stress
model is illustrated in Fig 1.1.
Figure 1.1 Relationships between acculturation and stress, as modified by other
factors (Berry et al., 1987)
10
Berry’s Acculturative Stress Model (1987) contends that acculturative stress
depends upon a number of moderating factors, including the mode of
acculturation, the nature of the larger society, the type of acculturating group,
and a number of demographic, social, and psychological characteristics of the
group and of individual members. In particular, one’s appraisal of the
acculturation experience and one's coping skills in dealing with the stressors
can affect the level of acculturative stress experienced. It is believed that
acculturation outcomes could vary depending on interactions between each
immigrant and their host society.
In order to gain a comprehensive understanding of the relationships between
the acculturation and wellbeing of immigrant women. An “acculturation and
well-being model” was developed for this study (see Figure 1.2). This model is
a modification of Berry’s “Acculturative Stress Model” that attempts to
systematize the process of psychological acculturation and to illustrate the
main factors that affect an individual’s physical and psychological health. In
this model, the research variables, include individual variables (pre-migration:
age, education, religious ethnicity, and occupation ; post-migration: marital
status, length of residence in Taiwan, occupation/employment status, number
of children, spouse’s age, and SES) and acculturation factors (linguistic
competence, social support, daily habits ethnic identity, perceived
discrimination and acculturation strategies, acculturative distress and well-
being). The variables and their relationships will be described in the following
chapters.
11
Figure 1.2 The hypothesized model of this study
Individual
Acculturation
process
Health
outcomes
Age ,Education
Religion, Ethnicity
Occupation
Marital status
Length of residence
Occupation/income
Spouse’s SES,Children
Factor
Linguistic Social
support
Ethnic identity
Daily habits
Perceived
discrimination
Strategy
Assimilation
Integration
Separation
Marginalization
Psychological
wellbeing
Physical
wellbeing
12
1.4. Research Significance
1.4.1 The Scope of Acculturation and Nursing Resear ch
The study of immigrants and immigration is rooted in many disciplines
including: anthropology, demography, economics, political science, sociology,
and cross-cultural psychology (Berry, 1997), while health science has lagged
behind somewhat. The multiple disciplines of health science research have
much to contribute to an understanding of the adaptation process in
immigration and of the immigrant’s physical and psychological health. Thus,
the psychological acculturation of immigrants and the changes in their health
status should be an important focus of health research (Aroian, 1990; Meleis,
1996; Miller & Chandler, 2002).
Over the last few decades, there have been considerable changes in nursing
practice. Nurses have had increasing responsibilities, as the expansion of the
scope of clinical and academic work has resulted in more clearly defined
professional roles. Nursing is concerned with the patterning of human
behaviour in continuous interaction with the environment, in normal life events
and in critical situations (Fawcett, 2002). Environment refers to the person’s
social network and physical surroundings and to the setting in which nursing
is taking place. It includes all the local, regional, national, cultural, social,
political, and economic conditions that might have an impact on a person’s
health (Fawcett, 2002).
In the mid-1950s, interest in and attention to the cultural care needs of
culturally diverse patients and families was first described by Leininger (1984).
Leininger (2002) defines acculturation as “the process by which an individual
or group from Culture A learns how to take on many values, behaviours,
norms, and life ways of Culture B” (p. 56); moreover, acculturated individuals
demonstrate that they have adopted the values and life styles of another
culture through their expression and actions. Leininger (1991) described five
nursing concepts adapted from anthropology that are essential in trans-
13
cultural nursing, as the basic international phenomena that nurses need to
know in order to understand trans-cultural context: culture encounter,
enculturation, socialization, assimilation, and acculturation. Leininger’s work
(1995; 1996; 1997; 2002) is summarised in her “Theory of Culture Care
Diversity and Universality”, and the “Sunrise model”, which are useful in the
assessment, along prescribed lines of difference, of the cultural variability of a
particular culture.
Further developments of cultural nursing studies have emerged that have
expanded on the tenets of Leininger’s original work. Purnell (2000; 2002)
developed a model for cultural competence, defining cultural competence as
the adaptation of care in a manner that is consistent with the culture of the
patient. Another emerging model is the “Process of Cultural Competence in
the Delivery of Health Care Service” model, by Campinha-Bacote (2002). In
addition, Spector (2002) has produced a model more concerned with cultural
diversity in health and illness, whose purpose is to increase nurse awareness
of the dimensions and complexities of delivering nursing care to people from
different cultural backgrounds. Spector (2002) has stated that heath belief and
practices can be analysed either in terms of the individual’s heritage or
according to the level at which one has acculturated to the dominant culture.
Through the culture-related literature documented in nursing studies, it is clear
that different levels of acculturation can, either negatively or positively,
influence the health status of immigrants. However, there is limited
information on the association between acculturation and health status of
Vietnamese immigrant women in Taiwan. This research aims to bridge that
knowledge gap by examining the relationships among demographic
characteristics, acculturation variables, and health outcomes among
Vietnamese immigrant women who marry Taiwanese men and gain
permanent residency. Thus, the result of this research will contribute to an
understanding of the acculturative process of immigration and of immigrants’
physical and psychological health.
14
1.4.2 Research Outcomes and Contributions
The findings of this study will be beneficial in three ways: firstly, by developing
knowledge about immigrant women’s health. This study will provide a
theoretical understanding of the psychological adaptation frameworks of
immigrant women, as well as the significant variables that influence these
immigrant women’s wellbeing. The absence of general information on their
health and well-being makes it extremely difficult for health professionals to
understand their health care needs; continued neglect of this group’s health
problems will lead to increases in morbidity, mortality, and health-care costs
for the government. Moreover, the study fills a major gap in the research into
the health of immigrant women, who have been marginalized for years from
Taiwanese society. As Meleis and Im (1998) have stated:
“Quality care requires a body of knowledge that reflects the experiences and responses of the marginalized populations to health and illness, developing an understanding of people who are marginalized in our societies all around the world (Meleis and Im ,1998, p. 97).
Secondly, the knowledge gained through this research may increase the
cultural competence of health care professionals and will assist those health
professionals responsible for managing acculturation, particularly for migrant
women, enabling host countries to develop an appropriate, effective health
promotion and mental distress prevention strategy. Immigrants from diverse
cultural backgrounds will all be able to be provided with health information,
counselling, and other forms of health assistance based on these findings.
Third, and finally, the application of this research will positively contribute to
helping the thousands of immigrant women and their families who find
themselves in a situation of cultural contact and encounter.
15
1.5. Definition of Terms
The key terms used in the research proposal are:
Vietnamese trans-national marriage women
The women who come from Vietnamese through brokered arrangements of
marriage to Taiwanese men. These women are often colloquially called,
“foreign brides or alien brides” in Taiwan. In some studies they are called
“intermarriage women” (Tezeng, 2000), or “cross-culture marriage women”
(Kalmijn, 1993). Taiwan has officially named this group of women as “new
immigrant women” to distinguish them from other forms of immigrants. In this
study we shall be neutral and simply refer to them as “Vietnamese immigrant
women” to avoid stigmatizing our research participants.
Acculturation
Acculturation is a complex process of conflict and negotiation between two
cultures, involving changes in language, life style, cultural identity and value.
Psychological acculturation
Psychological acculturation or so-called “individual-level acculturation” entails
changes in personal behaviour, attitudes, and identity. It is also defined as the
process by which individuals change and adapt to the cultural context in which
they live.
Acculturative distress
Acculturative distress is defined as a type of stress originating from the
process of acculturation, often resulting in a particular set of stress behaviours
that include anxiety, depression, feelings of marginality and alienation,
heightened psychosomatic symptoms, and identity confusion.
16
Acculturation strategies/modes
Berry’s approach conceptualizes acculturation as that process by which
immigrants and ethnic groups adapt to cultural change resulting from contact
with the dominant group, by using one of four strategies/modes: assimilation,
integration, separation, and marginalization (AISM).
Assimilation
The relinquishing of one’s own ethnic identity or showing a diminishing
interest in one’s cultural origin and an eagerness to adopt that of the dominant
(host) society or culture.
Integration
The incorporation of parts of another culture, while maintaining one’s own
cultural identity.
Separation
When immigrants withdraw from the host society and do not adapt to the host
culture, but maintain the ways of their culture of origin.
Marginalization
When the group or individual loses contact with its own culture, as well as with
that of the culture of the majority; it is usually characterized by alienation and
loss of identity.
17
Chapter 2 Literature Review
Introduction
This review of the literature begins with a general consideration of women
migrants and issues relating to their acculturation and health; it is then further
expanded, to include acculturation theory and measurement of health
outcomes, and examines the research variables in use in these areas. Finally,
it addresses current studies of the marriages of SEA immigrant women in
Taiwan. Although there has been rapid growth in the number of Vietnamese
immigrant women in Taiwan, there is limited information on the association
between acculturation and the health outcomes among them.
2.1 Migration and Women’s Health
According to the International Organization for Migration (2003), there are 175
million international migrants in the world; 48 per cent of these are women.
That is to say that one out of every 35 persons in the world is a migrant (IOM,
2003). Women’s migration within and across national borders is a key process
shaping the world in many complex ways.
2.1.1 Migration
The International Encyclopaedia of Social Science (Shills, 1968) defines
migration as the relatively permanent movement of persons over a significant
distance. Migration is also defined as a permanent or semi-permanent change
of residence (Lee, 1966). Bhugra (2004; 2005) states that migration: change
in the location of residence, is a universal phenomenon and has occurred in
all nations at all times. According to a review by Berry and colleagues (1987),
18
there are five different categories of mobility and its voluntariness: native
people, refugees ethnic groups, sojourners and immigrants. In these terms,
the migrant is a mobile individual who deliberately and consciously decides to
change the place of living. In the literature, ‘migration’ and ‘immigration’ are
used interchangeably.
The process of migration is both qualitative and quantitatively and a highly
heterogeneous process (Bhugra, 2004). It may involve individuals who move
to study, to seek better employment, to attempt to better their future, to avoid
political and religious persecution or to marry. In Asia, over 1.5 million Asian
women have migrated abroad; they outnumber men (IOM, 2003). Women in
Asia are the highest proportion of unskilled migrant workers in labour-
receiving countries and represent the largest number of trans-national
marriage migrants. According to the population mobility theory (UNDP, 2004),
cross-cultural marriage, intermarriage, or trans-national marriage is a distinct
type of human migration. Since 1990, groups of young Southeast Asian
women have been voluntarily crossing borders via the “Marriage trade” in
search of a better life.
Migrants often face poverty, discrimination and exploitation, alienation and a
sense of anonymity, limited access to social, education and health services,
separation from families and partners, and a sense of disconnect from the
socio-cultural norms that guide behaviour (Iredale, 2004). The migration
process, reflecting the structural socio-economic realities of today, has
become considerably more multi-faceted, impacting the lives not only of
migrants, but also of communities and nations, in several complex ways.
2.1.2 Migration and Women’s Heath
The focus of health care delivery for women has shifted from a traditional
emphasis on reproductive matters alone to a broader consideration of those
19
health issues that are impacted on by sex and gender, and of the contextual
factors that determine health and well-being (McDonald & Thompson, 2005).
Dan, Bernhard, and Wester, (1980) stated that:
Women's health involves women's emotional, social, cultural, spiritual and physical well-being and is determined by the social, political and economic context of women's lives as well as by biology. This broad definition recognizes the validity of women's life experiences and women's own beliefs about and experiences of health. (Dan, Bernhard & Wester, 1980, p.545)
Immigrant women tend to be more vulnerable to illness than immigrant men or
non-immigrants, and experience more barriers to their health care (Aroian,
1999). Among immigrants from the developing world, women are a highly
vulnerable population, primarily because of traditional cultural roles and
perspectives that place them as inferior and subservient to men. Women tend
to have lower educational levels, more health problems, less treatment for
health problems and, once in the new country, tend to be more isolated than
men (Aroian, 2001; Meleis et al., 1998; Lipson, 1992).
Immigrant women come from many different backgrounds and may find
themselves in a setting completely unlike the one that they are used to,
particularly in relation to housing, transportation, language, customs and
protocols, and technology. Moreover, many immigrants find themselves
dealing with a life of economic struggle and hardship, marginalized in the new
society (Anderson, 1990; Meleis, 1991). Numerous stressors that have
potentially negative consequences for the health of an immigrant have been
identified (Hattar-Pollara & Meleis, 1995); these include finding employment
and establishing an income source, establishing a new home, feelings of loss
of social status and loneliness and social isolation, often all affected by
language barriers (Mirdal, 1884; Meleis et al., 1998; Lipson, 1992).
Some researchers (Hill, Lipson & Meleis, 2003) view immigration as a
transition process and consider that immigrant women confront multiple
20
stressors of loss. Meleis (2003) argues that immigrant women face a new
society, new values, new norms, and new sets of expectations. To be
confronted with so much that is new, tends to create a sense of disequilibrium
and uncertainty. Transitions may also evoke fear of identity loss or changes in
roles, patterns of behaviour, and dynamics of interaction (Schumacher &
Meleis, 1994).
Immigrant women face multiple challenges in this transition process, such as
loss of familiar networks, support systems, known symbols, and identifiable
resources. They also face the stress associated with such losses (Meleis,
2003). Mirdal (1984) has stated that the feelings of being uprooted, coupled
with the need to function in an unfamiliar environment in which the symbols
must be constantly interpreted, leads to feelings of distress manifested as
depression and somatic complaints.
Aroian (1998) has found a high rate of negative effects on mental health, such
as anxiety and depression, in female migrants. Since they are often excluded
from certain social activities, they are often dependent on their husbands, and
they are discriminated against in the labour market. Several studies (Boyd,
1989; Frank & Faux, 1990; Nicassio, Solomon, Guest & McCullough, 1986;
Noh, Speechley, Kaspar & Zheng, 1992; Vega et al., 1986; Vega, Kolody,
Valle & Weir, 1991) have noted that immigrant women experience high levels
of anxiety, depression, and a variety of psychological problems, ranging from
lower self-esteem, depression and anxiety to alcohol and substance abuse,
psychosomatic symptoms and psychosis.
2.1.3 Southeast Asian Foreign Brides in Taiwan
Taiwan is currently experiencing very large immigration flows, female
migrants outnumbering males. Arranged marriages make up one part of the
cross–border migration flow to Taiwan, especially for women from Vietnam,
Indonesia, Philippines, Thailand, Malaysia, and Cambodia. The rise in number
21
of intermarried couples has sharply increased the number of foreign brides
married to Taiwanese men. The overwhelming economic differences between
Taiwan and other Southeast Asian countries are the greater part of the pull
and push forces that are increasing the numbers of Southeast Asian women
marrying Taiwanese man (Hsia, 2000).
Another factor could be the changing marriage values of young Taiwanese
women. Many young Taiwanese women are educated and employed and do
not rush into marriage, with the consequence that many older or
disadvantaged males have difficulty finding brides; so they take advantage of
services offered by marriage agencies who sell introductions to “imported
brides” from Southeast Asian countries; the number of these agencies has
exploded all over Taiwan in recent years. It is estimated that there were
131,000 foreign brides in Taiwan in 2005 (MOI, 2006).
Commercialisation and Objectification
The immigration of Southeast Asian brides started in 1987 in rural areas of
Taiwan (Hsia, 1997; 2000). This form of arranged marriage has created a
special social phenomenon of marriage trading that is popular among the
lower middle classes, especially in farming or fishing villages. Taiwanese
men, by arrangement with marriage brokers, take travel packages to
Southeast Asian countries and interview bridal candidates. Once satisfied,
they pay an agreed sum to transport brides home (Tang & Tsai, 2000). The
image of the Vietnamese bride formulated by the marriage agency is that she
becomes a perfect wife with traditional women’s virtues: submissiveness, filial
piety, and diligence. In effect, the women’s body becomes a product that can
be purchased with money (Tian & Wang, 2006).
Obviously, most SEA foreign brides don’t choose to marry Taiwanese men
out of love. Many of them decide to marry for economic reasons, in the hope
that their spouses will give them a better life and in the expectation that they
22
will send remittances to their family in Vietnam (Lee, 2006). Meanwhile, the
most important marital responsibility of these immigrant women is “to bear
and rear children in order to continue a family bloodline” (Yang & Wang,
2003). It is also the role most expected of them by their in-laws. In general,
their reproductive function is the centre of life for these women and their most
closely focused issue (Lee, 2006).
The form of cross-cultural marriage between Taiwanese men and young
Vietnamese young females can be described as marriage commercialisation;
Vietnamese immigrant women are objectified and commoditized in a world in
which women’s bodies are used in advertising to sell virtually every product.
Young Vietnamese women become bride candidates as a way to make
money or achieve a better life, but these results in many challenges to their
lives.
Stigmatisation
Young women who come from Vietnam are stigmatised by the ethnocentric
view of the Taiwanese society and by the mass media. Because these young
women enter into marriage to Taiwanese men under a brokerage
arrangement, they are often called, colloquially, “foreign brides” or “alien
brides”, a term which carries a negative connotation within Taiwan (Liu,
Chung & Hsu, 2001; Chang, 1999; Yang & Wang, 2003). The Taiwanese are
prejudiced toward Vietnamese due to their common perceptions of Vietnam
as a backward land that is simply a supplier of human labour for Taiwan. In
Ferguson & Browne’s (1991) view ethnocentrism readily converts into
prejudice against people of cultures deemed inferior to our own. Prejudices
are negative attitudes towards an entire category of people, based on who
they are rather than on their behaviour.
Disrespect for these Vietnamese women among household and community
members has also bred superficial media coverage that has come to
23
associate trans-national marriage with such concepts as distorted family life,
runaway brides, marriage fraud and prostitution (Cheng, 1998). The media
has come to describe these kinds of international marriage as a “marriage
trade for money” (Tain & Wang, 2006).
Discrimination and Oppression
Vietnamese women suffer discrimination from their new family and oppression
by them in many ways. Among their Taiwanese in-laws, the Vietnamese
women’s original culture is invisible, suppressed and even discriminated
against (Liu et al., 2001). Disregard for their original family ties is
demonstrated by their husbands’ views on Vietnamese culture and behaviour
towards it, or in their interactions with family members. Taiwanese husbands
do not encourage contact with Vietnamese relatives and seldom accompany
their wives back home, harbouring impressions of their wives’ hometowns as
backward, poor and dirty, and thinking the trip too costly. Taiwanese
husbands show a strong prejudice against other cultures and a sense of
superiority in their own (Yang & Wang, 2002).
Marginalisation
Young Vietnamese immigrant women experience extreme loneliness and
isolation for a number of reasons. In the first place, these women migrate to
Taiwan alone; they live far away from their homeland, without the support of
their own parents, friends and relatives and, as mentioned earlier, are unable
to obtain due respect and status in their marriage or among their husband’s
relatives. All these, plus a feeling of lack of true friendship and support in
social and personal relationships, exacerbate their loneliness and isolation,
resulting in a lack of wholesome friendship and support in their personal
relationships. All these factors exacerbate feelings of loneliness and isolation.
24
Another compounding obstacle to adaptation into the new culture and role for
these immigrant women is the language barrier, which further adds to feelings
of isolation and loneliness. Regardless of their former educational level in
Vietnam, they have to learn Taiwanese or Mandarin after marriage and
immigration. Inability to communicate may force a Vietnamese immigrant
woman to live an isolated life, unable to leave the house alone, take public
transportation, drive or ride a vehicle legally, go shopping, seek medical help
and prenatal examination, and form other family relationships (Yang & Wang,
2003). In addition, for fear of them running back to Vietnam and precipitating
financial loss for husbands, they are often intentionally prevented by their
husbands from going out alone and making social contacts. Thus, these
women usually are marginalized individuals at the periphery of the dominant
society, the central majority (Hall, 1999; Meleis & Im, 1999).
These women have also been marginalized in the healthcare system,
because of barriers to its use arising from inadequate information on medical
care resources due to their lack of connection with community resources and
their unfamiliarity with ways of obtaining medical services. Language barriers
also affect their access to and application of health related knowledge and
their doctor-patient interactions. Perceived discrimination and cultural
prejudice among healthcare professionals can also marginalize immigrant
women in terms of resource utilization, making them unable to use the
healthcare system and resources effectively (Yang & Wang, 2003). These
women are vulnerable to health risks resulting from discrimination, unmet
subsistence needs, illness, and restricted access to health care.
2.2 Acculturation
Acculturation was initially studied almost entirely within the discipline of
anthropology; it is now an important concept in the fields of ethnic studies,
social psychiatry, cross-cultural psychology and cultural nursing.
25
2.2.1 Definition of Acculturation
Acculturation was first identified as a cultural level phenomenon by
anthropologists. Redfield, Linton, and Herskovits (1936) stated that:
“Acculturation comprehends those phenomena which result when groups of
individuals having different cultures come into continuous first-hand contact
with subsequent changes in the original culture patterns of either or both
groups” (p.149-152). The Social Science Research Council (SSRC, 1954),
identified acculturation as:
Cultural change that is initiated by the conjunction of two or more autonomous cultural systems. Acculturative change may be the consequence of direct cultural transmission; it may be derived from non-cultural causes such as ecological or demographic modifications induced by an impinging culture; it may be delayed, as with internal adjustments following upon the acceptance of alien trait or patterns; or it may be a reactive adaptation of traditional modes of life (SSRC, 1954, p.10).
It emphasized that acculturation is not the only kind of assimilation; it can also
be reactive (triggering resistance to change in both groups), creative
(stimulating new culture forms, not found in either of the cultures in contact),
and delayed (initiating changes that appear more fully years later) (SSRC,
1954, p.974). Such broad and general definitions reflect the breadth and
complexity of the social phenomenon, but offer little unity in direction for
researchers attempting to identify, measure, and clarify the processes.
As a result of international migration, many countries become culturally plural
societies (Berry, 1997), when people of many cultural backgrounds come to
live together in a diverse society. When an individual moves between cultures,
he or she is required to make psychological adaptations and to start an
acculturating process in the host country. The term acculturation has been
coined to describe all the processes of change that take place when
individuals of different ethno-cultural groups come into prolonged contact with
one another (Berry, 1992).
26
The concept of acculturation has become widely used in cross-cultural
psychology. Berry (1997) has stated that “acculturation is a complex process
of conflict and negotiation between two cultures.” Similarly, Al-Issa and
Tousignant (1997) assert that “acculturation is one kind of cultural change
resulting from direct contact between two cultural groups.” Abe-Kim, Okazaki,
and Goto (2001) conclude that “acculturation is a process by which the
attitudes and behaviours of people from one culture are modified over time as
a result of contact with a different culture” (p. 233).
Ethno-nursing researcher, Leininger (2002), defines acculturation as “the
process by which an individual or group from Culture A learns how to take on
many values, behaviour, norms, and life ways of Culture B” (p. 56). Leininger
further explains that acculturated individuals demonstrate that they have
adopted the values and lifeways of another culture by their expression and
actions. However, an individual may still retain and use those traditional
beliefs and values from the old culture that will not interfere with taking on new
cultural norms (Leininger, 2002). Currently, researchers who study
acculturation contend that it is a broad range of concepts that includes not
only changes in behaviour, values, attitudes and identity, but also social,
economic and political transformations (Clark & Hofsess, 1998).
From these definitions, some key elements can be identified. First, there
needs to be contact or interaction between two cultures. Second, the result is
some change in the cultural or psychological phenomena among the
individuals in contact. Third, there is activity during and after contact, which is
a dynamic ongoing process. Hence, acculturation is a process that takes
place over time, and results in changes both in the culture and in the
individual (Lonner & Berry, 1987).
27
2.2.2 Acculturation Theories
As a result of increasing international migration over the last few decades,
acculturation is becoming recognized as a universal human process that
impacts on all people globally. In order to understand this dynamic and
increasing process, it is necessary to examine the major theories of
acculturation in the literature. The theoretical conceptualisation of
acculturation has shifted away from a unidimensional assimilation model, with
the recognition that acculturation is a complex, multifaceted process (Berry,
1997).
Early models viewed acculturation as a linear process with individuals ranging
on a continuum from un-acculturated to assimilated. Gorden (1968) proposed
a unidimensional model that implies a process of change along a single
dimension, a shift from cultural maintenance to full adaptation to the culture of
the majority. In its simplest form, acculturation is a continuum of acculturative
possibilities, from un-acculturated through bicultural to fully acculturated
(Keefe & Padilla, 1987). Acculturation has evolved from the unidimensional
conceptualisation to a bidimensional conceptualisation. The unidimensional
conceptualisation equates acculturation with assimilation. Some researchers
(Marin & Gamba, 1996; Zane & Mak, 2003) have argued that the limitation of
this approach was that there was no acknowledgment of the possibility that
acculturation toward the dominant culture does not necessarily preclude the
simultaneous retention of one’s culture of origin.
More recently, researchers (Berry, Kim, Power, Young & Bujaki, 1989) point
out that the conceptualisation of acculturation has allowed for bi-dimensional
or multidimensional conceptualisation while emphasising cultural pluralism.
Acculturation is regarded as a multidimensional process that includes an
orientation or 'attitude' toward one's own ethnic group and the larger society,
as well as toward other ethnic groups.
28
Currently, the most popular and widely used bidimensional model is that of
Berry (1992; 1997); in that concept of the dimensional model, culture
maintenance and cultural adaptation constitute relatively independent
dimensions; increasing identification with one culture does not necessarily
require decreasing identification with the other (Berry, 1997; Coleman &
Gerton, 1993). It has been suggested that researchers pay attention to
acculturation as an important variable that can influence individual’s values,
whereas investigations of acculturation use more multidimensional
conceptualisations in an effort to understand cultural orientation and
functioning better (Berry, 2003; Kim & Abreu, 2001).
2.2.3 Psychological Acculturation
The concept of acculturation is now widely used to refer to those changes
those groups and individuals undergo when they come into contact with
another culture. A distinction has been made by Graves (1967), between
acculturation as a collective or group-level phenomenon, and psychological
acculturation. Group-level acculturation entails a variety of changes, such as
economic, technological, social, cultural, and political transformations
(Redfield, Linton & Herskovits, 1936).
On the other hand, individual-level acculturation, called "psychological
acculturation" by Graves (1967), entails changes in behaviour, values and
attitudes, as well as identity. It can also be defined as the process by which
individuals change and adapt to the cultural context in which they live (Berry,
Kim, Boski, 1988). Many authors have stated that the individual acculturative
process refers to the affect, cognition, and behaviour of settlement due to
coexistence (Berry, 1994; Berry, Kim, Power, Joung & Bujaki, 1989). Berry
(1997) has shown that psychological acculturation is considered to be a
matter of learning a new behaviour repertoire that is appropriate for the new
cultural context. This also requires some “culture shedding” to occur (Berry,
1992), and it may be accompanied by some moderate culture conflict. If
29
individuals cannot easily change their repertoire, they may experience ”culture
shock” (Oberg, 1960) or “acculturative stress” (Berry, 1970; Kim, Minde &
Mok, 1987).
2.2.4 Acculturative Stress
As previously mentioned, the process of acculturation often involves
adjustment to a new culture, learning a new language, leaving family and
friends in the original country, loneliness or lack of support in the new culture,
underemployment or unemployment, as well as personal and institutional
discrimination. Therefore, the acculturation process can be a very stressful
experience. A major consequence experienced by many immigrants during
the cultural adaptation process involves acculturative stress (Berry, Kim,
Minde & Mock, 1987).
Acculturative stress has been defined as a type of stress originating in the
process of acculturation. Berry (1997) states that acculturative stress refers to
stress in reaction to the process of acculturation and includes lowered mental
health status, anxiety, depression, feeling of marginality and alienation,
increased psychosomatic symptoms and identity confusion. Rodriguez,
Myers, Morris, and Cardoza (2002) state that acculturative stress is a
phenomenon that may underlie a reduction in the health status of individuals
(including physical, psychological, and social health). Furthermore, Smart and
Smart (1995) asserted that the acculturative stress has been described as a
pervasive lifelong influence on the psychological adjustment, decision-making,
occupational functioning and physical health of migrants.
30
2.2.5 Acculturative Stress and Psychological Health
According to Berry’s (1998) interpretation, acculturative stress is in a way
linked to the general psychological models of stress as a response to
environmental stressors. Moderate difficulties can be experienced during
acculturation, such as psychosomatic problems; major difficulties can be
experienced, as psychopathology or mental illness (World Health
Organization, 1991).
Accumulated evidence (Bhugra, 2004; Rodriguez, Myers, Morris & Cardoza,
2002; Berry, Kim, Minde & Mok, 1987; Berry & Kim, 1988) has suggested that
acculturative stress may indeed have important implications for mental health.
Researchers have found that greater acculturative stress increases the risk of
developing psychological problems, particularly in the initial months of contact
with the new host society. The relationship between acculturation and stress
is likely to be mediated by a variety of variables, including the nature of the
migration, the receptiveness of the host society, and the degree of similarity
between the culture of origin and the new culture (Berry, Kim, Minde & Mok,
1987; Berry & Kim, 1988). The conclusion is that the important life changes
that may occur as a result of migration, such as loss of one’s previous role or
vocation, the need to rebuild one’s social network and separation from family
supports are related to acculturative stress and poor health outcomes.
In Taiwan, the issue of trans-national marriage, as with international
migration, is about stresses in life (Yang & Wang, 2003). As Vietnamese
immigrant women are culturally and geographically distinct from Taiwanese
people, the changes in culture, language, interpersonal relationships,
personal roles, value systems and attitude exert many negative impacts on
their health. Thus, greater levels of acculturation stress can be expected.
31
2.2.6 Berry’s Acculturative Stress Model
In a review and integration of the literature, Berry and Kim (1987) attempted to
identify the cultural and psychological factors that govern the relationship
between acculturation and mental health. They concluded that mental health
problems often arise during acculturation.
Berry’s Acculturative Stress Model (1987) illustrates that acculturative stress
is influenced by multiple factors, including the mode and phase of
acculturation, the nature of the larger society, the type of the acculturating
group, and a number of demographic, social, and psychological
characteristics of the group and its individual members. In particular, one's
appraisal of the acculturation experience and one's coping skills in dealing
with the stressors can affect the level of acculturative stress experienced
(Berry, Segall & Kagitçibasi, 1997).
Migration is a stressful, non-normative life event, which leads to a process of
re-adaptation on a personal as well as collective level, as has been shown in
studies on the acculturation of ethnic minorities (Berry, 1997). Studies show
that the level of acculturative stress depends on several factors that may
serve as buffers, including family and social support networks, certain SES
(social economic status) characteristics, such as education and income,
attributes of adaptive function (coping ability), and acculturation variables
(knowledge of language and culture) (Berry, Kim, Minde & Mok, 1987).
Other related factors that may influence acculturation preference include
length of cultural contact; permanence of immigration; population size of one’s
cultural group; policy toward one’s cultural group; and qualities of the culture
in contact (Berry, 1989), who believed that acculturation outcomes could vary
depending on interactions between each immigrant and their host society.
32
Critiques of Berry’s Acculturation Model
Although Berry’s model has been widely discussed for many years, it does
raise controversy. For example, Triandis (1977) argued that Berry’s
acculturation model is so complex that a large number of the dimensions of
the concept of acculturation can be included, and it is not practically testable
in the field. Lazarus (1997) argued that that acculturation is not everything,
and suggested that uprooting, dislocation, or relocation are some terms to use
instead of immigration and acculturation.
Recently, Danish researchers (Koch, Bjerregaard & Curtis, 2003) claimed that
Berry’s hypothesis about the relationship between acculturation and mental
health can not be empirically verified. Acculturation plays a lesser role for
mental health than do the covariates of gender, age, marital status,
occupation, and long-term illness. They argued that Berry only includes
psychological dimensions in his definition, which attaches great importance to
culture values, options and identity. They found that the most important
factors for mental health among Greenlanders living in Denmark were socio-
geographic and social-economic factors (Koch, Bjerregaard & Curtis, 2003).
However, the results of Koch, Bjerregaard and Curtis’s work (2003) might be
affected by bias in research methods, the construction of the acculturation
variables and the measurement tools. Acculturation has therefore tended to
be conceptualised as multidimensional (Rogler et al., 1991). Several
researchers (Koch, Bjerregaard & Curtis, 2003; Rudmin & Ahmadzdeh, 2001)
have expressed concern with the use of socio-economic variable as indicators
of acculturation. They argue that socio-economic factors are good predictors
of group trends but remain indirect and not very sensitive indicators of
individual differences.
33
Despite this criticism, the concept of acculturation has been used as a model
of explanation in many studies of lowered mental health among immigrants.
The strong points of Berry’s acculturation model include its meticulous
definition of terms, macro and micro level analysis, and its comprehensive
understanding of acculturative perspectives.
Acculturative Strategies /Mode
Berry (1997) illustrates that immigrants and ethnic groups use different
strategies to adapt to the host society. Acculturative strategies have been
shown to have a substantial relationship with positive adaptation. Berry (1992)
modified the two underlying fundamental attitudes, referring to them as
cultural maintenance and cultural adaptation (see Figure 2.2). Berry (1992)
showed that immigrants and ethnic groups adapt to cultural change resulting
from contact with the dominant group by using one of four strategies or
modes: assimilation, integration, separation, and marginalisation. These
different types of cultural orientation have been linked to different mental
health outcomes.
Figure 2.1 .The AISM Model (from Berry et al., 1992)
34
According to Berry and Kim’s AISM model (1988), there are four types of
cultural orientation that can occur as an outcome of the acculturation process:
assimilation, integration, separation, and marginalisation (AISM).
Assimilation is relinquishing one’s own ethnic identity and adopting that of
the dominant society. Individuals who are assimilated have completely
adapted to the behaviour and thinking of the dominant host culture to which
they have migrated. It occurs when maintenance of the culture is seen as
undesirable, while adaptation to the culture of the majority group is highly
important. Similarly, when people choose to assimilate, the notion of the
melting pot may be appropriate; but when forced to do so, this may be more
like a pressure cooker (Berry, 1997).
Integration is incorporating part of the other culture but maintaining one’s
own cultural identity. The end result is a multicultural society, with a number of
distinctive ethnic groups within a larger social system. The outcome of this
approach is biculturalism, which is the most adaptive resolution for
acculturation, because there is a relatively stable balance between
behavioural continuity with one’s traditional culture and accommodation of the
new cultural (Berry, 1989). Integrated individuals are called bicultural
individuals, who have more fluidity between their culture of origin and the new
host culture. Therefore, integration represents a successful transition,
balancing the host country’s culture with the traditional values of ones own
cultural origin.
Separation: individuals who are separatists remain completely immersed in
the language, activities, and beliefs of their culture of origin and withdraw from
the host society. Separation may take the form of segregation, when it is
imposed by the dominant group. In the separation strategy, acculturating
35
individuals retain their cultural heritage while rejecting a new culture (Berry,
1989; 1990).
Marginalisation occurs when immigrants lose contact with their culture of
origin as well as that of the dominant society; this is usually characterized by
alienation and loss of identity (Berry, 1992). In marginalisation, an individual
refuses to identify with either the original or the new culture. As a result, the
individual is suspended between the two cultures and becomes isolated
(Berry, 1989; 1990).
2.3 Factors Influencing Acculturation
The factors influencing acculturation and health outcomes have been defined
as: gender, socio-economic status (Aroian, 1998), length of residence in the
host country (Zheng & Berry, 1991; 1986; Nicholson, 1997), social support in
the new culture (Simich et al., 2003; Ramírez & Jariego, 2002), and
discrimination, whether personal or institutional, which affects the amount of
stress experienced by an acculturating individual (Finch, Hummer, Kolody &
Vega, 2001; Fuertes & Westbrook, 1996).
2.3.1 Gender and Acculturation
Acculturation preferences may be influenced by gender. Several studies
(Sam, 1995; Guendelman, 1987; Das, 1997; Aroian et al., 1998; Dion & Dion,
2001) on gender differences in acculturation and ethnic identification reveal
that females tend to be more identified with their natural culture than males.
Research (Das, 1997) has suggested that gender-typing pressure
experienced by females to make them adhere to traditional values and
behaviour may serve to increase their ethnic awareness more than for males.
36
Dion and Dion (2001) found that females reported a stronger desire to
understand the meaning of ethnicity in their lives compared with their male
partners. Women also have greater ethnic-related behaviours, such as
participation in cultural traditions or membership of organizations of their own
culture.
However, a study on birth outcomes among Mexican-Americans showed that
Mexican women had an increased risk of pre-term birth, despite having more
adequate prenatal care, more education and higher social-economic
indicators. This result might be due to acculturation factors such as earlier
pregnancy, loss of social support, and increased smoking and alcohol use
(Guendelman, 1987).
2.3.2 Socio-demographic Status
Socio-demographic factors that have been found to be associated with
acculturative stress are age, gender, language competence in host country,
and socio-economic status (SES). Socio-economic status factors, such as
education and employment, provide one with resources to deal with the larger
society, and these are likely to affect one’s ability to function effectively in new
circumstances. Aroian (1998) investigated 1647 former Soviet immigrants and
concluded that immigrants’ psychological distress was related to gender, age,
marital status, employment and length of time in the host society. Results
indicated that women, older immigrants, those with less education, and those
with greater immigration demands related to novelty, language, discrimination,
loss and not feeling at home were the most distressed (Aroian, Norris et al.,
1998). Likewise, (Shaffer & Harrison, 2001; James, Hunsley, Navara &
Malnnie, 2004) suggested that spouse variables and marital status play
important roles in immigrant adjustment. They reported significant positive
correlations between marital status and acculturative adjustment.
37
2.3.3 Length of Residence in the Host Country
Some studies have shown that the period of the greatest psychological strain
for immigrant women is just after their arrival in the new country (Aroian,
2001). According to Zheng and Berry’s (1991) longitudinal study of Chinese
sojourners in Canada, physical and psychological systems related to
acculturative stress increased until 4 months after migration. These physical
and psychological symptoms relative to acculturative stress then began to
gradually decline 5 months after migration and declined slowly for several
years thereafter to the departure baseline, forming an inverted U-shaped
function.
Similarly, Yeung and Schwartz, (1986) reported that Chinese immigrants who
had lived in the United Stated for less than one year reported greater health
problems (as measured by the GHQ) than immigrants who had lived in the
United Stated longer. However, Nicholson’s study (1997) of Southeast Asian
refugees in the United States found that persistent acculturative stress was
the stronger predictor of poor mental health status more than 4 years after
migration.
2.3.4 Characteristics of the Host Society
The characteristics of the host culture and its treatment of immigrants may
mediate the stress response and may determine adaptation to the new
environment. It is believed that the greater the disparity between the
immigrant culture and the host culture, the greater the acculturative stress
(Hsu, Hailey & Rang, 1987; Wang & Ujimoto, 1998).
Bhugra (2004) notices that new immigrants continue to face difficulties with
language ethnicity, and transferability of their foreign qualification. They are
38
more likely than others to be alienated from mainstream society and to
experience poverty, isolation, depression, domestic violence, and substance
abuse. Prejudice and discrimination by the receiving population may also be a
source of stress. Culturally plural society or societies with a multicultural
ideology (Berry & Kalin, 1977; Berry, 1997) and availability of a network of
social and cultural groups, may provide support for those entering into the
experience of acculturation, and greater tolerance for or acceptance of
cultural diversity. Racial discrimination has deterred immigrants from seeking
the needed health and social services and from assimilating into the host
country.
Berry (1984) suggests that policies designed (by a policy of segregation) to
exclude acculturating groups from participating in the larger society to the
extent that they wish, by denying them access to the desirable features of the
larger society (such as adequate housing, medical care, political rights), may
cause them increased levels of acculturative stress (Berry & Kim, 1988).
2.3.5 Social Support
Previous researchers (Stewart, 1993; Gilliland & Bush, 2001; Sandstrom,
1996; Coffman & Ray, 1999; 2002; Simich et al., 2003) have confirmed social
support as an important concept with a positive relationship with health status
and mental health (Stewart, 1993). It is sustained by initiating and enhancing
coping behaviours (Gilliland & Bush, 2001), and promoting an increased
sense of personal competence (Sandstrom, 1996). These factors lead to
diminished distress and overall perceptions of well-being (Coffman & Ray,
1999, 2002; Simich et al., 2003).
Some researchers interpreted social support as “social capital — the quantity
and quality of interpersonal ties between people“ (Aday, 1994). Fukuyama,
(1995) points out that social capital, not only serves as a social, health, and
psychological resource, but also acts as a form of economic capital,
39
promoting productivity and material well-being. Finfgeld-Connett (2005)
showed that: “social support is an advocative interpersonal process that is
centred on the reciprocal exchange of information and is context specific. Two
types of social support were identified: emotional and instrumental. They are
preceded by a need for social support and a social network and a climate
conducive to the process (Finfgeld-Connett, 2005).
Migration and Social Support
One stressful aspect of migration is social isolation and the loss of social
networks that provide both emotional and instrumental support (Manuel et al.,
2002). Social support refers to the existence of social and cultural formations
for the support of the acculturating individual. Researchers (Bronfenbrenner,
1979; Martínez et al.,1996) have conceptualised immigration as a process of
ecological transition in which individuals face the challenge of re-building their
social support system. Social networks transform during the migration
process, and such changes may reduce emotional support and become a
source of stress (Vega et al., 1991).
The importance of social support in immigrants’ process of adapting to a new
society is covered in the literature. For example, Snowdson (2001) found that
social and familial ties and community institutions have played a crucial role in
permitting African-Americans to adapt socially and psychologically in the face
of stigma and social rejection. Simich et al. (2003) examined the role of social
support as a determinant of refugee well-being and migration patterns during
early resettlement. García, Ramírez and Jariego (2002) investigated
Moroccan and Peruvian immigrant women in Spain and identified social
support as an important predictor of psychological well-being in immigrant
adjustment.
According to Lee (1994), a strong social network is the best buffer against the
negative effects of migration. Social isolation is a cause of stress and is
40
directly related to psychological symptoms; social inclusion is a source of
psychological support, since it provides a sense of belonging and the feeling
that help is available (Thoits, 1992). For example, Die and Seelbach (1988)
found that Vietnamese immigrant women in the United States perceived a
high level of emotional support given by the family and church. The number of
friends and the social support given (Franks & Faux, 1990), the frequency of
contact (Griffith, 1984), the support of people the immigrant can trust (Vega et
al., 1986) and the number of people living with the family (Furnham & Shiekh,
1993) all help to lessen the effect of stress and protect the immigrant from
depression.
Immigrant Women and Social Support
Marital status in the social network plays a fundamental role in female
immigration (Salgado, 1987; Guendelman, 1987). Following migration, the
social support available to the women in the new country may be limited to
their partner alone. Immigrant women accompany their spouses and perform
the traditional female role of mother and wife, but lose autonomy due to the
economic and linguistic obstacles they are faced with in the host country.
Often those that depend economically on their husbands live in difficult
circumstances, experiencing feelings of isolation and loneliness (Vega et al.,
1986; Lynam, 1985).
In addition, the lack of social support is important following pregnancy and the
birth of a baby; this is when the women might usually depend on her mother
(Stuchbery, Matthey & Barnett, 1998). Thus, if a new mother is geographically
and emotionally isolated from the closeness of family and community, this
might increase the psychological distress of motherhood (Ward, 2003).
41
2.3.6 Language Proficiency
The ability to use the host country‘s language is a key feature in social
integration and acculturation. For example, Takeuchi and colleagues (2007)
investigated 2,095 Asian-American individuals recruited in 2002 and 2003.
The data from the National Latin and Asian American Study (NLAAS) have
shown that, in America, those proficient in English generally had a lower rate
of lifetime and 12-month disorders (i.e., lifetime and 12-month prevalence
rates for depression, anxiety, substance abuse, and psychiatric disorders),
compared with non-proficient speakers. Language proficiency was associated
with mental disorders for Asian Americans.
Language proficiency may serve as a marker of the ability of immigrants to
move outside their immediate social circles and expand their opportunities for
employment and for other types of social and economic resources. Hatter-
Pollara and Meleis (1995) point out that a language barrier could hinder
immigrant women from judging, applying for and obtaining health-relative
information.
In Taiwan, a previous study found that the ability to understand, speak, read,
and write Chinese positively influenced women within international marriages,
their families, and society (Chiu, 2000). Lee and Wang (2005) investigated the
predicting factors of a health-promoting lifestyle (HPL) in 124 Southeast Asian
women in trans-national marriages living in Taiwan. They found that
Southeast Asian women who could read and write Chinese had a more
positive HPL outcome, indicating a higher level of health responsibility and
better stress management, concluding that reading ability for Chinese was the
most significant predictor of HPL. Therefore, Southeast Asian women who
have Chinese reading and writing abilities were more able to obtain health
information and make decisions about their health (Lee & Wang, 2005).
42
2.4 Acculturation and Health Outcomes
The relationships between acculturation and various measures of stress and
health have been substantially investigated. Acculturative modes or strategies
may have an important role in the levels of resulting psychological stress
(Berry, 1988). As for different modes of acculturation, those who feel
marginalized tend to be highly stressed, and so are those who seek to remain
separate; in contrast, those who pursue integration are minimally stressed,
while assimilation leads to intermediate levels of stress (Berry & Kim,1988;
Berry,1990)
This pattern is now found widely in the literature. In terms of adaptation,
bicultural identities and integrationist attitudes predicted better psychological
adaptation and school adjustment, whereas separated and marginalized
identities were associated with the least favourable outcomes (Berry, 1997).
There are similar findings in Abu-Baker-K (1999), who pointed out that the
separation and marginalisation types of acculturation process are suspected
of being the main cause of immigrants’ psychological problems.
Current studies on acculturation attitudes and psychological functioning
suggest that integration is the most adaptive form of acculturation. In several
studies assessing the acculturation strategies of various immigrant groups in
North America, Berry and others (Berry, Kim, Power, Young & Bujaki, 1989;
Berry & Sam, 1997) found integration was the preferred mode of
acculturation, followed by either assimilation or separation, while
marginalisation tended to be the least preferred acculturation strategy.
Integrated individuals experienced less acculturative stress (Berry et al., 1988;
Sam & Berry 1995) and anxiety, and manifested fewer psychological
problems, than those who were marginalised or separated, who suffered the
most psychological distress (Berry et al., 1987; Berry, 1980; Berry, Kim, Mide
& Mok, 1987). Rumbaut (1991) found in his longitudinal study of Southeast
43
Asian refugees in the United States that the level of distress decreased over
time but that biculturalism (integration) emerged as a significant predictor of
low levels of distress.
People in marginalisation exhibit heightened confusion, anxiety, depression
and psychosomatic symptoms (Berry, 1989). Sam and Berry (1995) found a
consistent relationship between marginality and emotional distress amongst
young Third World immigrants in Norway. Another study shows that the
marginalised group of Chinese immigrants in America expressed feelings of
anger, disgust, and alienation with their immigration experience (Lieber et al.,
2001). In conclusion, feeling marginalised, uncertain, and out of control can all
have a negative impact on an individual’s willingness to explore and interact in
a new unfamiliar environment. In fact, it has been found that depression,
social withdrawal, familial isolation, despair, and obsessive-compulsive
behaviour are all related to low levels of acculturation (Miranda, Estrada &
Firpo-Jimenex, 2000).
However, other researchers (Zambrana, Scrimshaw et al., 1997; Cobas,
Hollenbach & Fullerton, 1998; Koshar, Lee et al., 1998; Heilemann et al.,
2000; Bond et al., 2002) argued that the relationships between the level of
acculturation and health outcomes among Hispanic immigrant women in USA
were weak or inconclusive.
On the contrary, researchers indicated that adherence to traditional beliefs
and values serve as buffers to the stressors of immigrants’ assimilation and
therefore encourage positive health behaviours among Hispanic women. For
example, Bond et al., (2002) asserted that Hispanic childbearing women with
little acculturation to the US have healthier pregnancies and infant than do
those Hispanic women who have become acculturated. Several authors
(Zambrana et al., 1997) report reduced rates of low birth weight infants among
less acculturated Mexican-American women. Less acculturated Hispanics
44
smoked less; used less alcohol and have better patterns of nutrition than their
non-Hispanic White counterparts.
In addition, Koshar et al., (1998) claimed that prenatal and postnatal
complications, such as anaemia, pre-term labour, and postpartum
haemorrhage were higher among more acculturated Mexican American
women and adolescents than among those less acculturated. To conclude,
Heilemann et al., (2000) observed that immigrant women who were more
oriented to their original traditions had fewer complications and risk factors in
pregnancy than those who had greater acculturation to Western customs.
Similarly, it has been noted that social isolation, lack of language abilities and
economic distress contribute to elevated acculturative stress among
Indonesian immigrant women in Taiwan (Yang & Wang, 2003).
2.5 Measurement of Acculturation
Acculturation is an important variable in cross-cultural research because it
helps to highlight and explain the great heterogeneity existing within ethnic
immigrant groups. The crucial point is that not every person in the
acculturating group will necessarily enter into the acculturation process in the
same way or to the same degree (Berry, 1987). Hence, assessment of
individual acculturation is an important aspect of acculturation research.
Careful and appropriate measurement of acculturation allows health
researchers to better understand the cultural determinants and correlates of
health behaviour and outcomes.
Since acculturation has tended to be conceptualised as multidimensional
(Rogler et al., 1991), the various indicators of acculturation have been
classified into such categories as behavioural, attitudinal, linguistic,
45
psychological, and socio-economic (Pierce, Clark & Kaufman, 1978; Olmedo,
1979; Olmedo, Martinez & Martinez, 1978).
Marino and colleagues (2000) proposed that changes may be either overt
(behavioural acculturation) or covert (attitudinal acculturation). Behavioural
acculturation is defined as the adoption of the most observable, external
aspects of the dominant culture, including language use, social skills and the
ability to fit into the new socio-cultural reality. Attitudinal acculturation refers to
the acceptance of the values, cultural beliefs, attitudes, ideologies, and norms
of the dominant group.
Berry (2003) noted that the acculturative process, and its effects on various
aspects of behaviours and attitudes, may vary greatly among different people.
The issues are language, religion, values, dress, food, male-female
relationship, parent-child relations, social activities, friendship choices,
schooling, media use, prejudice, and discrimination; the list is virtually
endless.
Zan and Mak (2003) identified 10 different domains assessed by the most
popular measures of acculturation: language use, social affiliation, daily living
habits, cultural traditions, communication style, cultural identity and/or pride,
perceived discrimination or prejudice, generation status, family socialization,
and cultural knowledge, beliefs, or values. These measures have assessed
behaviours, as well as attitudes related to acculturation, which reflect the wide
range of dimensions that researchers have used to assess acculturation.
They conclude that most of the scales measured the behaviour and attitude
aspects of acculturation (language use, social affiliation, daily living habits,
and cultural identity).
46
Linguistic domain : The most frequently dimensions proposed tend to involve
linguistic and/or behavioural aspects of immigrant adaptation (Kim, Laroche &
Tomiuk, 2001). Typically, language is the most salient domain used in
assessments of acculturation. The linguistic factor in various acculturation
scales generally accounts over for 70% of the variance in the total
acculturation score (Deyo et al., 1985). Linguistic dimensions essentially
reflect host language use, and preference and proficiency in various
interpersonal and social communication contexts. In addition, this is an
instrumental component of communication by which immigrants develop their
understanding of a new culture (Kim, 1977).
Social affiliation domain: Social interaction, or social relations in host
cultural environments, also appears at the forefront of many measures. This
domain involves the people with whom individuals choose to socialize and
affiliate (e.g. marry, play with, work with, and reside with); they access actual
affiliation practices or social preferences for these.
Daily living habit domain: Daily living habit or daily practice includes such
issues as the type of food eaten, dress, housing or the type of media used,
such as listening to the radio, watching television, and reading newspapers
and magazines. In these domains, measures of daily living habits or actual
practices can vary depending on preferences.
Cultural identity domain : The process of acculturation is often conceived of
as encompassing not only behavioural and/or linguistic components but also
attitudinal components. In these attitudinal domains, cultural identity is often
assessed, namely a person’s identification with either their ethnic culture or
the host culture. The measure can take in various aspects: actual
identification, sense of belonging, cultural pride, religious shift, or perceived
acceptance by a certain cultural group (Zane & Mak, 2003).
47
It has been emphasized (Berry, Trimble & Olmedo, 1986; Berry, 1990) that
assessment of acculturation strategies requires an instrument that is culturally
appropriate and culture-specific for the acculturation context. This is because
the issues and domains that arise during intercultural contact, and that initiate
the process of acculturation, vary from one intercultural contact situation to
another.
Indeed, it may not to be possible to create a “standard” measure of
acculturation to be used with every acculturating group, even for groups within
the same society (Berry, 2003). Thus, it is important to conduct preliminary
ethnographic research to establish the issues that arise from the two cultures
in contact, and then to develop and validate a measure of behavioural and
attitude acculturation from an emic perspective for acculturating individuals,
as recommended by Berry.
Clark and Hofsess (1998) suggested that acculturation measurement requires
careful scrutiny of available instruments, revision of the language and
geographically specific measures, and consideration of the meaning and
implications of the total score produced by measuring individuals. When
available instruments are not adequate or amenable to modification for the
purpose of the clinical or research setting, a new instrument may need to be
developed.
2.6 Measurement of Health Outcomes
Immigrant adjustment refers both to the health outcomes of acculturation and
to the process of dealing with acculturation. As for the outcomes of
acculturation, Zheng & Berry (1991) suggest that immigrant adaptation may
be indicated by an individual’s well-being. The process of acculturation has
psychological and physical consequences for immigrants. Researchers have
identified a wide range of measurement of psychological and physical well-
being.
48
Numerous measurement scales of psychological health, physical health
status, and physical functioning have been developed for use in the
assessment of health outcomes. Researchers have identified a wide range of
measurement domains for health-related quality of life, including emotional
well-being (e.g. measures of life satisfaction and self-esteem), psychological
well-being (e.g. measures of freedom from anxiety and depression), physical
well-being (e.g. measures of physical health status and physical functioning)
and social well-being (e.g. measures of social network structure and support,
functioning in social role) (Bowling, 1996).
2.6.1 Health Related Quality of Life (HRQOL)
From the battery of the Medical Outcome study, Ware and Sherbourne
published a short-form health survey called the SF36, an easy-to-use generic
measurement of quality of life (QOL). The measurement consists of eight
health concept subscales representing two broad dimension of QOL: physical
health and mental health.
The 36-item short-form (SF-36) was constructed to survey health status in the
Medical Outcome Study in the United States. The SF-36 was designed for
use in clinical practice and research, health policy evaluation, and general
population surveys. The instrument measures eight domains of health:
physical functioning, role limitations due to physical health, bodily pain general
health perceptions, vitality (energy and fatigue), social functioning, role
limitations due to emotional problems, and mental health (psychological
distress and well-being). It yields scale scores for each of these eight health
domains, and two summary measures of physical and mental health: the
Physical Component Summary and the Mental Component Summary (Ware,
Kosinski, Bayliss et al., 1995; Ware, Kosinski & Keller, 1995). It is a generic
health assessment tool measuring health-related quality of life (Ware, Snow et
al., 1993; 2000).
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2.6.2 Acculturative Distress
Acculturative distress has been found among immigrants from many
countries, expressed as depression, anxiety, demoralization, and
somatization (Williams & Berry, 1991). Acculturative stress is usually
manifested in the form of depression (because of culture loss) and anxiety
(because of uncertainties).
Depression
It has been reported that high acculturative distress may be a risk for
experiencing depression. Elevated acculturative stress was significantly
associated with higher depression (Hovey & Magana, 2000). Falcon (2000)
found that social economic status, household arrangements, acculturation and
health problems were suspected to be associated with depression. Hwang et
al., (2000), in a study of psychological predictors of first-onset depression in
Chinese Americans confirmed the previous evidence that psychological
vulnerabilities, including higher acculturation, greater stress exposure and
reduced social supports, were important predictors of risk for first-onset
depression episodes. Falcon (2000) pointed out that the effect of acculturation
was observed as strongly related to depression among Dominican elderly in
the USA.
In Taiwan, a qualitative study (Wang & Yang, 2002) on the trans-national
marriage of women who self-reported their health status, found that
psychological health problems included emotional obstacles posed by
immigration-related stress (fatigue, loneliness, anxiety, depression, worry,
sadness and loss); self-withdrawal, shock at the gap between expectations
and reality; and marital adjustment problems related to disparity between
present conditions and premarital expectations.
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Somatization
Somatization is the name often given to the ubiquitous human tendency to
experience and express psychological distress in the form of bodily symptoms
(American Psychiatric Association, 1994). In somatization, the body is used
metaphorically (Kleinman, 1986). Somatization is a creator of psychiatric
morbidity, especially anxiety and depression. Although somatization is a
common mode of illness expression in many cultures, it has been found to be
a mode of distress expression more frequently used by people from non-
Western cultures (Kirmayer, Young & Robbins, 1994; Kirmayer & Young,
1998).
The relationship between somatization, distress, and mental disorder is
viewed as culturally specific. Tucker (1997) showed that the pathways
between somatization and psychological distress varied with acculturation. In
Hispanic women with low acculturation, problems such as poverty or domestic
violence led directly to somatization, less often to depression. Some research
studies have also identified recent immigrants, or those who less acculturated
or more behaviourally ethnic, as more likely to somatize than their more
acculturated counterparts (Angel & Guarnaccia, 1989). Aroian and Norris
(1999) also support the previous impression that somatization is common
among former Soviet immigrants, and overlapping forms of somatization and
depression are related to the stress of immigration.
Somatization among immigrants is a diagnostic and research challenge
because somatization is a help-seeking behaviour shaped by cultural norms
and beliefs (Aroian & Norris, 1999). The relationships between somatization,
distress, and mental disorder are likely to be culturally specific. For example,
Kaouchararng or “thinking too much” has been identified as a culture-bound
syndrome found among Cambodian immigrants in the United States. It is
considered a direct result of stress, and manifests itself through headaches,
chest pain, palpitations, shortness of breath, excessive sleeping, and general
withdrawal behaviour (Breslin & Lucas, 2003).
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The most common finding in Vietnamese clinical samples is that
patients/clients tended to describe their discomfort using somatic terms
(Cheung & Lin, 1997; Matkin, Nickles, Demos & Demos, 1996; Williams &
Berry, 1991). Frequently mentioned symptoms included headache, insomnia,
palpitation, aches and pains, dizziness, fatigue, poor memory and poor
concentration.
In Taiwan, Yang and Wang (2002) found that Indonesian immigrant women
described their first-year experiences of adjustment with evidence of bodily
ailments like loss of appetite, homesickness, crying at night, insomnia,
sleeping disorders and even psychosomatic complaints, such as
neurasthenia, headache, heartburn, loss of voice, fatigue, syncope, and skin
itching. These could be traced back to psychological anxiety and stress.
2.6.3 Psychological Well-being
Psychological well-being refers to the presence of wellness and is a
description of positive psychological functioning, as opposed to psychological
dysfunction. Psychological well-being has been positively associated with
internal control, self-esteem, and life satisfaction, and as negatively related to
depression, chance control, and powerful others (Ryff & Singer, 1996; Ryff &
et al., 1998). This functioning tends to be relatively consistent over time, and
can be viewed as a dispositional characteristic of individuals, a predisposition
to good mental health and resilience, given the stressful nature of post-
immigration experiences (Kuo & Tsai, 1986; Pernice & Brook, 1996).
2.7 Current Studies in Taiwan
Despite the rapid growth in the numbers of Vietnamese immigrants in Taiwan,
there have been a limited number of health-related studies on Vietnamese
immigrant women or other subgroups of immigrant women coming from SEA
52
countries. Most academic studies (Lee, 2006;Gong, 2006;Tian & Wang, 2006;
Ko & Chang, 2006) on SEA immigrant women in trans-national marriages
take a macro-sociological approach, from the perspectives of sociology,
capitalism, economic labour, globalisation and cultural diversification, in
discussing their social networks, family relationships and forms of marriage.
Benjen (1996) pointed to adaptability of foreign spouses to living and culture
as a key success factor in married life involving Chinese and foreigners. Liu et
al., (2001) suggested that the healthcare community should consider cultural
adaptation issues of foreign brides from a professional viewpoint, and take the
initiative to actively develop cultural sensitivity, so that foreign brides receive
proper medical care under the different medical system (Liu, Chung & Hsu,
2001). Wang and Lee (2005) emphasise the language ability to read and write
in Chinese as a predictive factor of a health-promoting lifestyle (HPL) in
Southeast Asian women in Taiwan. Recently, Lin & Wang’s (2007) study
focused on Southeast Asian pregnant women and found they have irregular
prenatal examination behaviour. Lin, Wang & Chung’s (2007) qualitative study
explores that experience for Vietnamese primipara in Taiwan.
Previous qualitative studies have generated rich descriptions of stressors
associated with SEA immigrant women’s experience in Taiwan (Benjen, 1996;
Xia, 1997; Chang, 1999; Xia, 2000; Liu, Chung & Hsu, 2001; Yang & Wang,
2003; Lin, Wang & Chung, 2007). However, qualitative research does not
provide the level of qualification that is necessary for testing hypotheses, nor
is it particularly well suited for generalization of study findings to other SEA
immigrant subgroups (Lincoln & Guba, 1985).
The Research Gap
As Taiwan has been a member of the WTO (World Trade Organization) since
2002, further impacts of multicultural society and globalisation are expected,
so acculturation of migrants and changes in their health status should be an
53
important focus of health-related research. Although the linkages between
migration and acculturation have been acknowledged across the world,
Taiwan has only seen limited research on the acculturation and health
outcomes among these groups of women. The absence of an accepted
measure of acculturation and health outcomes is one of the barriers to
exploring the relationship between acculturation and health.
The process of acculturation can potentially make immigrant women
particularly vulnerable in Taiwanese society, as it often involves cultural
alienation, communication difficulties due to lack of language proficiency, and
racial discrimination. In spite of the multifaceted information about these
immigrant women, few studies have examined the effects of acculturation
indicators in relation to health outcomes among cross-cultural women.
Furthermore, there is a lack of evidence based on health studies among these
minority groups, especially those conducted in cross-sectional quantitative
research designs with Vietnamese immigrant women.
2.8 Summary
This chapter reviewed the literature about acculturation theory and immigrant
health. In addition, it attempted to show that immigrant women tend to have
more health problems in their process of assimilating to the host society. The
review of the literature has demonstrated that, although an overwhelming
amount of related research has dealt with the health of immigrants, little
research covered evidence based on health studies among these minority
groups. To challenge some of these limitations, it is important to establish a
theoretical understanding of the psychological adaptation frameworks of
immigrant women as well as the significant variables that influence their well-
being.
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55
Chapter 3 Methodology
Introduction
This chapter will present the research design, the research strategies, the
participants, the sample (including sample size and sample size calculation),
instrumentation, variable measurement, reliability and validity, and data
management, and data analysis plan. The ethical considerations associated
with this study will also be discussed.
3.1 Research Design
The aims of this study were to examine the relationships between
acculturation and acculturative distress and health outcomes among
Vietnamese marriage immigrant women in Taiwan. The quantitative study
was divided into two phases: the first was a pilot study and the second the
main study.
The objectives of these two phases of the study were:
Phase one study: Pilot study
1. To obtain permission to produce a Vietnamese version of the Acculturation
scale, the DI scale and the SF-36 scale.
2. To translate and validate the research instruments.
3. To test protocols, data collection and sample recruitment strategies.
4. To conduct a pilot study to test the reliability and validity of the revised
survey instruments.
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Phase two study: Main survey
1. To utilise the revised scales to identify the acculturation mode used by
Vietnamese immigrant women in Taiwan.
2. To examine the relationships between acculturation and demographic
factors, acculturative distress, and health outcomes among Vietnamese
immigrant women in Taiwan
3. To identify acculturation impact factors on health outcomes among
Vietnamese immigrant women in Taiwan.
3.2 Sampling Recruitment and Sample Size
3.2.1 Sample Recruitment
Two sampling techniques that were used in this phase: (a) convenience
sampling, drawn from registration records at the Public Health Center of
Kaohsiung and (b) snowball or chain sampling, with participants referred to
researchers by other participants of the study. Study participants were
recruited through convenience sampling at first, and subsequently through
snowball sampling.
Sampling by convenience could be an economical and easy way to begin in
the sample process in this study. This study was conducted in a community-
based health centre in the south of Taiwan, targeting Taiwanese households
with Vietnamese wives in the south of Taiwan, including the Tanam,
Kaohsiung, and Pentong areas. This involved convenience sampling with
participants drawn from registration records at the Public Health Centre of
Kaohsiung.
The snow-ball technique
Snowball sampling is useful when the people being studied are well
networked and difficult to approach directly and it is also often used to access
57
hidden populations. Furthermore, with an introduction from a referring person,
researchers can have an easier time establishing a trusting relationship with
new participants (Polit & Beck, 2005, p.306).
Yang & Wang (2003) have described social isolation among Indonesian
immigrant women in Taiwan. Due to fears about them running away to
Vietnam and precipitating financial losses for their husbands, these women
are often intentionally prevented by husbands and parents-in-law from going
out alone and making social contacts with others. For this reason, snowball
sampling could be the most appropriate strategy to gain access to these
hidden and isolated populations.
3.2.2. Sample Size Estimation
Power analysis was used to calculate the sample size of the phase 2 survey.
A number of factors were taken into consideration. Polit and Beck (2004)
suggest that effect sizes in nursing research tend to vary between small and
moderate, and seldom rise above 0.5 of standard deviation. In Polit and
Shermen’s (1990) analysis of effect sizes, the correlation found in nursing
studies was in the vicinity of 0.20. With an α of 0.05 and power of 0.80, the
sample size needed in the study lies around 197 and the effect size equals
0.20.
Another relevant finding, was based on Chandler and Miller’s (2002) study
that examined the acculturative stress contributing to depression among
immigrants from the former Soviet Unit in America, in which the sample size
was 200 women. In addition, Green (1991) proposed a rule: N ≥ 50+8m
(where m is the number of independent variables), to calculate the sample
size for multiple regression. The rule assumes an alpha of 0.05, and a power
of 0.08 with medium effect size. It is estimated there are 18 independent
variables in this study, that is m=18. From this formula, N ≥ 50+8×18, hence
the minimum sample size is 194 subjects. In the event, the effective sample
size was 200.
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3.2.3 The Participants
The inclusion criteria are as follows:
• female Vietnamese immigrant;
• married to a Taiwanese man;
• has basic conversational ability in Taiwanese or Mandarin;
• has basic reading ability in the Vietnamese language; and
• is willing to participate.
The exclusion criteria are:
• women hospitalised for psychiatric illness in the past 12 months; or
• taking antipsychotic medication; or
• illiterate in the Vietnamese language.
3.2.4 Data Collection
The data collection was carried out in the participants’ homes, or at public
health centres with the consent of the individuals. The researcher employed a
well-structured questionnaire to collect the data. The study objectives were
fully explained before each survey. Each survey took about 15 to 20 minutes.
3.3 Instrumentation
The researcher first obtained permission to use the instruments from the
authors who developed them (Appendix 4, 5, 6). This questionnaire was then
translated from English to Vietnamese. Cross-translation was then done from
Vietnamese to English to ensure that meaning was not lost in translation.
59
The instruments included the following measures: (1) Socio-demographic
information (2) Acculturation (3) Acculturative distress, and (4) Health
outcomes. Questions related to immigrant women’s acculturation level and
health status were modified. The sample questionnaires are attached as
Appendix 3.
3.3.1 Socio-demographic Information
The socio-demographic Information included: age, marital status, religion
ethnicity, overseas Chinese background, education, length of residency, pre-
and/or post-migration occupation, employment status, number of children and
the spouse’s age, occupation, level of education, religion and employment
status.
3.3.2 Acculturation Measurement
The Suinn-Lew Asian Self-Identity Acculturation Sca le (SL-ASIA).
The acculturation questionnaire was adopted and modified from the Suinn-
Lew Asian self-identity acculturation Scale (SL-ASIA). The Asian self-Identity
Acculturation Scale (SL-ASIA; Suinn, Rickard-Figueroa, Lew & Vigil, 1987) is
the most widely instrument used for assessing acculturation variation among
Asian Americans. This scale was initially conceptualised for use with
respondents of East Asian background (Chinese, Japanese, Korean,
Vietnamese and Cambodian Americans) in the United States. It is a 21-item
instrument, consisting of multiple-choice questions, many of which had been
adopted from the Acculturation Rating Scale for Mexican Americans (ARSMA;
Cuellar, Harris & Jasso, 1980) as a developmental model (Suinn et al. 1987).
The SL-ASIA assesses language preference (4 questions), friendship choice
(4 questions), cultural identity (4 questions), behaviour (5 questions), and
generational and/or geographic history (3 questions). These responses are
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score on a 5-point Likert scale. In scoring these 21 items, each answer for
each question on the scale was added up, and then a total value was
obtained by summing across the answers for all 21 items. A final acculturation
score is then calculated by dividing the total value by 21, hence the score can
range from 1.00 to 5.00; a low score reflects low acculturation, while a high
score reflects high acculturation.
Another way of interpreting the total score relies upon recent discussions
pointing out that there are actually three dimensions of acculturation. Thus, a
person may be entirely assimilated into the new culture in all three ways; this
would be called "assimilation" and would be represented by an SL-ASIA score
of "5". Another person may retain the identity of their ethnic heritage and
refuse attempts to become integrated into the host society; this would be
called "separation" and would be represented by an SL-ASIA score of "1".
Finally, it is now recognized that a person may be capable of assuming the
better of the two societies; the term used in this case is "bicultural" and would
be reflected in an SL-ASIA score of "3" (Suinn, Ahuna & Khoo, 1992).
Suinn and his colleagues (1992) suggest that the original 21-item scale
cannot serve to classify research participants in terms of the current theory
that acculturation is not linear and uni-dimensional but multi-dimensional and
orthogonal. Five new experimental questions (Questions 22 and 23, 24 and
25, and 26) have been devised for researchers who want to include such
items. Using item 22 and item 23, the procedure involves categorizing and is
not on a continuum. For convenience, name the scoring of item 22 and 23 the
“value score”; item 24 and 25 the “behaviour competencies score” and item
26 the “self-identity score”. The SL-ASIA was modified in this study, replacing
“Asian” by “Vietnamese” and “Western” by “Taiwanese”, to assess
acculturation in different dimensions. The modified scale treats acculturation
as a multi-dimensional construct.
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Reliability and Validity
The results demonstrated high internal consistency reliability across different
Asian American samples, with Cronbach’s alpha ranging from 0.88 to 0.91
(Atkinson & Gim.1989; Suinn et al., 1987; Suinn, Ahuna & Khoo, 1992). Suinn
et al., (1992) used the principal components method with an oblique rotation,
considered values above 1.0 and factor loadings above 0.50. According to the
authors, five interpretable factors emerged, accounting for 69.7% of the
common variance: reading, writing, and cultural preference (5 items; 8.71;
41.5% of common variance) ethnic interaction (3 items; 2.25; 10.7%), affinity
for ethnic identity and pride (3 items; 1.39; 6.6%), generational identity (4
items; 1.23; 5.9%), and food preference (2 items; 1.06; 5.0%).
Strong and consistent convergent-related validity evidence was found in five
studies (Park & Harrison, 1995: Suinn et al., 1992; Suinn et al., 1995; Suinn et
al., 1987; Tata & Leong, 1994). More recently, researchers (Ownbey,
Horridge 1998; Suinn et al., 1995) distributed the SL-ASIA to Asians living in
Singapore. Cronbach’s alpha was 0.79. The resultant factors matched the
same five factors closely and accounted for 65% of the variance.
3.3.3 Acculturative Distress Measurement
The Demand of Immigration Specific Distress Scale ( DI)
The acculturative questionnaire was translated and modified from the
Demands of Immigration scale developed by Aroian and colleagues (1998),
which has been the only instrument available to nurses and other health care
professionals; it is appropriate for measuring immigration-specific distress.
The first psychometric evaluation of the DI scale was completed with a
sample of 1,647 former Soviet immigrants who had resided in the United
States from a few months to 20 years. This scale consisted of 23 items rated
on a 4-point Likert-type scale ranging from 0 (not distressed at all) to 3
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(distressed very much). High scores indicate high levels of distress related to
the demands of immigration.
There were six subscales found, from the meta-ethnography that generated
the content domain for the DI scale, that were also consistent with findings
from interviews with other immigrant groups, (Aroian, 1990; Baker et al., 1994;
Baider et al., 1996; Lipson & Omidian, 1997), including: loss, novelty,
occupational adjustment, language accommodation, discrimination, and not
feeling at home in the receiving country (Aroian et al., 1998). The loss
subscale elicits information about longing for unresolved attachment to
people, places and things in the homeland. The not feeling at home subscale
asks about feeling like a stranger or a foreigner, who is not part of one’s
surroundings or included in the social structure. The novelty subscale asked
about newness, unfamiliarity, or information deficits related to living in the new
country. The occupational adjustment subscale taps the difficulty of finding
acceptable work, status demotion, and lack of opportunities for professional
advancement.
The language accommodation subscale pertains to the immigrant’s subjective
perception of the host language, including extent of vocabulary,
comprehension of local dialect, and ability to be understood given the strength
of one’s accent. Finally, the Discrimination subscale includes items about
active or subtle discrimination, such as being made to feel as if immigrants do
not belong in the host society or do not deserve the same rights as the native
born.
Reliability and Validity
The first psychometric evaluation of the DI scale was completed with former
Soviet immigrants in the Boston area of USA (Aroian & et al., 1998). The DI
subscales were internally consistent and showed good test-retest reliability,
with Cronbach’s α of 0.82 to 0.95 for internal consistency and Pearson’s r of
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0.78 to 0.92 for test-retest reliability of the total scale and subscales. Thus,
overall, items of the DI scale were consistent in measuring the construct of
distress related to immigration (Tsai, 2002).
With regard to validity, concurrent validity was demonstrated by a positive,
moderate correlation between the DI scale total scale and subscale scores
and other measures of depression and somatization. Discriminate validity was
evidenced, as shown by significant differences in age effect and the length of
stay in the USA on each subscale (P>0.0001). Tsai (2002) ran a pilot study to
evaluate the readability and psychometric properties of the Chinese version of
the DI scale among Taiwanese-Chinese immigrants in United States, which
showed that the Chinese version is easy to read and understand. The internal
consistency and test-retest reliability are satisfactory. Cronbach’s α for the
total scale was 0.92, which suggests adequate internal consistency of the
scale in measuring the construct of interest. The alphas for subscales ranged
from 0.68 for the novelty subscale, to 0.90 for the not at home subscale (Tsai,
2002).
The DI scale would be appropriate to use as a generic measure of
immigration-related distress (Tsai, 2002). Aroian et al. (1998) suggested that
the DI scale not only provides information about immigrants at risk of distress
but also identities the types of stressors that are most problematic for certain
individuals and subgroups. This information would assist nurses working with
immigrant populations to accurately identify the source of their distress and to
develop theoretically relevant interventions to alleviate it. Furthermore, the DI
scale can be used to identify individual and situational differences among
immigrants that may buffer the stress of immigration.
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3.3.4 Health Outcomes Measurement
The Health Related Quality of Life (HRQOL) — SF-36
The acculturative questionnaire was translated and modified from one of the
numerous available health status measures, the Short Form-36vs2 (SF-36), a
multipurpose, short-form health survey with only 36 questions. The SF-36 was
developed by Ware and associates in 1992, and was designed for use in
clinical practice and research, health policy evaluation, and for general
population surveys (Ware, Snow et al., 1993; 2000). It is used as the principal
measure of health status outcomes in this study. There are three
considerations to take into account (Ware & Sherbourne, 1992).
First, the SF-36 is based on a multidimensional model of health that was used
to assess the many dimensions of health status and well-being. This 36-item
survey measures eight domains of health: physical functioning (PF), role
limitations due to physical health (RP), bodily pain (BP), general health
perceptions (GH), vitality (energy and fatigue) (VT), social functioning (SF),
role limitations due to emotional problems (RE), and mental health
(psychological distress and well-being) (MH) (Ware et al., 1993; 2000).
It produces scale scores for each of these eight health domains, and also two
summary measures of physical and mental health: the physical component
summary (PCS) and the mental component summary (MCS) (Ware, Kosinski
& et al., 1995; Ware, Kosinski & Keller, 1995). It is a generic health
assessment tool measuring health-related quality of life outcomes (Ware et
al., 1993; 2000).
Second, compared with other health status measures, the SF-36 contains
fewer questions. Because of its brevity and its comprehensiveness, the SF-36
is less difficult to translate and is easy to administer. The instrument has only
36 questions, and has proven useful in surveys of general and specific
populations (Ware, 1992). The SF-36 currently has been translated into 14
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languages, and the psychometric test results for the translated versions
indicate that SF-36 is a reliable generic health survey instrument across
different nations (Ware, 2000). Finally, the 36-item short-form (SF-36) is a
well-validated instrument for assessing health status that is widely used for
clinical and research purpose (Bowling, 1997).
Calculating the overall SF-36 score involves transforming the raw scale
scores to a 0 to 100 scale using the formula below (Ware, Kosinski & Dewey,
2002). Transformed Scale= [Actual raw score-lowest possible raw score] /
possible raw range x 100. Each subscale score varies between 0 and 100,
and the higher the score the better the health condition (Tanriverdi et al.,
2003).
Prior to using the SF-36 scoring rules, it is essential to verify that the
questionnaires being scored, including the questions asked (item stems), the
response choices and the numbers assigned to response choice at the time of
data entry, have been reproduced exactly.
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Figure 3.1 SF-36 Measurement Model (Ware, Kosinski & Dewey, 2002)
Ware, Kosinski and Dewey (2002) illustrated the taxonomy of items and
concepts underlying the construction of the SF-36 scales and summary
measures (see Fig. 3.1). The taxonomy has three levels: (1) the 36 items; (2)
eight scales that aggregate 2 to 10 items each; and, (3) two summary
measures that aggregate those scales. All but one of the 36 items (self-
reported health transition) was used to score the eight SF-36 scales. Each
item contributes to the scoring of only one scale (Ware, 2000).
The MH scale has been shown to be useful in screening for psychiatric
disorders (Berwick, 1991; Ware et al., 1994), as has the MCS summary
measure (Ware et al., 1994). For example, using a cut-off score of 42, the
MCS had a sensitivity of 74% and a specificity of 81% in detecting patients
diagnosed with depressive disorder (Ware & et al., 1994). Specifically, the
MH, RE, and SF scales and the MCS summary measure have been shown to
67
be the most valid of the SF-36 scales as mental health measures (Ware,
2000).
The PF, RP, and BP scales and the PCS summary have been shown to be
the most valid SF-36 scales for measuring physical health. Criteria used in the
known-groups validation of the SF-36, which include accepted clinical
indicators of diagnosis and severity of depression, heart disease, and other
conditions, are well documented in peer-reviewed publications and in the two
users’ manuals, (Kravitz, Greenfield, Rogers, Manning, Zubkoff, Nelson,
Tarlov & Ware, 1992; McHorney et al., 1993; Ware et al., 1993; Ware et al.,
1994; Ware et al., 1995).
Reliability and Validity
The SF36 is an instrument for measuring health perception in a general
population. It is easy to use, acceptable to patients, and meets high criteria of
reliability and validity. A minimum Cronbach's alpha coefficient of 0.7 is
considered satisfactory for group level comparisons. Validity was assessed
using convergent and discriminate validity checks, factor analysis, and
construct validity (Ware et al., 1994). Extensive literature reviews are reported
by Ware to confirm the high psychometric standards of the tool. Means and
standard deviations for all SF-36 scales have been standardized to a mean of
50 and standard deviations of 10, in the general U.S. population.
Because the SF-36 is a generic measure, there are some concepts not
included; sleep adequacy, cognitive function, sexual functioning, health
distress, family functioning, self-esteem, eating, recreation and hobbies,
communication, and symptoms and problems that are specific to one
condition (Ware, 2000). However, according to McDowell and Newell (1996),
the short form Health survey (SF-36) was designed as a generic indicator of
health status for use in population surveys, and also for specific measures of
outcome in practice and research. This instrument has been widely used in
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many previous research studies (McHorney, Ware & Raczec, 1993;
McHorney, Kosinki & Ware 1994; McHorney & Ware 1995; Davis et al., 1998).
The SF-36 has shown excellent psychometric properties when used in large
population studies and in many different clinical situations (Genazzani et al.,
2002).
Norm of SF-36 Taiwanese version
A comparison of the norms of Health Related Quality of Life – SF-36
(HRQOL) was made between Vietnamese and Taiwanese. The norm of SF-
36 Taiwanese version are recorded from the centre for Population and Health
Survey Research, Bureau of Health Promotion, Department of Health in
Taiwan (Tseng, Lu & Tsai, 2003). The norm scoring of the Taiwanese SF-36,
was conducted with 18,142 subjects aged 12 and above from the “2001
Health Interview Survey” (Lu, Tseng & Tsai, 2002). Norming and validation of
SF36 Taiwanese version was performed on a valid sample of 17,515
subjects. Subscale correlation coefficients range from 0.40 to 0.83. Also,
internal reliability has been reported to be acceptable level for all scales (α>
0.70). In summary, the SF-36 Taiwanese version was shown to possess good
psychometric properties (Lu, Tseng & Tsai, 2002).
Tseng, Lu, and Tsai’s (2003) study aim to establish the norms of the SF-36
Taiwan Version and to test criteria-validity underlying the scale construction.
Tseng, Lu, and Tsai’s (2003) study indicated that male subjects tend to score
significantly higher than females on all scales (p<0.0001). As age increases,
the scale in the physical health dimension tends to decrease, while the age
effect on the scales in the mental health dimension is less pronounced. Using
age ranges as criteria, preliminary results from the criteria validity testing
performed on younger (25-34 y/o) and older (55-64 y/o) adults found similar
patterns to the US version. The norm of the SF-36 Taiwan version, therefore
can serve as a valuable reference for cross-cultural comparison research (Lu,
Tseng & Tsai, 2003).
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3.3.6 Instrument Translation
Linguistic validation is extremely important in this study, since most of the
questionnaires were originally developed in English. The process of linguistic
validation provides confidence by ascertaining that the translated versions of
the instrument will be culturally relevant to the target country and conceptually
equivalent to the original versions. The instruments were processed through a
procedure of forward translation, back translation and comparison of results
(Brislin, 1986).
The researcher first obtained permission to use the Instruments from the
authors and institutions that developed these instruments. The researcher
arranged forward translation; the Vietnamese version of the questionnaire
being prepared by two independent Vietnamese translators, bilingual in
English and Vietnamese, who are PhD students in the Faculty of Health. A
third person, a Vietnamese social worker familiar with English and
Vietnamese who has experience working with Vietnamese transnational
marriage women in Taiwan than saw the translations. Based on this
evaluation, modifications were made to several items. In particular, formal
language was modified to everyday language suitable for laypersons, for the
Vietnamese women participants to read and answer.
The result of the consensus version of the forward translation was then
translated back by two other independent bilingual Vietnamese translators;
the results being reconciled to obtain a consensus version. After the individual
translations were made, the translators all met together in a consensus
session to discuss discrepancies and potential translation problems and
create a final version of the translated questionnaires. Three health
professionals were invited to examine the face validity in terms of the clarity
and adequacy of the wording of the translated questionnaire. In order to
obtain content validity, the health professionals were further asked to assess
70
the relevance and appropriateness of each item in representing its measured
variables. Finally, the questionnaire was pilot tested with a convenience
sample of 20 Vietnamese trans-national marriage women.
3.4 Data Management
3.4.1 Data Management Procedures
All questionnaires were stored in a secure locked filing cabinet in a room that
was locked when it was unattended. The data were stored electronically and
password protected. After collecting the data, it was scrutinized for invalid or
missing data, where the participants did not answer the questions or
misclassified the information. Manual coding and double entry verification
data entry was required. In the pre-analysis phase, outliers or extreme values
have been checked. In the preliminary assessments, the missing values were
checked as to whether they were dependent, independent, or descriptive
variables and whether the missing data was random. When the missing
values were reasonably random, they were substituted with the mean value.
3.4.2 Data Analysis Procedures
Quantitative data was coded and entered into the Statistical Package for
Social Science (SPSS) program for statistical analysis (version 14) (Green &
Salkind, 2005). Data screening was first performed by examining the
frequencies, means, standard deviations, ranges, and graphic representations
of the scores on research variables (Tabachinick & Fidell, 1996). The data
analysis process involved descriptive, bivariate, and multi-variate analysis.
The analysis strategies of the quantitative data for this study are shown in
Table 3.1.
71
Descriptive analysis of the data was calculated for all variables and scales
through the SPSS program. Frequencies and percentages have been used to
describe participants’ demographic information, such as age, educational
level, length of residence in Taiwan, numbers of children and so forth. Means
and standard deviations have been used to present variables such as scores
of acculturative stress and health outcomes.
The main dependent variables were defined as acculturation, health
outcomes, and acculturation distress. All independent variables have been
compared with the main dependent variables to establish relationships, using
set correlation techniques. Pearson’s Correlation and Spearman’s Correlation
have been used to test the existence of a relationship between two variables,
including: age, marriage status, years in Taiwan, and numbers of children with
levels of acculturation, acculturation stress and health outcomes.
Analysis of variance used ANOVA to test the difference among the means of
Independent groups: (i.e., religion, generation background, marital status,
employment status, spouse’s employment, spouse’s education and mode of
acculturation) for health outcomes and acculturation stress. The Chi-square
test, a non-parametric test of statistical significance used to assess whether a
relationship exits between two nominal-level variables was used to examine
the associations between: religion, generation background, marital status,
employment status, spouse’s employment, spouse’s education and
acculturation strategies.
Due to the multivariate nature of the data, regression techniques have been
employed to determine the ranking of the variables in order of their influences
on the dependent variables. Multiple regressions were to examine the
simultaneous effects of age, years of marriage, years in Taiwan, and levels of
acculturation on health outcomes or acculturation stress. Statistics have been
reported at the conventional 5% confidence level.
72
The Classification and Regression Trees (CART) approach (Breiman,
Friedman, Olshen & Stone, 1993) was conducted to predict the significant
acculturative related risk factor on the health outcomes among Vietnamese
immigrant women in Taiwan. Conventional statistics were run through
StatView for Windows (SAS Institute Inc., version 5.0.1,1998); CART was run
through CART Salford Systems (Holford, 2002). This modelling was applied to
a series of variables potentially predictive of HRQOL among Vietnamese
immigrant women.
73
Table 3.1 Strategies for analysis of quantitative data for this study
Measurement Level
Independent variable Dependent variable
Continuous Continuous
Descriptive
Analysis
Bivariate
Analysis
Multi-variate
Analysis
Demographic:
1.Age
2.Years in Taiwan
3.Number of children
Level of acculturation
1.Linguistic competence
2.Social support
3.Daily practices
4.Identity
Acculturative distress (DI)
Health outcomes (SF-36)
1.Physical functioning
2.Role limitations due to
physical health
3.Bodily pain
4.General health perception
5.Vitality
6.Social functioning
7.Role limitations due to
emotional problems
8.Mental health
Acculturative distress (DI)
Mean (S.D)
Median (Range)
Pearson’s Correlation
if normally distributed
Spearman’s Correlation
if not normal distribution
Purpose:
To test the existence of a relationship between two variables
Multiple Regression
Purpose:
To examine the simultaneous effect of two or more independent (predictors) variables on a dependent variable
Classification and Regression Trees (CART)
Nominal Continuous
Health outcomes (SF36)
1.Physical functioning
2.Role limitations due to
physical health
3.Bodily pain
4.General health perception
5.Vitality
6.Social functioning
7.Role limitations due to
emotional problems
8.Mental health
Level of acculturation
Acculturation (ACC)
1.Linguistic competence
2.Social support
3.Daily practices
4.Identity
Acculturative Distress (DI)
Continuous
Mean (S.D)
Median
(Range)
ANOVA
Purpose:
To test the difference among the means of independent groups, or independent variables.
Nominal
Demographic:
1.Religion
2.Ethnic background
3.Education level
4.Employment status
5.Spouse’s employment
6.Spouse’s education
7.Spouse’s religion
Mode of acculturation
Mode of Acculturation
Frequency
Percentage
Chi-Square Purpose: Test significance between two nominal-level variables
74
3.5 Ethical Statement
In order to protect human rights, participants were made aware of the purpose
of this research before they consented to be involved in the study. The study
procedures were fully described in advance, the participants had an
opportunity to decline participation and appropriate consent procedures were
implemented.
The participants in this study did not experience any physical harm,
discomfort or psychological distress. They were fully aware of participating in
a study and understood the purpose of this research by giving their informed
consent. There were many appropriate steps taken to safeguard the privacy
of participants. The researcher explained that code numbers would be used
instead of personal private information. They were given a copy of the
informed consent (see Appendix 1) form that included a statement of their
rights as subjects and the name and phone number of a contact person
should they have any questions.
For confidentiality, each questionnaire was marked with the participants’ code
instead of their name and separated from the informed consent sheets. The
researcher stored identifying information and lists of identification numbers
with corresponding identifying information in a locked file. Only non-identifying
information was entered onto computer files. When the research reports were
published, their names were not associated with the publication.
Ethical Approval had been sought and given for this project by the University
Human Research Ethics Committee (UHREC), on 03/11/2005 QUT ref no
4290H, and is valid for three years. The project has qualified for Level 1 (Low
Risk) ethical clearance status. The Ethical Approval and Research
Agreements are attached as Appendix 1.
75
3.6 Summary
This methodology chapter has outlined the justification for the study design.
Participants, sample (including sample size and sample size calculation),
instrumentation, variables measurement, reliability and validity, and data
management, and data analysis plan were established. These allowed the
researcher to modify quantitative scales and to employ regression and
correlation statistical methods. All these methods have been used in
addressing the research questions regarding the factors affecting Vietnamese
immigrant women’s acculturation and well-being. The ethical considerations
associated with this study have also been identified. The following chapter
outlines the pilot study.
76
77
Chapter 4 Pilot study
Introduction
This chapter presents the Phase I Pilot study, outlining sample recruitment,
strategies and procedure, instrument translation and modifications to the
items of the Acculturation Scale, the Demands of Immigrant Stress (DI) Scale,
and the Health Related Quality of Life (HRQOL). Finally, the results of the
Pilot study will be discussed.
4.1 Phase 1 study
4.1.1 Pilot Study
A pilot study is one of the necessary steps in the research process. The
function of the pilot study is to obtain information for assessing the project’s
feasibility and for improving it. The purpose of the pilot study in this case was
not to test research hypotheses, but rather to test protocols, data collection
instruments and sample recruitment strategies. It also checked the stability of
the research instrument, using a test-retest procedure to compute a reliability
coefficient, the magnitude of which indicates the instrument’s reliability for the
larger study (Polit & Beck, 2004, p.196). In addition to determining the
feasibility of the major study, one purpose of this Pilot study was to test the
translated Vietnamese versions of the Acculturation scale, DI scale and SF-36
scale prior to their use in the main study.
78
4.1.2 Sample Recruitment Strategies & Procedure
The pilot study was conducted with a snowball sampling in Taiwan from May
2006 to July 2006. Twenty Vietnamese trans-national marriage women
participated in the pilot study, recruited by a snowball sampling technique.
Selection criteria: Vietnamese woman immigrant, married to a Taiwanese
man; able to understand Taiwanese or Mandarin; has basic reading ability in
the Vietnamese language; and willing to participate.
The snowball technique was followed; the researcher first contacted a few
female acquaintances with a Vietnamese trans-national background and
obtained their agreement to participate in this study. These participants were
then asked to identify and refer other women who met the eligibility criteria.
The researcher contacted the women by telephone to obtain their initial oral
consent. The place for a face-to-face questionnaire interview was chosen by
the participant, the most common interview location being the participant’s
home or workplace.
All the participants were notified of the purpose of this study and agreed to re-
answer the questionnaire two weeks after the first interview. They were also
informed that they were free to withdraw or discontinue the interview at any
time, or to refuse to respond to any question that made them feel
uncomfortable. In order to examine its face validity, all the participants were
also asked to give suggestions about the wording of the instrument.
4.1.3 Instrument Translation
Linguistic validation is extremely important in this study as most of the
questionnaires were originally developed in English. The process of linguistic
validation confirms that the translated versions of the instrument will be
79
culturally relevant to the target country and conceptually equivalent to the
original versions. The procedure consists of forward translation and back
translation of the instrument and comparison of the results (Brislin, 1986).
Consensus meeting
Forward translation
Consensusmeeting
Backtranslation
Consensus meeting
Version
1
Version
11
Version
2
Version
2
Version
3
Version
3Pilot test
Final
version
Final
version
2 translators &
Research
2 bilingual translatorsEnglish to Vietnamese
3 Vietnamese women
2 bilingual professionals& Researcher
Modify
inappropriate
items
N=20
2 translatorsVietnamese to English
Figure 4.1The translation process of instruments
The procedure for translation is that the English version of the questionnaire is
translated into Vietnamese by two translators, bilingual in English and
Vietnamese. The consensus version of the forward translation is then
translated back into English by two other independent bilingual translators, the
results being reconciled to obtain a consensus version. After the individual
translations are made, the translators meet together in a consensus session
to discuss discrepancies and potential translation problems and create a
semi-final version of the translated questionnaire.
4.1.4 Face Validity of the Instruments
Three health professionals were invited to check for face validity, in terms of
the clarity and adequacy of the wording of the translated questionnaire. One
reviewer was a faculty member of a university school of psychology with a
PhD degree in psychology. The other two reviewers were university
academics with expertise on women’s health and evidence-based nursing
80
research also with PhD degrees in Nursing. In order to achieve face validity,
the health professionals were further asked to assess the relevance and
appropriateness of each item in representing its measured variables. Data
were analysed with SPSS for Windows, version 15.0, for internal consistency
and to obtain test-retest reliability coefficients for the Acculturation Scale, DIS
scale, and SF-36 Survey.
Pilot test
Face validit yFace validit yFace validit yFace validit y
CCCConst ruct valid it yonst ruct valid it yonst ruct valid it yonst ruct valid it y
IIII nt ernal nt ernal nt ernal nt ernal consist encyconsist encyconsist encyconsist ency
St abil i t ySt abil i t ySt abil i t ySt abil i t yTestTestTestTest ---- ret est reliabil i t yret est reliabil i t yret est reliabil i t yret est reliabil i t y
3 professionals3 professionals3 professionals3 professionals
Pilot test N=20
Women participants
Statistical analysis:
Cronbach’s Alpha
Interval
2 weeks
N=20
Women Participants
SemiSemiSemiSemi ---- f inal f inal f inal f inal quest ionnairequest ionnairequest ionnairequest ionnaire
CrossCrossCrossCross---- sect ional sect ional sect ional sect ional SSSSurvey urvey urvey urvey n= 200n= 200n= 200n= 200
Figure 4.2 The process for the Pilot study
4.2 Results of Pilot study
The sample consisted of 20 Vietnamese women who migrated to Taiwan
between 1990 and 2005. Descriptive statistics showed that 66 per cent of the
sample (n=20) were aged between 21 and 42 years, with a mean age of
29.25 (SD=4.44). The mean length of residence in Taiwan was 5.5 years
(SD=2.35, Max=10, Min=1) (see table 4.1). The majority of the participants
had at least junior high school education in Vietnam. For 13 of the participants
the employment status was ‘none’, they were housewives, while 7 had full-
time jobs (see table 4.2).
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Table 4.1 Demographic characteristic of Vietnamese women (n=20)
Item M SD Min Max
Age (years) 29.25 4.44 21 42
Spouse's age 42 5.2 34 55
Number of children 1.65 0.8 0 3
Length of residence in Taiwan (years)
5.51 2.35 1 10
Table 4.2
Socio-demographic variables of participants (n=20)
Variable N Frequency
Marital status Married 18 90
Divorced 1 5
Widowed 1 5
Religion Buddhist/Taoist 19 95
None 1 5
Overseas Chinese No 17 85
Yes 3 15
Education Elementary school 4 20
Junior high school 9 45
High school 5 25
University/College 2 10
Employment status None (housewife) 12 60
Full-time 7 35
Part-time 1 5
82
Table 4.3
Internal Consistency/Reliability of Scales (n=20)
Scale Number of Items
Cronbach's Alpha
Acculturation Scale 25 0.7
DI Scale 23 0.8
SF-36 36 0.8
4.2.1 The Acculturation Scale
The mode of acculturation was assessed by the modified version of the
Suinn-Lew Asian self-Identity Acculturation Scale (SL-ASIA Suinn, Rickard-
Figueroa, Lew & Vigil, 1987). This instrument originally consisted of 21 items,
and used a 5-point scale to assess the participants’ preference across a
number of areas, including language, self and ethnic identity, friendship,
generational and geographic background, and behaviour competence. The
SL-ASIA scale reflects the orthogonal, multidimensional perspectives of
acculturation and is the most widely used measure to study acculturation
among Asian American people (Abe-Kim, Okazaki & Goto, 2001; Sue et al.,
1998).
Overall, the reliability coefficients for the translated and modified Acculturation
scale in this pilot were 0.7 for the 20 Vietnamese transnational marriage
women. This is lower than Suinn, Khoo & Ahuna (1995) reported with the
same scale, where they found that Cronbach’s Alpha for an Asian American
of sample of 324 was 0.91, and for Ownbey and Horridge (1998), who
distributed the SL-ASIA to Asians living in Singapore (n=238), producing a
Cronbach’s alpha of 0.91. However, a two-week test-retest reliability
coefficient in this Pilot study was 0.86 (n=20), which ensured that the reliability
83
of the modified Vietnamese version of Acculturation scale was satisfactory
and acceptable.
For most of the items of the Vietnamese version of the Acculturation Scale,
the participants stated that they could respond easily, however a few of them
said that they had a little trouble responding to some items, such as, “Whom
do you now associate with in the community?” and “If you could pick, whom
would you prefer to associate with the community?” In Vietnamese, the
definition of ‘”community” is a very formal and concrete concept, the women
rarely using the term “community” to express their social network. This item
was therefore modified to “With whom do you now associate in the
neighbourhood?” and “If you could pick, whom would you prefer to associate
with the neighbourhood?”
The items, “What was the ethnic origin of the friends and peers you had, as a
child up to age 6?” and “What was the ethnic origin of the friends and peers
you had, as child from ages 6 – 18?” were not applicable for Vietnamese
women who immigrated to Taiwan via marriage. They were modified to “What
is the ethnic origin of the friends and peers you have?”, “With whom do you
socialize and go shopping?”, “From whom do you receive emotional support?”
In addition, the researcher rearranged the sequence of the original scale so it
started with the subscale “daily habit” instead of the subscale “language
preference and ethnic identity”. This was undertaken to reduce the non-
response rate of the questionnaire interview, and to enhance the comfort of
the Vietnamese women in answering the questionnaire.
4.2.3 The Demand of Immigration Specific Distress ( DI) Scale
The DI Scale developed by Aroian et al., (1998) is widely regarded as an
appropriate tool to measure immigration-specific distress. This instrument
originally consisted 23 items, and used a 4-point scale to assess six
subscales, including: loss (items 2,10,18, 23), novelty (items 4,14,16, 22),
84
occupational adjustment (items 5, 6,11,19, 21), language accommodation
(items 1, 8,12), discrimination (items 7, 9, 13, 20), and not feeling at home in
the receiving country (items 3,15, 17).
Overall, the reliability coefficients for the translated Vietnamese version of DIS
scale in this study were 0.80 (SD=4.1, df=19, n=20) among the 20
Vietnamese transnational marriage women. The mean of the DI scale was 39
(SD=7.3). The two-week test-retest reliability coefficient was 0.82. The
internal consistency and stability coefficients of the DI scale were high and
satisfactory. The results were similar to the original psychometric evaluation of
the DI scale (Arion, 1996) completed by former Soviet immigrants in the
Boston area of USA. The reliability showed a Cronbach’s alpha score of 0.82
to 0.95 (n=907) for internal consistency and a Pearson’s R of 0.78 to 0.92 for
test-retest reliability of the total scale and subscales. In the Taiwanese-
Chinese version, Tasi (2002) reported that the Cronbach’s alpha for
Taiwanese-Chinese immigrant in US was 0.92 (n=47), which was higher than
this pilot study. However, the Vietnamese Version of the DI scale still had
good stability in eliciting consistent responses from the respondents.
The most problematic items identified in the pilot study were occupation-
related. Many participants (n=14) didn’t work. In addition, some participants
did not use their past work credentials for their job in Taiwan. As a result, 14
participants did not complete the occupation sub-scale items (item 5, 6, 19,
21). Aroian (2007) suggests using systematic missing error when the
participant never worked or was retired and not looking for work. For this
reason, the researcher subsequently expanded 0 to "not at all or not
applicable”. Also, the format and wording of some items required additional
modification. For example, the item which was originally “Talking in English
takes a lot of effort”; in the rural area of Taiwan people are used to speaking
Taiwanese dialect instead of the official language, Mandarin. This item was
therefore modified to “Talking Mandarin or Taiwanese dialect takes a lot of
effort”. In Item 14 which measured the distress of novelty; ”I must learn how
85
certain tasks are handled, such as renting an apartment or getting a driving
licence,” the participant women proposed that they had stress in learning new
tasks. In Taiwan, the motorcycle is the most convenient and common vehicle
for these women. Therefore the item was modified to: “I must learn how
certain tasks are handled, such as getting motorcycle driving licence”. Overall,
based on the responses of the Vietnamese immigrant women, the
Vietnamese version of DI scale was reported as being easy to read and
follow.
4.2.4 The Health Related Quality of Life (HRQOL)-Th e SF-36
The Short Form 36 Health Survey (SF-36) is a self-administered
questionnaire measuring Health Related Quality of Life (HRQOL) in eight
areas of perceived health, using a 5-point Likert scale, with higher scores
(range 0 to 100) reflecting better perceived health. The English SF-36
standard version 2.0 (4 weeks recall) has been validated, and has reported
psychometric properties. The 36-item survey measures eight domains of
health: physical functioning (PF), role limitations due to physical health (RP),
bodily pain (BP), general health perceptions (GH), vitality (energy and fatigue)
(VT), social functioning (SF), role limitations due to emotional problems (RE),
and mental health (psychological distress and well-being) (MH). The reliability
of the eight sub-scales has been estimated using both internal consistency
and the test-retest method. With rare exceptions, published reliability statistics
have exceeded the minimum standard of 0.70 recommended for measures
used in group comparisons in more than 25 studies (Ysai, Bayliss & Ware,
1997); with most exceeding 0.88 (McHorney et al.,1994; Ware et al.,1993).
The translated Vietnamese version of SF-36 scale showed good internal
consistency, with Cronbach’s Alpha exceeding the value of 0.82 (n=20)
recommended for group comparisons for all scales. A two-week test-retest
reliability coefficient recorded 0.82. This result was similar to the standard
86
psychometric evaluation of the SF-36 Scale. The internal consistency and
stability coefficients of the translated SF-36 scale were high and satisfactory.
4.3 Discussion
The main limitation of the pilot study was the barriers of language. There is no
doubt that trying to get messages across to participants from different cultures
and languages may create misunderstandings or communication breakdown.
In order to decrease language barriers and increase the awareness of culture
differences, the following strategies were undertaken to the Pilot study, (1)
providing a Vietnamese version of the questionnaire to Vietnamese women
and (2) the use of trained bilingual research assistants to facilitate the data
collection.
Sample recruitment was another limitation of this study, because the
Vietnamese women were usually isolated at home with few opportunities to
interact with the community; being isolated made it difficult to access and
recruiting the sample. Therefore, the snowball sampling technique was a
useful strategy to solve the problem when the participants were difficult to
approach directly.
4.3 Summary
This chapter has illustrated the result of a pilot study, in which twenty
Vietnamese trans-national marriage women participated. The pilot study
demonstrated that both internal consistency and stability of the Acculturation
scale, DI scale, and SF36 scale gave satisfactory values of Cronbach's Alpha
from 0.68 to 0.82. The results indicated that the modified Acculturation scale,
DI scale, and SF-36 Scale are appropriate for use with Vietnamese immigrant
women in Taiwan. The next chapter will present the results of the phase 2
study.
87
Chapter 5 Results
Introduction This chapter presents the results of phase 2 of the study, in three sections. The
first is a descriptive analysis of the sample and describes the research
instruments. The second section reports the relationships between level of
acculturation, acculturative distress, and Health Related Quality of Life. The third
section is an examination of the results of testing the research hypotheses, using
a Pearson correlation matrix to test the relationship between the main variables.
A p-value of less than 0.05 was considered statistically significant. A one-way
ANOVA was conducted to evaluate the relationship between immigrant distress
and three acculturation groups, falling into the categories of marginalization,
integration, and assimilation. The Classification and Regression Trees (CART)
approach is conducted to predict the significant acculturative related risk factors
on the Health Related Quality of Life among Vietnamese immigrant women in
Taiwan.
5.1 Descriptive Data Analysis
The first section represents the analysis of the characteristics of the sample and
of the research instruments: the Acculturation scale, the Demand of Immigration
Specific Distress Scale, and the Health Related Quality of Life – SF-36.
5.1.1 Characteristics of the Participant
The overall sample characteristics were further analysed by examining the mean
score of the selected demographic variables. For dichotomous variables (e.g.
marital status), a chi-square test was used to test for group difference. All
remaining differences were tested with one-way ANOVA. Of the 220 Vietnamese
88
women invited to participate, 213 completed the whole of the questionnaire.
Seven subjects were omitted from the analyses because of incomplete data. The
characteristics of the sample are shown in Tables 5.1 and 5.2.
Participants ranged in age from 20 to 46 years, with a mean age of 27.41 years
(SD=4.6). The average length of stay in Taiwan for all of the participants was 4.3
years (SD=2.63), ranging from 6 months to 12 years. Geographically, all of the
participants lived in southern Taiwan, 44% of them in the city of Kaoshiung and
the remaining 56% distributed across the rural areas of Kaoshiung, Tainan and
Pinton. The education levels of participants were: 3 (1.4%) no formal education,
49 (23%) elementary school, 104 (48.8%) junior high school, 54 (25.4%) high
school, 3 (1.4%) university or college. In terms of the number of years of
schooling within Vietnam, more than half of the participants reported spending 9
years in Vietnamese schools. As for religion, the majority, 192 (90.1%), were
Buddhists or Taoists, 12(6) had no religion or said ‘other’, 6 (2.8%) were
Catholics or other Christians, and 3 (1.4%) were Muslims. Of the participants,
126 (59.2%) had full-time or part-time jobs and 87 (40.8%) of them worked as
housewives.
In regard to ethnic background, there were only 37 (17.4%) participants who
identified their ethnic background as Chinese ancestry, while 176 (82%)
identified themselves as Vietnamese. The mean number of children among these
women was 1.40 (Min=0, Max=4, SD=0.79). More than half of the participants,
132 (62%) live with spouse, children and parents-in-law, 79 (37%) were nuclear
families, and 2 (1%) were single parent families.
Table 5.1 The means and standard deviations of socio-demographic variables
Variables Mean SD Min Max
Age 27.41 4.64 20 46
Spouse's age 41.49 6.34 27 72
Number of children 1.4 0.79 0 4
Years in Taiwan 4.33 2.6 6 months 12
89
Table 5.2 Frequencies of socio-demographic variables of participants
Variables N %
Age
20-29 133 67.1
30-39 63 29.6
40-49 7 3.3
Age of spouse
25-29 1 0.5
30-39 78 36.6
40-49 118 55.4
50-59 13 6.1
above 60 3 1.4
Years of residency in Taiwan
under 1 15 7.0
1—2 35 16.3
3—4 77 36.7
5—6 68 31.8
7—8 10 4.5
9—10 6 2.8
11—12 2 0.9
Number of children
0 27 12.7
1 85 39.9
2 91 42.7
3 8 3.8
4 2 0.9
90
Table 5.3
Frequencies of socio-demographic variable of participants
Variable N %
Marital status
Married 207 97.2
Divorced 3 1.4
Widowed 3 1.4
Religion
Buddhist/Taoist 171 80.3
Christian/Catholic 18 8.5
Muslim 3 1.4
None 16 7.5
Other 5 2.3
Chinese ethnicity
No 176 82.6
Yes 37 17.4
Education
None 3 1.4
Elementary school 49 23
Junior high school 104 48.8
High school 54 25.4
University/College 3 1.4
Employment status
None 87 40.8
Full-time 91 42.7
Part-time 35 16.4
Occupation
Housewife 93 43.7
Labourer 108 50.7
Professional 12 5.6
91
5.1.2 Characteristic of the Spouse
Spouses’ age ranged from 27 to 72 years old, with a mean age of 41.49
(SD=6.3). More than half of the spouses (48.8%) reported having Junior high
school level of education (year 9); 25.4% had completed high school and 23.0%
had completed elementary school.
The religion of the majority was Buddhist/Taoist (90.1%). 202 (93.4%) spouses of
participants had a full-time or part-time job and 14 (6.6%) participants’ husbands
were currently unemployed. Among the 213 spouses of participants, 202 (94.8%)
reported their primary occupation as being a labourer, while 11 subjects (5.2%)
reported having professional employment. As for the health status of spouses,
196 (92.0%) reported that their husbands’ health status were good or fair, and 17
(8.0%) indicated poor health status. A full description of the spouses’
demographic variables can be viewed in Table 5.4.
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Table 5.4 Frequencies of socio-demographic variables of spouses
Variable N %
Spouse's religion
Buddhist/Taoist 192 90.1
Christian/Catholic 6 2.8
Muslim 3 1.4
None 10 4.7
Other 2 0.9
Spouse's
education
Non formal education 2 0.9
Elementary school 18 8.5
Junior high school 97 45.5
High school 83 39.0
University/College 13 6.1
Spouse's employment status
None 14 6.6
Full-time 174 81.7
Part-time 25 11.7
Spouses’
occupation
None 7 3.3
Labourer 99 93.4
Professional 7 3.7
Spouse's health
status
Poor 17 8.0
Fair 97 45.5
Good 99 46.5
Family type
Nuclear family 79 37.0
Single parent 2 0.1
Extended family 132 63.9
93
5.2 Study Instruments
Four instruments were used in this study: Demographic Inventory, Acculturation
scale (ACC), Demand of Immigration Specific Distress scale (DI), and Health
Related Quality of Life (HRQOL): Short-Form 36 scale (SF-36). The
Demographic Inventory was used to measure demographic variables, including
age, education, socio-economic status, and length of stay in Taiwan, number of
children and spouse’s health and socio-economic status. Acculturation was
measured with a Vietnamese version of a five–item self–rated questionnaire on
level of acculturation.
Demand of Immigration Specific Distress Scale (DI) was measured using a
Vietnamese version of a four–item, self-rated questionnaire about a range of
immigrant distress. The Vietnamese version of the Short-Form 36 scale was
used to measure the Health Related Quality of Life (HRQOL).The Cronbach’s
Alpha coefficient and descriptive statistic of ACC, DI, and HRQOL including
means and standard deviation are presented in Tables 5.5, 5.6, 5.7 and 5.8.
Reliability
Reliability checks were conducted for each scale. The analyses resulted in the
following reliability coefficients (Cronbach’s Alpha) for the study instruments.
Acculturation scale: 0.68, Demand of Immigration Specific Distress Scale (DI):
0.79, and Health Related Quality of Life – SF-36 (HRQOL): 0.82. The alpha for
the acculturation scale was 0.68, which appears slightly low, primarily, probably,
because of the translation process or the word formatting. However, the reliability
coefficients (Crobach’s Alpha) for the study instruments were acceptable and
satisfactory. Expert and face validities were acceptable for the scales, thus all of
the items in the study were retained.
94
Table 5.5. Internal consistency reliability of instruments (n=213)
Instrument Number of
Items
Cronbach's Alpha
Acculturation scale 25 0.68
DI scale 23 0.79
HRQOL 36 0.82
5.2.1 Acculturation Scale (ACC )
The Acculturation scale assesses daily activity (5 items), language usage (4
items), social interaction (8 items) ethnic identity (4 items), and behavioural
competence (4 items). These responses were scored on a 5–point Likert scale.
In scoring these 25 items, a score can range from 1.00 (low acculturation) to 5.00
(high acculturation); a low score reflects marginalisation, or separation, while a
high score reflects assimilation. Integration was a dichotomous variable with a
score of 3.00 on the Acculturation Scale. The means used for acculturation by
Vietnamese women in Taiwan (M=2.77, SD= 0.35, Min=1.7,Max=3.89,
range=2.9) indicated biculturalism or integration as their acculturative mode,
which means that most participants had kept their Vietnamese ethnic and cultural
traditions as well as adapting to the Taiwan society.
The means, standard deviation and ranges of acculturation on sub-score scale is
presented in Table 5.6.
95
Table 5.6 The means, standard deviations and ranges of Acculturation scales
Item mean SD Min Max Range
Total score 25.0 2.77 0.29 1.7 3.89 2.19
Sub-score
Daily activity 5.0 3.16 0.47 1.2 4.75 3.5
Language usage 4.0 2.82 0.46 0.1 4.0 3.0
Social interaction 8.0 2.7 0.49 1.17 4.17 3.0
Ethnic identity 4.0 2.37 0.67 1.4 4.6 3.2
Behavioral competence 4.0 2.9 0.25 2.0 4.0 2.0
Figure 5.1 Histogram of three groups of acculturation
GroupsGroupsGroupsGroups of Acculturation of Acculturation of Acculturation of Acculturation
Assimilation Integration Marginalization
200
150
100
50
0
FrequencyFrequencyFrequencyFrequency
96
5.2.2 Demand of Immigration Specific Distress Scale (DI)
The DIS is used to assess acculturative distress. There are six subscales: loss (4
items), novelty (5 items), occupational adjustment (6 items), language
accommodation (3 items), discrimination (4 items), and not feeling at home in the
receiving country (3 items). The DIS scale consists of 23 items rated on a 4-point
Likert type scale ranging from 0 (not distressed at all) to 3 (distressed very
much). High scores indicate high level of acculturative distress related to the
demands of immigration.
Results showed that the mean score of DI for Vietnamese women in Taiwan was
10.38 (SD= 1.75 Min=4.35, Max=16.63, range=12.28). According to the mean of
sub-score, participants report high scores for immigration stress for these items
(see Table 5.7).
Table 5.7 The means, standard deviation and ranges of acculturative distress
DI scale Item mean SD Min Max Range
Total score 23 40.36 6.77 16 64 48
Sub-score
Loss 4 2.25 0.48. 0.25 3.0 2.75
novelty 5 1.98 0.31 0.75 3.0 2.25
occupational adjustment 6 1.76 0.47 0.40 3.0 2.60
language accommodation 3 1.73 0.49 0 2.67 2.67
discrimination 4 1.43 0.54 0 3.0 3.0
not feeling at home 3 1.21 0.58 0 3.0 3.0
97
5.2.3 Health Related Quality of Life – SF36
The Short-Form 36 scale measured eight domains of Health Related Quality of
Life: physical functioning (PF), role limitations due to physical health (RP), bodily
pain (BP), general health perceptions (GH), vitality (energy and fatigue) (VT),
social functioning (SF), role limitations due to emotional problems (RE), and
mental health (psychological distress and well-being) (MH). Each subscale has a
standard formula represented by [(raw score – lowest raw score)/possible raw
score]*100. Each subscale varies between 0 and 100, and the higher the score
the better the health condition. Table 5.8 presents the result of eight domains of
health, for which the mean sub-score of SF-36 ranges from 62.07% to 82.65%.
Table 5.8 The mean and standard deviation of Vietnamese SF-36 score.
Mean
SD
Min Value
Max Value
Physical functioning (PF) 82.65 18.69 15 100
Role-Physical (RP) 73.88 20.8 0 100
Bodily Pain (BP) 77.43 17.51 25 100
General Health (GH) 62.07 16.82 15 100
Vitality (VT) 70.65 15.41 25 100
Social Functioning (SF) 74.70 16.57 25 100
Role-emotional (RE) 71.59 21.42 0 100
Mental Health (MH) 61.39 13.91 10 95
98
5.3 Results of the hypotheses
This section presents the results of the six main hypotheses below:
Hypothesis 1
“Integration” is the mode of acculturation that most Vietnamese immigrant
women use to adapt to Taiwanese society.
Hypothesis 2
Social-demographic variables (age, marital status, years living in Taiwan,
Chinese ethnic background, education level, type of family, spouse’s educational
level, and religion and employment status) will demonstrate significantly different
effects on level of acculturation among Vietnamese immigrant women in Taiwan.
Hypothesis 3
A significant interaction will be seen between the levels of acculturation and
acculturative distress among Vietnamese immigrant women in Taiwan.
Hypothesis 4
Acculturative distress is strongly associated with psychological health among
Vietnamese immigrant women in Taiwan.
Hypothesis 5
Vietnamese immigrant women will show lower scores of Health Related Quality
of Life – SF-36 (HRQOL) than Taiwanese women.
Hypothesis 6
Acculturation factors will impact on the Health-Related Quality of Life, as
measured by SF-36 (HRQOL), among Vietnamese immigrant women in Taiwan.
99
5.3.1 Hypothesis 1
“Integration” is the mode of acculturation that mos t Vietnamese immigrant
women use to adapt into Taiwanese society.
The Acculturation scale assesses daily activity (5 items), language usage (4
items), social interaction (8 items) ethnic identity (4) and behavioural competence
(4 items). These responses were scored on a 5-point Likert scale. In scoring
these 25 items, a score can range from 1.00 (low acculturation) to 5.00 (high
acculturation). In other words, a low score reflects marginalization or separation),
while a high score reflects assimilation. Integration was a dichotomous variable in
which the score was (3.00) on the Acculturation Scale. The means of
acculturation for Vietnamese women in Taiwan (M=2.77, SD=0.35
(Min=1.7,Max=3.89,range=2.9) indicated biculturalism or integration as their
acculturative mode which means that most of the participants had kept their
Vietnamese ethnic and cultural tradition as well as adapting to Taiwan society.
5.3.2 Hypothesis 2
Social-demographic variables (age, marital status, years living in Taiwan,
Chinese ethnic background, education level, type of family, spouse’s
educational level, and religion and employment stat us) will demonstrate
significant differences on levels of acculturation among Vietnamese
immigrant women in Taiwan.
Social-demographic variables will demonstrate significant differences on level of
acculturation among Vietnamese immigrant women in Taiwan. The hypothesized
bivariate relationships between the study’s variables were tested using the
Pearson correlation coefficient (see Table 5.9). The Bivariate Correlation
procedure also computes a Kendall’s Tau-b or Spearm when the measurement
scales underlying the variables are ordinal, such as marital status, family type,
education level, religion and employment status.
100
The Relationship between Acculturation and Socio-de mographic Variables
Pearson product-moment correlations were conducted for participants’ level of
acculturation (dependent variable) with socio-demographic variables
(independent variables). Correlation coefficients were computed among the
selected demographic variables and acculturation. Using the Bonferroni
approach to control for Type I error across the correlations, a p value of less than
0.05 was required for significance. The socio-demographic variables such as
“marital status, education, religion, family type, religion of spouse, and
employment of spouse” are needed convert codes for dichotomous dummy
variables.
The results of the correlation analysis are presented in Table 5.9. The years of
residency in Taiwan, number of children, marital status, education, religion of
spouse, employment of spouse were statistically significant and greater than or
equal to 0.11. The correlation of acculturation with participants’ age, religion,
family type spouse‘s age, education level, and health status tended to be lower
and not significant. In general, the results showed no significant relationships
with participants’ age, education level attained in Vietnam, religion, family type,
spouse‘s age, education level, and employment status.
In addition, the Independent T test showed that the mean of Chinese Vietnamese
3.1 (n=37), SD=0.41, and Vietnamese (n=174), Mean=2.7 SD= 0.29, composite
score reveals a small but significant difference (t=7.07 p<0.001), showing those
women who have Chinese ancestry experienced a slightly higher level of
acculturation than the native Vietnamese women. As predicted, this result
showed a significant positive relationship between acculturation level and length
of residency in Taiwan (r= 0.15, P< 0.02), Chinese ethnicity (r= 0.15, P< 0.02),
number of children (r= 0.17, P< 0.01), marital status (r= 0.21, P< 0.000),
education (r= 0.11, P< 0.02), religion of spouse (r= 0.16, P< 0.009) and
employment status of spouse (r= 0.11, P< 0.04).
101
Table 5.9 Correlations of acculturation difference with socio-demographic variables
Acculturation
Socio-demographic variables r P Value
Years of residency in Taiwan.
0.15
0.02*
Chinese ethnicity 0.15 0.02*
Number of children
Marital status
Education
Religion of spouse
Employment of spouse
0.17
0.21
0.11
0.16
0.11
0.01**
0.000**
0.02*
0.009**
0.04*
Note: ** Correlation is significant at the 0.01 level (2-tailed)
* Correlation is significant at the 0.05 level (2-tailed)
5.3.3 Hypothesis 3
There were significant interactions between the lev els of acculturation and
acculturative distress among Vietnamese immigrant w omen in Taiwan.
A significant interaction was seen between the levels of acculturation and
acculturative distress on health outcomes: physical functioning, physical role,
bodily pain, general health, vitality, social functioning, emotional role, and mental
health among Vietnamese immigrant women in Taiwan. Pearson product-
moment correlation was used to test the relationships. In addition, a one-way
analysis of variance was conducted to evaluate the relationships between the
three levels of acculturation and acculturative distress.
Findings from statistical analysis showed the level of acculturation was negatively
associated with acculturative distress. In addition, acculturative distress was
negatively associated with bodily pain, vitality, mental health and psychological
well-being. The second set of hypotheses was validated, indicating that level of
acculturation was positively associated with mental health.
102
The Relationship between Level of Acculturation an d Acculturative Distress
The hypothesized bivariate relationships between the study variables were tested
using the Pearson correlation coefficient. The acculturation would be negatively
associated with immigration distress (r= -0.26**, P< 0.000). It is suggested that a
higher level of acculturation will be associated with a lower level of acculturative
distress. The results of the correlation analysis are shown in Table 5.10. In
addition, the correlations of daily activity (r= -0.205** < 0.003), language usage,
(r= -0.146*, P<0.034), social interaction (r= -0.137*, P< 0.045) ethnic identity (r= -
0.164*, P< 0.016), and total acculturation score (r= -0.26**, P< 0.004), with
Demand Immigration Distress tend to be negatively significant.
Table 5.10 Bivariate correlations among acculturation distress variables
Variable DI DA SI LU EI ACC
DI
1.00
DA - 0.205* 1.00
SI - 0.146* - 0.332* 1.00
LU - 0.137* - 0.246** - 0.246** 1.00
EI - 0.164* - 0.151* - 0.152* - 0.303** 1.00
ACC - 0.260* - 0.146* - 0.118** - 0.685** - 0.689** 1.00
DI= Demand immigration distress DA=Daily activity, LU= Language usage
SI= Social interaction EI= Ethnic identity, ACC= acculturation total score
Note: ** Correlation is significant at the 0.01 level (2-tailed)
* Correlation is significant at the 0.05 level (2-tailed)
103
A one-way ANOVA was conducted to evaluate the relationship between
acculturative distress and the three groups of acculturation, from low to high
level. The independent variables are the three acculturation groups:
marginalization (n=26), integration (n=147) and assimilation (n=20). The
dependent variable was the level of acculturative distress. The ANOVA was
significant, F (2,190) = 3.692, p<0.02. Because the p value is less than 0.05, we
reject the null hypothesis that there are no differences among the group. The
strength of relationship between groups of acculturation and the perceived
immigrant distress, was assessed by ň2 (0.03).
As the result of the F test was significant, follow-up tests were conducted to
evaluate pair-wise difference among the means. The mean of values among the
three ranges from 9.97 to10.99, and the variance ranges from 1.10 to 1.41, so
we chose not to assume that the variances were homogeneous and conducted
post hoc comparisons with the Turkey HSD pair-wise, a multiple comparison
procedure that shows the significant difference for acculturative distress between
group one and three (marginalized group/assimilated group), regarding the
marginalized group immigrant distress to be higher than that for the assimilation
group.
The result of the one-way ANOVA supported the hypothesis that the different
types of acculturation had a differential effect on immigrant distress. As
predicted, there was a statistically significant difference in the means between
the assimilation and marginalization groups. The marginalized group showed
greater immigrant distress than the assimilated group. The 95% confidence
intervals for the pair-wise difference, as well as the means and standard
deviations for the three groups, are reported in Table 5.10. Otherwise, the
distribution of the dependant variable for the levels of the group are shown in
Figure 5.2.
104
Table 5.11
95% Confidence interval of pair-wise difference in mean change in acculturative
distress. Acculturation
group
M
SD
Marginalization
Integration
Assimilation
Marginalization 9.97 1.74
Integration 10.49 1.18 -0.2128 to 1.2079*
Assimilation 10.99 1.04 0.1249 to1.8978* -1.1479 to 0.1203*
Note: An asterisk indicates that the 95% confidence interval does not contain zero, and therefore
the difference in means is significant at the 0.05 level, using the Turkey HSD procedure.
Figure 5.2 Immigrant distress for marginalization,
integration, and assimilation groups
Marginlization Integration AssimilationMarginlization Integration AssimilationMarginlization Integration AssimilationMarginlization Integration Assimilation 3.00 2.00 1.00
11.00
10.80
10.60
10.40
10.20
10.00
9.80
Mean ofMean ofMean ofMean of immigrant disstress immigrant disstress immigrant disstress immigrant disstress
105
The Kolmogorov-Smirnov and Shapiro-Wilk tests were used to confirm that the
values of the outcome variable (immigrant distress) were normally distributed
across each level of the independent variable (acculturation group). Both the
Kolmogorov-Smirnov and the Shapiro-Wilk’s statistics were significant (p<0.001)
indicating a violation in the normality assumption. Visual inspection of the
histograms and normal Q-Q plots confirmed this result.
1.00 1.50 2.00 2.50 3.00
accgroupaccgroupaccgroupaccgroup
8.00
10.00
12.00
14.00
16.00
totaldis
totaldis
totaldis
totaldis
SS
S
S
Figure 5.3 Distributions of acculturative distress score
across acculturative groups
Although the One-Way ANOVA may yield accurate p values when the normality
assumption is violated, particularly with group sample sizes of 15 or more, the
nonparametric Kruskal-Wallis one-way ANOVA was used and its result
compared with the ANOVA F statistic. The Kruskal-Wallis one-way ANOVA test
was significant, . The result is similar to the result
obtained with the One-Way ANOVA procedure. Levene’s test for Equality of
Variances was not significant (p=0.388) indicating that the variance of the
dependent variable is homogeneous across the three levels of the independent
variables. In addition, there were negative relationships with the subscales of
106
acculturative distress: perceived discrimination (r=-0.21, p=0.002), language
utilization (r=-0.13, p< 0.001), feel not at home (r=-0.21, p, <0.004).
5.3.4 Hypothesis 4
Acculturative distress is positively associated wit h HRQOL among
Vietnamese immigrant women in Taiwan.
5.3.4.1 The Relationship between Level of Accultura tion and HRQOL
There was a significant positive relationship found between the level of
acculturation and mental health (psychological distress and well-being) (r= -0.21,
P=0.001**). Thus, a higher level of acculturation can be associated with a higher
level of mental health and thus with one of the summary measures of mental
health: mental component summary (MCS) (r= 0.088, P= 0.032*), where as the
level of acculturation decreases, the mental health and well-being would also
decrease.
The results show that there was no significant relationship found between the
acculturation level and the other seven domains of health: physical functioning,
role limitations due to physical health, bodily pain, general health perceptions,
vitality (energy and fatigue), social functioning, and role limitations due to
emotional problems and one summary measure of physical: the physical
component summary (PCS). The results shown here in Figure 5.4 can also be
seen in Table 5.12.
107
Figure 5.4 The mean Plot for degree of acculturation and mental health
1= marginalization (n=26), 2=integration (n=147), and 3=assimilation (n=20).
Table 5.12. Correlation matrix of level of acculturation and HRQOL
ACC PF BP GH SF RP VT RE MH PCS MCS
ACC 1
PF -0.048 1
BP 0.050 0.328** 1
GH 0.055 0.406** 0.312** 1
SF 0.012 0.326** 0.500** 0.406** 1
RP -0.021 0.475** 0.433** 0.397** 0.553** 1
VT 0.097 0.440** 0.465** 0.474** 0.476** 0.448** 1
RE 0.056 0.334** 0.285** 0.366** 0.469** 0.702** 0.350** 1
MH 0.127** 0.212** 0.336** 0.327** 0.465** 0.373** 0.610** 0.372** 1
PCS 0.048 0.752** 0.693** 0.698** 0.578** 0.804** 0.617** 0.586** 0.422** 1
MCS 0.088** 0.431** 0.511** 0.482** 0.781** 0.703** 0.795** 0.771** 0.755** 0.762** 1
PF=physical functioning, BP=bodily pain, GH= general health perceptions. SF=social functioning
RP=role limitations due to physical health, VT=vitality , RE=role limitations due to emotional
problems, MH=mental health, PCS=Physical Component Summary, MCS=Mental Component
Summary .Note: ** Correlation is significant at the 0.01 level
* Correlation is significant at the 0.05 level
Acc groupAcc groupAcc groupAcc groupssss
3Assimilation Integration Marginalization
MH
668.00
66.00
664.00
62.00
60.00
58.00
108
Table 5.13 Correlation matrix of acculturation subscales and mental health
Mental
Health
Daily
Activity
Social
Interaction
Language
Usage
Identity
Ethnic
Behavior
Competence Acculturation
Mental
Health
Pearson
Correlation 1 0.209(**) 0.162(*) 0.146(*) 0.162(*) 0.107 0.234(**)
Sig. (2-
tailed) 0.002 0.015 0.029 0.016 0.109 0.000
Daily Activity Pearson
Correlation 0.209(**) 1 0.287(**) 0.440(**) 0.355(**) 0.188(**) 0.673(**)
Sig. (2-
tailed) 0.002 0.000 0.000 0.000 0.005 0.000
Social
Interaction
Pearson
Correlation 0.162(*) 0.287(**) 1 0.245(**) 0.256(**) 0.193(**) 0.553(**)
Sig. (2-
tailed) 0.015 0.000 0.000 0.000 0.004 0.000
Language
Usage
Pearson
Correlation 0.146(*) 0.440(**) 0.245(**) 1 0.335(**) 0.224(**) 0.654(**)
Sig. (2-
tailed) 0.029 0.000 0.000 0.000 0.001 0.000
Ethnic
Identity
Pearson
Correlation 0.162(*) 0.355(**) 0.256(**) 0.335(**) 1 0.384(**) 0.690(**)
Sig. (2-
tailed) 0.016 0.000 0.000 0.000 0.000 0.000
Behaviour
Competence
Pearson
Correlation 0.107 0.188(**) 0.193(**) 0.224(**) 0.384(**) 1 0.690(**)
Sig. (2-
tailed) 0.109 0.005 0.004 0.001 0.000 0.000
Acculturation Pearson
Correlation 0.234(**) 0.673(**) 0.553(**) 0.654(**) 0.690(**) 0.690(**) 1
Sig. (2-
tailed) 0.000 0.000 0.000 0.000 0.000 0.000
** Correlation is significant at the 0.01 level (2-tailed).
* Correlation is significant at the 0.05 level (2-tailed).
109
5.3.4.2 The Relationship between Acculturative Dist ress and HRQOL
Results showed that there was a significant negative relationship between the
acculturative distress and four domains of health outcomes: bodily pain, (r= -0.154
P=0.029), vitality (energy and fatigue) (r=-0.145, P< 0.04), social functioning (SF)
(r=-0.134, P< 0.025), mental health (r= -0.155,P<0.027) and the summary measure
of mental health: mental component summary (MCS) ( r=-0.131, P< 0.032, one
tailed). (See table 4.2.13). This indicated that higher acculturation distress will be
associated with lower score of Health Related Quality of Life (HRQOL) on bodily
pain, vitality, social functioning, mental health and mental component summary
(MCS).
Table 5 .14 Correlation matrix of acculturative distress and HRQOL
DI PF BP GH SF RP VT RE MH PCS MCS
DI 1
PF 0.023 1
BP -0.154* 0.328** 1
GH -0.020 0.406** 0.312** 1
SF -0.134* 0.326** 0.500** 0.406** 1
RP -0.012 0.475** 0.433** 0.397** 0.553** 1
VT -0.145* 0.440** 0.465** 0.474** 0.476** 0.448** 1
RE -0.039 0.334** 0.285** 0.366** 0.469** 0.702** 0.350** 1
MH -0.155* 0.212** 0.336** 0.327** 0.465** 0.373** 0.610** 0.372** 1
PCS -0.056 0.752** 0.693** 0.698** 0.578** 0.804** 0.617** 0.586** 0.422** 1
MCS -0.131* 0.431** 0.511** 0.482** 0.781** 0.703** 0.795** 0.771** 0.755** 0.762** 1
DI = Distress, PF=physical functioning, BP=bodily pain, GH= general health perceptions. SF=social functioning RP=role limitations due to physical health, VT=vitality, RE=role limitations due to emotional problems, MH=mental health, PCS=Physical Component Summary MCS=Mental Component Summary
Note: ** Correlation is significant at the 0.01 level (2-tailed)
* Correlation is significant at the 0.05 level (2-tailed)
5.3.4.3 Ancillary Analysis
A linear regression analysis was conducted, in which acculturation and
acculturative distress were used to predict mental health among Vietnamese
110
immigrant women in Taiwan. These predictors, taken together, did not
significantly predict mental health. The findings indicated that there was no
evidence of an interaction between the two independent variables. Note, that
although the correlation for level of acculturation and mental health (r=0.17,
P<0.007**) was statistically significant due to the large sample (n=213). The
research suggests that the acculturation level plays a major role in mental health.
However, the model summary provides the over all regression model (R²= 0.057,
Adjusted R² = 0.053, F=6.26 and Standardized Coefficients Beta 0.171).The
research reveals that the acculturation may not be a significant predictor for
mental health among Vietnamese immigrant women in Taiwan (Table 5.15).
The strength of the relationship between acculturative distress and mental health
among Vietnamese immigrant women in Taiwan was examined. Regression
analysis was also conducted on the evaluation of the mental health from
acculturative distress for Vietnamese immigrant women in Taiwan. The study
found that the correlation for mental health (r=0.234, P<0.000**) was statistically
significant, and suggests that acculturative distress plays a major role in
predicting mental health. The results showed that acculturation distress did not
significantly predict mental health (R=0.17, R ² =0.015, Adjusted R² =0.010,
F=4.93, Standardized Coefficients Beta =-0.12) for the total sample (Table 5.15).
Table 5.15
Acculturation and acculturative distress as predictors of mental health
95% CI for B
Predictor
Var.
Dependent
Var.
Standardized
Coefficients
Beta
F
R²
Adj
R² Lower
Bound
Upper
bound
Acculturation
Level
Mental
Health
0.171
6.265
0.057
0.053
2.50
0.013
Acculturative
Distress
Mental
Health
-0.12 4.93 0.015 0.010 -2.84 0.19
111
5.3.5 Hypothesis 5
Vietnamese immigrant women will report lower scores of Health Related
Quality of Life – SF-36 (HRQOL) than Taiwanese wome n.
An independent sample t-test was conducted to compare the Health Related
Quality of Life-SF-36 scale for Vietnamese immigrant women and for Taiwanese
women. The means for Vietnamese immigrant women in physical functioning,
role-physical bodily pain, general health, social functioning, role-emotional and
mental health were lower than that for Taiwanese women, while for vitality it was
a little higher than for Taiwanese women. These results indicate that Hypothesis
Five was partially validated (see Table 5.16 & Table 5.17).
The t-test assesses whether the means of two groups are statistically different
from each other. Three assumptions are: that the test variable is normally
distributed for each of the two populations as defined by the grouping variable
(the Independent variable), that the variances of the normally distributed test
variable for the populations are equal, and that cases are a random sample and
the scores of the test variable are independent of each other (Green & Salkind,
2003). The tests were significant in that the p value was <0.05.
The results suggest that the Vietnamese immigrant women have a lower score
for Health Related Quality of Life than Taiwanese women. An inspection of the
mean scores indicated that the Vietnamese immigrant women recorded lower
levels of PF, RP, BP, GH, SF, RE, and MH. Only one domain, vitality, has a little
higher level (Figure 5.5).
112
Table 5.16 Comparison of mean scores for SF-36 by Taiwanese and Vietnamese women
Vietnamese Taiwanese SF-36 subscale
(mean±SD) (mean±SD) T test p Value
Physical functioning 82.65 ±8.69 90.25 ±16.16 7.00 p<0.00
Role-Physical 73.88 ±20.8 80.91 ±15.31 2.89 p<0.01
Bodily Pain 77.43 ±17.51 82.14 ±20.32 3.35 p<0.01
General Health 62.07 ±16.82 67.08 ±21.99 3.30 p<0.01
Vitality 70.65 ±15.41 65.64 ±19.02 -3.81 p<0.01
Social Functioning 74.70 ±16.57 85.78 ±17.46 9.16 p<0.01
Role-emotional 71.59 ±21.42 77.59 ±17.33 2.34 p<0.05
Mental Health 61.39 ±13.91 77.59 ±17.33 8.23 p<0.01
Taiwanese norm: Lu JF Tseng H M Tsai YJ (2002). Assessment and Health –related quality of life in Taiwan
(I): development and psychometric testing of -36 Taiwan versions. Taiwan Public Health. 22. (6).501-511.
Vietnamese SF-36 compare to Taiwanese norm
0
10
20
30
40
50
60
70
80
90
100
PF RP BP GH VT SF RE MH
SF-36 subscore
Per
cent
age
Vietnam
Taiwan
Figure 5.5
The SF-36 score of Vietnamese immigrant women compared toTaiwanese women
113
Table 5.17
The Health Related Quality of Life in Vietnamese immigrant women and Taiwanese
women 95% confidence Interval
Dependent variable Group Mean Std.error Lower
Bound
Upper
Bound
Physical functioning Vietnamese 82.65 8.69 73.96 91.34
Taiwanese 90.25 16.16 74.09 100
Physical Role Vietnamese 73.88 20.8 53.08 94.68
Taiwanese 80.91 15.31 65.6 96.22
Bodily Pain Vietnamese 77.43 17.51 59.92 94.94
Taiwanese 82.14 20.32 61.82 100
General Health Vietnamese 62.07 16.82 45.25 78.89
Taiwanese 67.08 21.99 45.09 89.07
Vitality Vietnamese 70.65 15.41 58.13 86.06
Taiwanese 65.64 19.02 46.62 84.66
Social Functioning Vietnamese 74.70 16.57 55.24 91.27
Taiwanese 85.78 17.46 68.32 100
Emotional Role Vietnamese 71.59 21.42 50.17 93.01
Taiwanese 77.59 17.33 60.26 94.92
Mental Health Vietnamese 61.39 13.91 47.48 75.03
Taiwanese 77.59 17.33 54.11 87.87
114
Table 5.18 The Health Related Quality of Life of Vietnamese immigrant women compared to Taiwanese women, by age group
Taiwanese norm: Lu JF Tseng H M Tsai YJ (2002). Assessment and Health-related quality of life in Taiwan (I): development and psychometric testing of -36 Taiwan versions.
Taiwan Public Health. 22. (6).501-511.
PF RP BP GH VT SF RE MH
Age group Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
18-24
Vietnamese n=61 84.50 (16.75) 71.10 (22.79) 78.64 (17.06) 65.37 (15.83) 72.95 (14.05) 76.84 (16.11) 70.08 (3.29) 60.90 (13.37)
Taiwanese n=1233 97.40 ( 9.24) 88.18 (26.92) 86.92 (17.83) 72.81 (19.02) 69.22 (17.46) 87.19 (15.49) 76.78 (33.40) 71.65 (16.22)
25-34
Vietnamese n=138 81.84 (19.10) 74.95 (20.42) 76.89 (17.33) 60.16 (17.43 69.42 (16.12) 73.64 (17.13) 71.31 (21.12) 61.02 (13.97)
Taiwanese n=1695 95.77 (18.53) 88.55 (39.28) 85.84 (21.6) 72.83 (22.09) 66.94 (20.12 87.32 (18.04) 80.26 (35.44) 71.16 (17.36)
35-44
Vietnamese n=12 80.84 (22.64) 73.95 (14.79) 75.29 (19.96) 64.66 (12.17) 70.83 (13.14) 72.91 (10.43) 79.86 (13.03) 64.58 (14.84)
Taiwanese n=1781 94.14 (29.04) 85.44 (45.97) 83.45 (23.97) 68.79 (21.15) 65.81 (21.98) 87.36 (25.38) 81.49 (44.45) 71.55 (17.63)
44-54
Vietnamese n= 2 82.65 (18.62) 84.37 (22.09) 77.43 (17.51 62.07 (16.82) 84.37 (4.41) 93.75 (8.83) 87.50 (17.67) 82.5 (10.62)
Taiwanese n=1475 90.25 (6.47) 80.08 (27.08) 80.89 (17.05) 64.01 (19.63) 65.13 (17.65) 86.75 (14.87) 79.88 (36.54) 71.66 (16.24)
115
5.3.6 Hypothesis 6
There are acculturation-related factors that will i mpact on the Health
Related Quality of Life – SF-36 (HRQOL) among Vietn amese immigrant
women in Taiwan.
The models of linear regression adopted for predicting HQOL have many
potential limitations, namely that correlation (collinearity) between predictive
variables can weaken the variance explanation of the dependent variables
(HRQOL), and that the regression coefficients represent the contribution given
to prediction by a unitary change in each individual variable (D’alisa, Miscio et
al., 2006). It was to deal with these weaknesses that the classification and
regression tree (CART) technique was adopted (Breiman, Friedman, Olshen
& Stone, 1993), aimed at overcoming the methodological weakness of this
study. However, interaction between two or more variables can actually be
much more predictive, so CART modeling was applied to a series of variables
potentially predictive of HRQOL among Vietnamese immigrant women.
The outcome variables (the mental component of the SF-36 (MCS), the
physical component of the SF-36 (PCS)) and exploratory variables (alienation,
occupation, loss, language, discrimination, and novelty) were numeric
variables. A minimum node deviance of 20% of the total deviances was used
to prune the trees.
The Classification and Regression Trees procedure (CART) (Breiman,
Friedman, Olshen & Stone, 1993) was conducted to predict the significant
acculturative related risk factor on the Health Related Quality of Life among
Vietnamese immigrant women in Taiwan. Contentional statistics was run
through StatView for Windows (SAS Institute Inc., version 5.0.1, 1998); CART
was run through CART (Salford Systems) (Holford, 2002). The reason for
using CART was to identify key acculturative predictors for determining health
outcomes. The result is that the CART procedure gives strong support to the
conclusion that the predictive variables for the physical component of the SF-
116
36 (PCS) were: alienation, occupation, loss, language accommodation, and
novelty (predicted 28.8% of the variance explained). The predictive variables
for the mental component of the SF-36 (MCS) were exactly the same:
alienation, occupation, loss, language accommodation, and novelty (predicted
28.4% of the variance explained).
In addition, two advantages of this technique are robustness with respect to
distributional assumptions (rarely met by scores coming in from
questionnaires) and its sensitivity to high-order interactions, between
independent variables difficult to direct through conventional multiple
regression. The outcome variables are two component of Health Related
Quality of Life: MCS and PCS and exploratory variables: alienation, loss,
novelty, occupational adjustment, language accommodation, and
discrimination.
D’alisa, Miscio et al., (2006) explain that from the many variables available in
the database, at each split a variable is selected that will allow the
maximization of the variance explained by the dependent variable. CART was
deemed to be advantageous in comparison to ordinary multiple linear
regression. The first step in CART is to divide the population into groups with
very different levels of outcomes. To draw a diagram of the process such as
shown in Figures 5.10 and 5.11, we start with the entire population, which is
represented by the first node, and then draw lines or branches to two
daughter nodes which then represent the first partition. We proceed to
partition these daughter nodes, continuing this process until we effectively run
out of information so that we cannot partition the data further. The result of
this process obviously resembles the form of a family tree (Holford, 2002). An
important criterion for a good classification procedure is that it not only
produce accurate classifiers, but that it also provide insight and understanding
into the predictive structure of the data (Breiman, Friedman, Olshen &
Stone,1993).
117
The CART for HRQOL are constructed by repeatedly splitting the data on the
individual total score of the two domains of health (MCS and PCS). The
regression models for Vietnamese immigrant women in Taiwan are shown in
Figure 5.10 to 5.11 for these two domains respectively. In these figures, all
observations that satisfy the criterion are split to the left-hand or right-hand
side node. The score of MCS and PCS, which is equal to the model estimated
is shown for each terminal node. A 10-fold cross-validation procedure was
used. The chosen tree was the minimum-cost tree, obtained with the ‘one
Standard Error rule’ (Lewis, 2005). As splitting criteria, we used variance
reduction procedure that for CART the minimum per leaf is 5 and the
reservation required for split is 13 and more. Figure 5.10 and Figure 5.11
provide the output of two CART analyses on summary global SF-36 score.
Node 1n=194
Alienation
N=37 ,< 2.12Average 71.63
N=22 >=2.12Average 76.83
N=31 >=1.83Average 65.08
N= 33 < 2.12
Average 65.37
N= 9 >=2.12 Average 54.25
N=55 <1.83Average 70.84
N=7 <1.87Average 76.20
Occupation<1.5
N=145 average71.17
Novelty>=1.87N=42
Average 62.99
Loss.1.<1.9N=59
average 74.69
Loss>=1.5N=49
average 64.88
LanguageN=86
Average68.76
Figure 5.6 . CART for identifying differential risks on MCS of SF-36
118
AlienationN=195
Average.74.51
N=81 ,< 1.7Average 74.21
N=59 >=2.37Average 78.55 N=16 ,< 1.62
Average 65.17N=22 ,>= 1.62Average 74.75
N=6 >=2.37Average91.04
N=14 >=2.12
Average=59.2
Figure 5.7 CART for identifying differential risks on PCS of SF-36
Novelty <1.5N=146,
Average76.65
Discrimination <2.12N=38
Average 70.72
Loss <2.37N=140
average 76.04
Novelity>=1.5N=49
Average 68.13
5.4 Summary
213 Vietnamese immigrant women participated in this survey. Six hypotheses
of this study were validated. Demographic data was presented and it revealed
that there are statically significant differences between levels of acculturation
and years of residency in Taiwan, number of children, marital status,
education, religion of spouse, employment status of spouse and Chinese
ethnic background by Pearson correlation and Kendall’s Tau-b or Spearman
test. The correlations of daily activity, language usage, social interaction
ethnic identity, and total of acculturation score with DI tend to be negatively
significant.
In addition, the result of the one-way ANOVA supported the hypothesis that
the different types of acculturation had a differential effect on immigrant
distress. The marginalized group showed greater immigrant distresses in
119
comparison with the integrated group. Furthermore, the comparison t-test
revealed that the Vietnamese immigrant women showed a lower score than
Taiwanese women in Health Related Quality of Life. The higher acculturation
distress will be associated with lower score of (HRQOL) on bodily pain,
vitality, social functioning, mental health and mental component summary
(MCS).
The result of this study shows the strong support given by the CART
procedure leading to the conclusion that the predictive variables for the
physical component of the SF-36 (PCS) were: alienation, occupation, loss,
language accommodation, and novelty (predicted 28.8% of the total variance
explained). The predictive variables for the mental component of the SF-36
(MCS) were the same: alienation, occupation, loss, language accommodation,
and novelty (predicted 28.4% of the total variance explained).
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Chapter 6 Discussion
Introduction
This study was designed to investigate the relationship between acculturation
and health outcomes among Vietnamese immigrant women in Taiwan. This
chapter begins with a review of the major findings, comparing them with
previous research and assessing them against the six research hypotheses,
particularly when they fail to support them or do so only partially. In this study
of 213 Vietnamese immigrant women, the hypotheses were largely supported.
In the last section a theoretical framework for the acculturation and health
outcomes of this study are proposed.
Hypothesis 1
“Integration” is the mode of acculturation that Vietnamese immigrant women
will use most often to adapt into the Taiwanese society.
Hypothesis 2
Social-demographic variables (age, gender, marital status, years living in
Taiwan, Chinese generation background, education level, number of children,
spouse’s, educational level, and religion and employment status) will show
significant differences in relation to level of acculturation among Vietnamese
immigrant women in Taiwan.
Hypothesis 3
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A significant interaction will be seen between the levels of acculturation and
acculturative distress on health outcomes among Vietnamese immigrant
women in Taiwan.
Hypothesis 4
Acculturative distress is significantly associated with psychological health
among Vietnamese immigrant women in Taiwan.
Hypothesis 5
Vietnamese immigrant women will report lower scores of Health Related
Quality of Life – SF-36 (HRQOL) than Taiwanese women.
Hypothesis 6
Acculturation factors will impact on the Health Related Quality of Life – SF-36
(HRQOL) among Vietnamese immigrant women in Taiwan.
6.1 Characteristics of the Sample
In comparison with previous studies, the demographic characteristics of
participants in the present study are similar. The literature (Chang, 1999;Liu,
Chung & Hsu, 2001; Yang & Wang, 2003) indicates that most Southeast
Asian immigrant women in Taiwan are much more younger than their
husbands (14 years), have 1 to 3 children and live in a three-generation
extended family. In addition, their spouses seem to belong to disadvantaged
minorities, with lower socio-economic status, lower levels of education and
greater ages than the general population in Taiwan. Their marriages were
largely mediated by private agencies. The present study is one in a series that
has probed the nature of this marriage.
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According to Shia’s study (2000), a special phenomenon has developed in
Taiwan due to national capitalization and liberalization. This has led to more
and more young female marriage immigrants coming from Southeast Asian
countries to marry disadvantaged Taiwanese males. Marriage immigration
may be an aspect of the unequal economic relationships between Taiwan and
its less prosperous neighbours, and it is supported through government
policies and marriage brokers in Taiwan. As previous studies of this special
phenomenon have shown, these Southeast Asian “foreign brides” usually
marry Taiwanese men of lower socio-economic status, educational level
and/or income, some of them having physical or intellectual disabilities
(Chang, 1999; Liu, Chung & Hsu, 2001; Yang & Wang, 2003; Lin & Wang,
2007).
6.2 Discussion of Research Hypothesis One
“Integration” is the mode of acculturation that Vie tnamese immigrant
women will use most often to adapt into the Taiwane se society.
The mean score on the acculturation scale for Vietnamese women in Taiwan
is 2.7, which indicates moderate levels of acculturation, and point to
“biculturalism or integration” as their acculturative mode, meaning that
participants had kept their Vietnamese ethnic and culture traditions while also
adapting to Taiwanese society.
Items 21 and 22 of the SL-ASIA scale examine the participants’ tendency to
endorse Vietnamese and Taiwanese values, and items 23 and 24 examine
the degree to which they felt they generally fit culturally into the Vietnamese
and Taiwanese communities. A few noteworthy observations can be made
from this analysis. Firstly, nearly 78% (n=166) of the participants reported they
tended to endorse two cultures, in contrast to two minority groups who
reported either that they tended to assimilate into Taiwanese society (14.7%;
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n=33), or that they withdrew from that culture, meaning that their acculturation
mode was marginalized or separated, (12.6%; n=26).
The results of this study indicated “biculturalism or integration” was the most
common acculturative mode, meaning that most Vietnamese participants had
kept their Vietnamese ethnic and cultural tradition as well as adapting to the
Taiwanese society. This finding is consistent with previous research on
minorities that followed the underlying assumption of Berry’s acculturation
AISM model (1997). Integrated individuals are called “Bicultural individuals”,
who are more fluid between both their culture of origin and the new host
culture. So integration represents a successful transition to balancing the host
country’s culture with the traditional values of one’s own cultural origins.
According to one of the models of acculturation proposed by Berry and Kim’s
(1988) AISM acculturation model, there are four types of cultural orientation:
assimilation, integration, separation, and marginalization, that can occur as an
outcome of the acculturation process. Consequently, the acculturative
measurement in this study was focused on the degree or level of
acculturation. The results are presented in terms of only assimilation,
integration and marginalization or separation (taken together).
As previous studies (Marino et al., 2000; Zan & Mak, 2003) have shown, the
concept of acculturation can encompass a number of different ideas, from
beliefs and values, to customs, habits and behaviour. As such, studies that try
to examine the process of acculturation may inevitably be limited as to their
definition and measurement of acculturation. Berry’s acculturation model is
pragmatic for studying diverse cultural societies; since it provides a view of
immigrants whose entry into a new cultural does not necessarily mean that
they wish to relinquish their former culture (Lee, 1997). In addition, Berry’s
AISM model addresses both the level and the type of acculturation.
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Recently, there has been increased criticism of the AISM model. Instead of
being a multidimensional model, it focuses on the acculturation process
related to individual cultural traits, instead of considering general levels of
overall acculturation. As this model explains, individuals are likely to acquire
some new traits from the host culture more quickly than other traits. Moreover,
the types of acculturation are not mutually exclusive; for example, immigrants
could use an assimilation strategy in a work environment but a separation
strategy with their choice of friends or food (Im & Yang, 2006). Thus, unlike
the AISM model, a multidimensional model can explain selective acculturation
among immigrants. However, the idea of a multidimensional model may
increase the complexity and difficulties in the measurement of acculturation.
That is a question that we need to continue to discuss.
6.3 Discussion of Research Hypothesis Two
Social-demographic variables ( age, marital status, years living in
Taiwan, Chinese generation background, education le vel, number of
children, spouse’s, educational level, and religion and employment
status ) will show significant differences in relation to level of
acculturation among Vietnamese immigrant women in T aiwan.
6.3.1 Acculturation and Socio-demographic Variables
As predicted, the results showed significant positive relationship between level
of acculturation and years of residency in Taiwan, number of children, marital
status, education, religion of spouse, employment of spouse. Contrary to
prediction, age, religion, family type, spouse‘s age, education level, and health
status had no significant relationships with participants’ level of acculturation.
Many studies have demonstrated a relationship between acculturation effects
and social-demographic variables (Berry, 1990; Zheng & Berry, 1991;
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Nicholsn, 1997; Aroian, 1998; Wang & Ujimoto, 1998; Dela Cruz, Padilla &
Agustin, 1998; Aroian, Norris & Chiang, 2003; Yang & Wang, 2003; Lee &
Wang, 2004). For instance, Aroian & et al., (1998; 2003) investigated 1647
former Soviet immigrants and concluded that immigrants’ psychological
distress was related to gender, age, marital status, unemployment and length
of time in the host society. Results indicated that women, older immigrants,
those with less education, those not being sponsored by friends or a religious
organization and those with greater immigration demands were the most
distressed.
Length of Residency in Taiwan
Those Vietnamese immigrant women who had longer residency in Taiwan,
had a better level of acculturation and lower acculturative distress. In contrast,
those Vietnamese immigrant women who had shorter residency in Taiwan,
had lower levels of acculturation, and higher acculturative distress. These
findings are consistent with findings of previous studies, (Yeung & Schwartz,
1986; Zheng & Berry’s, 1991; Nicholsn, 1997; Aroian, 1998, Miller & Chandler,
2002, Yang & Wang, 2003) of a positive relationship between length of
residence in the host country and acculturation.
For example, Yeung and Schwartz (1986) found that Chinese immigrants who
had lived in the United States for less than 1 year reported greater health
problems than immigrants who had lived there longer. Similarly, in Zheng and
Berry’s (1991) longitudinal study of Chinese sojourners in Canada, physical
and psychological systems related to acculturative stress increased until 4
months after migration. Arian (1998) concluded that immigrants’ acculturation
was related to length of time in the host society. Yang and Wang, (2003) also
supported this finding that SEA immigrant women experience acculturative
stress during their first year in Taiwan.
Chinese Ethnicity
It is believed that the greater the disparity between the immigrant and host
cultures, the greater the acculturative stress (Hsu, Hailey & Rang, 1987;
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Wang & Ujimoto, 1998). The finding showed that Vietnamese-born immigrant
women who have Chinese ancestry achieved a higher level of acculturation in
Taiwan than those who were ethnically Vietnamese. This interpretation of the
findings may reflect better levels of psychological adjustment, as they are able
to identify and connect with an already established group of Chinese relatives
in Taiwan.
Marital Status
The spouse and marital status play an important role in immigrant adjustment.
The finding of the present study is consistent with the finding of James,
Hunsley Navara, Malnnie (2004); Aroian (2001) who all reported significant
positive correlations between marital status and acculturative adjustment.
Level of Education
Past research has shown that education has an effect on acculturation (Berry,
1990; Dela Cruz, Padilla & Agustin, 1998; Aroian et al., 1998; Miller &
Chandler, 2002). This study found that the participant‘s level of education in
Vietnamese was related to level of acculturation in Taiwan, possibly due to
socialization in school and more exposure to schooling.
Religion of Spouse
The spouse’s religion was found to have an effect on participants’
acculturation. A majority of the spouses were Buddhist/Taoist (90.1%). The
explanation of this result may be that immigrant women usually follow their
husband’s religion, their compliance with Buddhist/Taoist ceremonies and
rituals are regularly demonstrated at home and they go to a Buddhist or Taoist
temple for worship; this may increase the interaction with the outside
community and with Taiwanese people. Thus, spouse’s religion was found to
have an effect on participants’ acculturation in Taiwan.
Spouse’s Employment Status
Most of the participants were housewives, which means that their financial
condition were more dependant on their spouses. This may explain the
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significant positive relationship shown between levels of acculturation and
spouse’s employment status.
Number of Children
The degree of acculturation was related to number of children among these
immigrant women. The number of children among these women was 1 to 2.
The interpretation of the finding may be to do with the effect of the parental
role. The parental role, as well as childbearing, includes socialization of
children; immigrant women must teach and guide their children’s home work
at home. This parenting role may not only encourage them to increase their
ability in writing and reading Mandarin, but may also encourage them to
establish connection with outside world and become more involved in their
children’s activities at school or in other community organizations. Previous
studies have support the significant relationship between number of children
and immigrant adaptation. For example, Lee and Wang (2004) found that
immigrant women who have more children had higher scores in health
responsibility and immigrant stress management.
As predicted, these results corroborate previous studies that showed
significant positive relationships between acculturation level and length of
residency in Taiwan, Chinese ethnicity, number of children, marital status,
level of education, religion of spouse, and employment status of spouse.
Gender
Acculturation preferences may be influenced by gender. Several studies
(Guendelman, 1987; Sam, 1995; Das, 1997; Arian et al.1998; Dion & Dion,
2001) on gender differences in acculturation and ethnic identification reveal
that females tend to be more identified with their natural culture than males.
However, the participants targeted in this study were only trans-national
marriage Vietnamese women in Taiwan, so the influence of gender on
acculturation was not investigated.
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6.4 Discussion of Research Hypothesis Three
A significant interaction will be seen between the levels of acculturation
and acculturative distress on health outcomes among Vietnamese
immigrant women in Taiwan.
The result of this study indicates that there was a significant positive
relationship between the level of acculturation and mental health. Thus, higher
levels of acculturation, classed as integration or assimilation, can be
associated with a higher level of mental health and thus with one of the
summary measures of mental health: mental component summary (MCS),
whereas at a lower level of acculturation, classed as marginalization or
separation, the mental health and well-being would decrease, assuming that
participants who are marginalized or separated might have poorer mental
health outcomes and psychological distress (Sundquist, 2000).
Previous studies have supported a significant relationship between
acculturation and health outcomes (Berry, Kim, Power, Young & Bujaki, 1989;
Berry & Sam 1997), indicating that the subjects who had higher levels of
acculturation also experienced less acculturative stress, and manifested fewer
psychological problems, than those who were marginalized or separated who
suffered the most psychological distress (Berry et al., 1988; Sam & Berry
1995). Rumbaut (1991) found, in his longitudinal study on Southeast Asian
refugees in the United States, that the level of distress decreased over time
but that biculturalism (integration) emerged as a significant predictor of low
level of distress. Acculturation attitudes and psychological functioning
confirms that integration is the most adaptive form of acculturation.
As predicted, the main finding of this study is that the integrated population
exhibits better health-related quality of life and lower levels of distress. In
contrast, the marginalized and separated population had more distress and
poorer mental health.
Compared to those groups, studies (Sam & Berry, 1995; Berry, 1989; Ying,
Akutsu, Zhang & Hung, 1997; Miranda, Estrada & Firpo-Jimenex, 2000;
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Lieber et al., 2001) described other acculturation effects on mental health. For
example, Berry, (1989) noted that immigrant women who adopt
marginalization exhibit heightened confusion, anxiety, depression and
psychosomatic symptoms. Sam and Berry (1995) stated a consistent relation
between marginality and emotional distress amongst young Third World
immigrants in Norway.
In a study of 2,234 Asian refugees, Ying, Akutsu, Zhang, and Hung (1997)
found that a more traditional or separation-style cultural orientation was
associated with poorer mental health outcomes. Other studies showed that
the marginalized group of Chinese immigrants in America expressed feelings
of anger, disgust, and alienation with their immigration experience (Lieber et
al., 2001). Furthermore, it has also been found that depression, social
withdrawal, familial isolation, despair, and obsessive-compulsive behaviour
are all related to low acculturation levels (Miranda, Estrada & Firpo-Jimenez,
2000).
In Taiwan, Yang and Wang (2003) reported that SEA immigrant women who
identified with Taiwanese culture and lifestyle had a positive learning attitude.
They accept local traditional religions, study Taiwanese and Mandarin, and
can watch and understand TV programs. They had a strong motivation to
assimilate into Taiwanese society, welcoming the assistance offered by
healthcare professionals during the first year of immigration, and responding
positively to their teaching of health-enhancing behaviour. So healthcare
professionals should develop programs as soon as possible for the healthcare
of Vietnamese immigrant women; the earlier the involvement, the more
effective the program.
Although there is a significant bivariate correlation between level of
acculturation and mental health (r= -0.21, P< 0.001**), consistent with the
findings of previous studies (Sam & Berry, 1995; Berry, 1989; Ying, Akutsu,
Zhang & Hung, 1997; Miranda, Estrada & Firpo-Jimenex, 2000; Lieber & et
al., 2001), some studies argued for a link between acculturation and
depressive symptoms. For example, Kaplan and Mark (1990) found that as
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Mexican immigrants became more acculturated, their CES-D score were
significantly high. They posit that those Latino immigrants who are more
acculturated deal with more emotional and psychological distress in the
United States.
Still other researchers, Heilemann and colleagues (2004) found that Mexican
women who were born in the United States and spoke English were
significantly more likely to gain excessive weight during pregnancy or use
alcohol, drugs, or cigarettes; and have more psychological complaints. Thus,
further research is needed to deepen the understanding of acculturation in
relation to community mental health for SEA ethnic’s subgroups such as
Indonesian, Filipina, Cambodian, and Thai marriage immigrant women in
Taiwan.
6.5 Discussion of Research Hypothesis Four
Acculturative distress is significantly associated with psychological
health among Vietnamese immigrant women in Taiwan.
One important finding is that acculturative stress had a significant negative
direct effect on three domains and one summary component of Health
Related Quality of Life (HRQOL) among Vietnamese immigrant women in
Taiwan, including: bodily pain, vitality (energy and fatigue), social functioning,
mental health, and the summary measure of mental health: mental component
summary.
It is conjectured from these results that acculturative stress may not only
entail general difficulties in acculturating to a new host culture, but also
difficulties in trying to manage and adhere to two different environments with
two different set of cultural beliefs. As some studies have shown a positive
correlation between difficulties acculturating to a host culture with poor
psychological functioning (Miranda, Estrada & FirpoJimene, 2000; Nguyen,
Messe & Stollak, 1999), it is not surprising that there would be some negative
psychological impact of the various type of acculturative stress, as
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documented in previous studies. The explanation for this result is simply that
these Vietnamese immigrant women may not have successfully negotiated
the demands and expectations conflicting between Vietnamese and
Taiwanese society.
Previous studies that have looked at cultural pluralism have suggested that
being bi-cultural not only has a positive impact on one’s ability to successfully
negotiate interactive aspects of different cultures, but it also may serve as a
buffer against some negative psychological consequences, whilst also
increasing one’s ability to cope with daily stressors and improve overall
confidence (Berry,1991). Therefore, unsuccessful acculturation may result in
conflict and a sense of alienation, as well as some negative psychological
consequence, like depression.
Although there was a strong correlation found between acculturation and
participants’ mental health, it is important to be mindful that this does not
necessarily prove causation. It is also important to keep in mind the possible
aspects of mental health in general, regardless of level of acculturation;
another possible interpretation as to why participants scored poorly on mental
health may be related to family problems and other variables, rather than just
having acculturation difficulties alone.
Overall, deterring the relationships between acculturation and health
outcomes may not be clear-cut. While the results have shown a strong
relationship between acculturation and psychological function, it is very
difficult to determine exact causality. Thus, the more plausible conclusion is
that low acculturation and acculturative distress may have a negative impact
on an individual’s level of psychological health.
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6.5.1 Acculturative Distress and HRQOL
The Mental Health subscale of the SF-36 measurement model has been
shown to be useful in screening for psychiatric disorders (Berwick, 1991;
Ware et al., 1994), as has the MCS summary measure (Ware et al., 1994).
The MH, RE, and SF subscales and the MCS summary measure have been
shown to be the most valid of the SF-36 scales as mental health measures.
Thus, this suggests that higher acculturative stress will be associated with
lower score of HRQOL on bodily pain, vitality, social functioning, mental
health, and mental component summary. This evidence supports the
hypothesis that, for Vietnamese immigrant women in Taiwan, higher
acculturative stress has negative correlations with psychological well-being.
Accumulating evidence has confirmed that acculturative stress may indeed
have important implications for mental health (Berry, Kim, Minde & Mok, 1987;
Berry & Kim, 1988; Berry, 1998; Hovey & Magana, 2000; Williams & Berry,
1991; Hwang et al., 2000; Falcon, 2000). Researchers have found that greater
acculturative stress increases the risk for developing psychological problems
and reducing well-being. Berry and Kim (1998) have identified the cultural and
psychological factors that govern these relationships with mental health. But
the present study found that acculturative stress may not only be correlated
with psychological health but may also influence physical health.
6.5.2 Mental Health, Depression and Anxiety
Results showed that there was a negative relationship between the
acculturative stress and mental health and the mental component summary
(MCS) of Health Related Quality of Life (HRQOL) among Vietnamese
immigrant women in Taiwan, indicating that acculturative stress has significant
influence on their mental health.
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The finding was consistent with previous studies, which indicated that,
acculturative stress is usually manifested in the form of depression (because
of culture loss) and anxiety (because of uncertainties) (Williams & Berry,
1991). Most studies support our findings, for example (Farooq et al., 1995;
Hwang et al., 2000; Hovey & Magana, 2000; Falcon, 2000) report that high
acculturative stress may be a risk for experiencing depression.
Elevated acculturative stress was significantly associated with increased
levels of depression (Hovey & Magana, 2000). Farooq et al., (1995)
investigated the comparative rate of somatic complaints of Asian and
Caucasian clients in a primary care setting; their finding was that the Asian
patients reported significantly more depressive syndrome than the Caucasian
patients. Hwang et al., (2000) in a study on psychological predictors of first-
onset depression in Chinese Americans, confirmed the previous evidence that
psychological vulnerabilities, including higher acculturation, greater stress
exposure and reduced social support, were important predictors of risk for
first-onset depression episodes. Falcon (2000) pointed out that the effect of
acculturation was observed as strongly related to depression among
Dominican elderly in the USA. These findings are confirmation by Heilemann
and colleagues’ (2004) study that use the acculturation parameters in CES-D
to measure depressive syndrome among women of Mexican decent living in
the United States. They found that the mean CES-D scores for the entire
sample of childbearing women are raised, indicating a very high risk for
depression.
In Taiwan, the results of this study are consistent with Wang and Yang’s
(2002), qualitative research findings on psychological health problems among
Indonesian immigrant women; their complaints included emotional obstacles
posed by immigration; related stress (fatigue, loneliness, anxiety, depression,
worry, sadness and loss); self-withdrawal, and shock at the gap between
expectations and reality.
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6.5.3 Bodily Pain, Vitality, and Somatization
The finding of this study showed that there was a negative relationship
between acculturative stress and bodily pain (BP), (r= -0.154 P=0.029 ),
vitality (energy and fatigue) (VT) (r=-0.145 P< 0.040 ) of Health Related
Quality of Life (HRQOL) among Vietnamese immigrant women in Taiwan. The
findings indicated that the Vietnamese immigrant women who have higher
levels of acculturative stress also complain of bodily pain, low vitality and low
energy and feel fatigued in everyday life.
Most of the Vietnamese immigrant women believed their health conditions
were not changed by marriage immigration (Yang & Wang, 2003), but the
results from this study’s assessment of physical symptoms of HRQOL showed
changes in bodily function and bodily pain. This finding is confirmed by Yang’s
(2002) study that SEA immigrant women suffered from physical function
disorder which included: intestinal and stomach problems (poor appetite,
gastric ulcer, constipation, diarrhoea); immune system disorder (susceptibility
to the common cold, skin allergy, dry skin, eczema); and endocrine disorders
(menstrual disorder, headaches, low back pain).
The interpretation of this result may be that it is actually a response to stress
caused by rapid assimilation into Taiwan’s lifestyle, which has transformed
psychological problems into physical ones. Thus, during medical evaluation, it
is necessary to pay greater heed to their physical symptoms, such as: bodily
pain and fatigue, in order to unearth hidden health adjustment problems. For
instance, chronic headache, chest pain, palpitations, and shortness of breath
have been found to be associated with depression among Cambodians in
American (Handeman & Yeo, 1996).
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6.5.4 Somatization
The interpretation of this finding may related to somatization, the name often
given to the ubiquitous human tendency to experience and express
psychological distress in the form of bodily symptoms (American Psychiatric
Association, 1994), where the body is used metaphorically (Kleinman, 1986).
Although somatization is a common mode of illness expression in many
cultures, the relationships of somatization to distress, and mental disorder are
likely to be culturally specific; it has often been found to be a more frequently
used mode of distress expression by people from non-Western cultures
(Melesis et al., 1992; Kirmayer, Young & Robbins, 1994; Kirmayer, Young,
1998). Somatization is a marker for psychiatric morbidity, especially anxiety
and depression. Immigrants of different ethnic populations exhibit different
psychosomatic symptoms, family conditions and social attitudes; those more
strongly inclined to their original culture and traditions have a higher chance to
develop psychosomatic problems (Melesis et al., 1992).
Somatization among immigrants is a diagnostic and research challenge,
because somatization is a help-seeking behaviour shaped by cultural norms
and beliefs (Aroian & Norris, 1999). For example, South-east Asia refugees
suffering from depression may complain of “weak heart,” weak kidney,” or
“weak nervous system” (Mueck, 1983). In addition, the most common finding
from Vietnamese clinical samples is that patients/clients tended to describe
their discomfort using somatic terms (Cheung & Lin, 1997; Matkin, Nickles,
Demos & Demos, 1996; Williams & Berry, 1991). Frequently-reported
symptoms included headache, insomnia, palpitation, aches and pains,
dizziness, fatigue, poor memory and poor concentration.
The finding of this study is consistent with the findings of a relationship
between migration and somatic complaints (Williams & Berry, 1991; Matkin,
Nickles, Demos & Demos, 1996; Cheung & Lin, 1997; Aroian & Norris, 1999;
Small, Lumley & Yelland, 2003). For example, Cheung and Lin’s (1997)
finding from Vietnamese clinical samples is that patients/clients tended to
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describe their discomfort using somatic terms; frequently-mentioned
symptoms including headache, insomnia, palpitation, aches and pain,
dizziness, fatigue, poor memory and poor concentration. Some research
studies have also identified recent immigrants or those who are less
acculturated, or more behaviourally ethnic, as more likely to somatize than
their more acculturated counterparts, (Angel & Guarnaccia, 1989). Aroian and
Norris’s (1999) study findings also support a previous impression that
somatization is common among former Soviet immigrants, and that
overlapping forms of somatization and depression are related to the stress of
immigration.
6.5.5 Cross-cultural Issues and Mental Health
The Western conception of mental illness is seen as a dichotomy of mind and
body, whereas Vietnamese culture views it as a mind-body duality (Kawanishi,
1992). The result of this belief system is that Vietnamese tend to express
psychological distress through somatic symptoms. There is a stigma attached
to mental illness in Asian communities, which prevents members from
expressing symptoms of distress, and hence mental health problems are not
acknowledged. Mental health problems do not reach health services, because
they are taken care of within the extended family network. Also, mental illness
is highly stigmatized in Vietnamese culture and is seen as a reflection on the
entire family line, including ancestors and future offspring. The Vietnamese
are often regarded as somatizers in Western eyes, and it is assumed that they
deny psychological symptoms because of cultural taboos on mental illness
(Small, Lumley & Yelland, 2003). Simon and colleagues (1991) conclude that
somatic symptoms should probably be seen as a core component of the
depressive syndrome in all cultures.
However, contrary to earlier research, Small, Lumley and Yelland’s (2003)
studies argue that Vietnamese-Australian women and Filipina women had a
low prevalence of depression on the EPDS and SF-36 measures and
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relatively lower levels of somatic symptom reporting. Some studies (Kirmayer
& Robbins, 1991; Arian & Norris, 1999) also argued that, contrary to clinical
impressions, they find that somatization and depression do not always
coexist, which means that not all depressed former Soviet immigrants will be
somatic. In addition, some participants were somatic and not depressed. They
also caution that somatization can comprise additional categories of
psychological distress that do not overlap with depression.
In conclusion, the expression of somatic symptoms may be a culturally
sanctioned method of expressing psychological distress, allowing individuals
to seek help for physical complaints, hence avoiding the stigma of seeking
help for mental health problems (Chung & Bemak, 1998). Somatization is a
key feature of these people; they don’t complain, like Westerners do, of
feeling lonely and depressed. Instead, they complain about a “pain” or “sore”
over here or over there, and if the health professional does not find a physical
reason for their aches, pains and sores they keep going to more doctors. It is
also important for health professionals to be aware that Vietnamese immigrant
women exhibit distress through somatic channels.
6.5.6 Social Functioning and Social Isolation
There was a negative relationship between the acculturative stress and social
functioning (SF) (P< 0.025) of Health Related Quality of Life (HRQOL) among
Vietnamese immigrant women in Taiwan, indicating that Vietnamese
immigrant women who have higher levels of acculturative stress also have
higher level of difficulties with social functioning with others.
The explanation of this finding may be due to the form of immigration; a “trade
marriage” female was usually single, and migrated alone to Taiwan. Not only
do “Vietnamese brides” live far from their homeland, without the support of
their own parents, friends and relatives, but they are also labelled as people
from a backward country, being “sold” into marriage. Naturally, they were
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belittled as soon as they married, unable to obtain due respect and status in
their marriage or among the husbands’ family relations. All these factors
exacerbate loneliness and isolation, increasing the feeling of a lack of true
friendship and support in social and personal relationships. In addition, due to
fear of their running away to Vietnam and precipitating financial loss for
husbands, they are often unintentionally, or even intentionally, prevented by
their husbands from going out alone and making social contacts in the
community (Yang & Wang, 2003).
Furthermore, language barriers may increase Vietnamese immigrant women’s
social isolation and reduce their social functioning. Regardless of their prior
educational level in Vietnam, they have to learn Taiwanese or Mandarin after
marriage and immigration. The language barrier may force them to live in an
isolated environment, unable to leave the house alone, take public
transportation, ride or drive a vehicle legally, go shopping, seek medical help
and prenatal examination, communicate with family members (especially
mother-in-law), and help her young children to develop language ability and
assist them in homework. Sometimes they have to rely on their spouses or
other family members for indirect communication, augmented by body
language, in order to be understood, thereby frustrating interpersonal
communication and self-expression.
Marital status in the social network plays a fundamental role in female
immigration (Salgado,1987; Guendelman, 1987). Following migration, the
social support available to these women in Taiwan may be limited to their
partner only. Since, most of the Vietnamese brides are products of the
marriage trade; their marriages are arranged by the marriage brokers and are
hence built on fragile relationship grounds. Immigrant women perform the
traditional female role of mother and wife, but lose autonomy due to the
economic and linguistic obstacles they are faced with in Taiwan. Often those
who depend economically on their husbands live in difficult circumstances,
experiencing feelings of isolation and loneliness.
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Researchers and theorists have treated social support as an important
concept that has a positive relationship with health status and mental health
(Stewart, 1993). The finding of this study are confirmed, by Snowdson (2001);
García, Ramírez and Jariego (2002); Simich et al., (2003), that social
functioning in the process of immigrants adapting to a new society is
important. For example, Snowdson (2001) confirms that social and familial
ties and community institutions have played a crucial role in permitting African
Americans to adapt socially and psychologically in the face of stigma and
social rejection. García, Ramírez and Jariego, (2002) investigated Moroccan
and Peruvian immigrant women in Spain, and identified social support as an
important predictor of psychological well being in immigrant adjustment.
Simich et al., (2003) asserted the role of social support as a determinant of
refugee well-being and migration patterns during early resettlement. In
addition, Lee (1994) agreed that strong social functioning may be the best
buffer against the negative effects of migration.
In Taiwan, these findings are confirmed by Yang and Wang’s (2003) studies
that Indonesian immigrant women experience the breaking of ties to family
and friends in their country of origin, resulting in feelings of loss and
loneliness. Moreover, they may also experience lack of social support, social
isolation, and language inadequacy that are specific to integration into
Taiwanese society.
6.6 Discussion of Research Hypothesis Five:
Vietnamese immigrant women will report lower scores of Health Related
Quality of Life – SF-36 (HRQOL) than Taiwanese wome n.
Cross-cultural comparisons suggest that Vietnamese immigrant women show
a generally lower mean score on HRQOL than do Taiwanese women, among
the seven dimension of the HRQOL: physical functioning, role limitations due
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to physical health, bodily pain, general health perceptions, vitality (energy and
fatigue), social functioning, role limitations due to emotional problems, and
mental health (psychological distress and well-being).
The purpose of this study was to evaluate health-related quality of life across
this unique population and provide specific cross-cultural comparisons. While
this result is consistent with previous studies, that the immigrants’ health
status was lower than that of the people in the host society (Aroian, 2001;
Lipson, 1992; Hill, Lipson & Meleis, 2003; Thurston & Vissandjee, 2005;
Meadows et al., 2001), some evidence reveals that individual migrants’ health
deteriorates and continues to deteriorate with the passage of time in the host
country. Thurston and Vissandjee (2005) have found that immigrant women
have poorer health status than women born in the host country concerned,
while Meadows et al., (2001) conclude that mid-life immigrant women reported
deteriorating health status since immigration, and attributed that to the
stresses experienced pre-and post-migration. However, we have discovered
that acculturative variables account for this decline in health status after
migration.
The interpretation of this result may be related to our previous finding: the
acculturation distress may have negative effect on HRQOL among these
Vietnamese immigrant women. Another possible interpretation may be issues
about language barriers affecting access, use of health care services,
resources and information, social status, and economic distress among these
Vietnamese immigrant women.
Several studies (Frank & Faux, 1990; Vega, Kolody, Valle & Weir, 1991; Noh,
Speechley, Kaspar & Zheng, 1992) support the idea that immigrants from
developing countries are a highly vulnerable population, primarily because
women tend to have lower educational levels, more health problems, less
treatment for health problems and, once in the new country, tend to be more
isolated. Numerous stressors that have potentially negative consequences on
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the health of an immigrant have been identified (Aroian, 2001; Mirdal, 1884;
Meleis et al., 1998; Lipson, 1992). As previously predicted, Vietnamese
immigrant women show a general lower mean score of HRQOL than
Taiwanese women, and experience high levels of anxiety, depression, and a
variety of psychological problems.
There are many barriers to tackle, then, to achieve a high health-related
quality of life, such as barriers to access, use of health care services, lack of
information on National Health Insurance (NHI), lack of Information about
medical care resources and knowledge, for these Vietnamese immigrant
women. Firstly, barriers to healthcare system use arise from inadequate
information on medical care resources: lack of connection with community
resources, unfamiliarity with obtaining medical services, and language barriers
affecting access to and application of health related knowledge.
Secondly, because the spouses of SEA immigrants are less educated, it is
more difficult for them to obtain welfare information and to contact community
resources. Lack of information on National Health Insurance (NHI) and social
welfare leads to loss of entitlements, like free hepatitis B tests, free prenatal
examinations and obstetrical services provided by primary health care
centres. Most Vietnamese women and their spouses still believed that NHI is
only issued to national ID card holders. Moreover, the language barrier affects
access to health related knowledge; being unable to read and write Chinese is
another barrier hampering foreign women’s access to, application of and
judgment in health related knowledge.
Yang and Wang (2003) found that SEA immigrant women believed their
health conditions were unchanged by marriage immigration, but from their
descriptions of physical symptoms, the researcher found that change in bodily
function was actually a response to stress caused by rapid assimilation into
Taiwan’s lifestyle, which transformed psychological problems into physical
ones. Thus, during medical evaluation, it is necessary to pay greater heed to
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their physical symptoms, in order to uncover hidden health adjustment
problems.
Economic distress is another serious problem in life faced by these women
and their families. Most families of participants in this study belong to a lower-
middle socio-economic class. Researchers (Yang & Wang, 2003) have
correlated socio-economic status with health condition, and find that health
problems emanate from poverty, such as unsuitable living conditions, inability
to afford and/or obtain medical services, malnutrition and poor mental
condition among these immigrant women, who are particularly vulnerable and
have difficulty meeting the Health Related Quality of Life in comparison with
Taiwanese women.
6.7 Discussion of Research Hypothesis Six
Acculturation factors will impact on the Health Rel ated Quality of Life –
SF-36 (HRQOL) among Vietnamese immigrant women in T aiwan.
A finding from this study is the strong support given by the CART procedure
(Breiman et al., 2003) to the conclusion that, among the many variables
explored (predicted 28.4% of the variance explained), there are five
acculturative risk factors that can impact on the Health Related Quality of Life
(HRQOL) among Vietnamese immigrant women in Taiwan (refer to Table 6).
The factors examined: alienation, occupational adjustment, loss, language
accommodation, and novelty were significant predictors of psychological
distress among Vietnamese immigrant women in Taiwan.
Previous studies have confirmed the significance of the findings that risk
related factors impact on psychological health among immigrant women,
pointing out that many immigrant women confront extensive change in lifestyle
and experience greater emotional distress than their host populations (Berry,
Kim, Minde & Mok, 1987; Aroian, 1990; Aroian & Patsdaughter, 1989; Meleis,
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1991; Lipson, 1992; Hattar-Pollara & Meleis, 1995; Meleis et al., 1998; Aroian
et al.,1998; Arion et al., 2003).
Numerous stressors that have potentially negative consequences on the
health of an immigrant have been identified (Hattar-Pollara & Meleis, 1995),
these include finding employment and establishing an income source,
establishing a new home, feelings of loss of social status and loneliness,
social isolation, and language barriers (Mirdal, 1884; Meleis et al., 1998;
Lipson, 1992). Bhurgra indicated that (2004) major predictors of experiencing
problems among migrations are: rejection by locals, age, low English
proficiency and unemployment. Aroian and colleagues (2003) conclude that
women, older immigrants, those with less than a college education, and those
with greater immigration demands related to novelty, discrimination, loss,
occupation adjustment, language accommodation, and not feeling at home
were the most distressed.
6.7.1 Alienation
The finding of this study revealed that not feeling at home in the receiving
country — alienation, becomes an important risk factor impacting on the
Health Related Quality of Life (HRQOL) among Vietnamese immigrant women
in Taiwan. The concept of “not feeling at home” is about immigrants feeling
like a stranger or a foreigner who is not part of the surroundings or included in
the social structure, the feeling includes: “I do not feel at home, even though I
live in Taiwan, it does not feel like my country, and I do not feel that this is my
true home.” The feeling may describe a sense of alienation. This finding is
confirmed by Kaplan and Mark’s (1990) study, which found that Latino women
who were born in the United States and spoke English, still have more
psychological complaints due to alienation, discrimination and psychological
distress in the United States. In a similar study, Miller et al.,(2006) indicates
that social alienation has been identified as a risk factor for depression among
midlife women from the Former Soviet Union in the USA.
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The interpretation of this result may illustrate the true inside feeling of these
Vietnamese immigrant women in Taiwan. Participants face the following
socio-cultural adjustment problems: lack of social support, social isolation.
Participants not only live far from their homeland, without the support of their
own parents, friends and relatives, but are also labeled as people from a
backward country, “sold” into marriage. They are also unable to obtain respect
from marital relatives. All these exacerbate loneliness and isolation, plus a
feeling of lack of true friendship and support in social and personal
relationships (Yang & Wang, 2003)
As previously mentioned, most “Vietnamese Alien Brides” are products of the
marriage trade. These kinds of international marriages are described by the
mass media as a “marriage trade for money” (Lee & Wang, 2006 ), and these
SEA immigrant women are stigmatised by Taiwanese society as “foreign
brides” or “alien brides”, terms which carry negative connotations; in Chinese
culture the term “foreign” implies an outsider or exotic who can never become
one of its own. There is a strong feeling of prejudice and discrimination due to
their cultural origin; thus, these immigrant women suffer from these stigmata,
and “not feeling that they belong to Taiwanese society”. Not surprisingly,
alienation becomes an important risk factor that impacts on the Health
Related Quality of Life (HRQOL) among Vietnamese immigrant women in
Taiwan.
6.7.2 Language Accommodation and Health
This study found that language accommodation was strongly associated with
psychological health (MCS), which traced depression, anxiety, and psychiatric
disorder. The language accommodation subscale pertains to the immigrant’s
subjective perception of the host language, including extent of vocabulary,
comprehension of local dialect, and ability to be understood, given the
strength of one’s accent (Aroian et al, 1998). This result may indicate that
language accommodation serves as a marker for the ability of immigrant
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women to move outside of their immediate social circle and expand their
opportunities for employment and other types of social and economic
resources. Capability in Chinese is a key feature in the social integration and
acculturation of Vietnamese immigration women in Taiwan.
The finding is consistent with previous studies (Faroo et al., 1995; Hatter-
Pollara & Meleis, 1995; Lee & Wang, 2004; Takeuchi et al., 2007) that found
that language proficiently of immigrants was associated with their health. For
example, Takeuchi et al. (2007) found Asian immigrants in the USA who
spoke English proficiently generally had lower rates of lifetime and 12-month
mental disorders, compared with non-proficient speakers. Language barriers
could hinder immigrant women from obtaining, applying, and assessing
health-relative information (Hatter- Pollara & Meleis, 1995).
In Taiwan, Lee & Wang (2004) found that Chinese reading ability was the
most significant predictor of health promotion lifestyle, indicating that SEA
immigrant women in Taiwan who could read Chinese had a more positive
health promotion lifestyle. Yang (2003) also indicated that the language
barrier is another difficult adaptation problem for Indonesian immigrant women
in Taiwan. Regardless of their prior educational level in Indonesia, they have
to learn Taiwanese or Mandarin after marriage and immigration. The language
barrier may force an Indonesian woman to live in an isolated environment,
unable to leave the house alone, take public transportation, ride a motorcycle
legally, go shopping, seek medical help and prenatal examination,
communicate with family members (especially mother-in-law), and help her
children to develop language ability and assist them in homework. With
pronunciation and enunciation difficulties, they still spoke with slurred accents,
making their Taiwanese or Mandarin less than comprehensible. Sometimes
they have to rely on their spouses or other family members for indirect
communication, so frustrating their interpersonal communication and self-
expression.
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6.7.3 Occupational Adjustment
The occupational adjustment subscale taps difficulty in finding acceptable
work, status demotion, and lack of opportunities for professional advancement
(Arion et al, 2003). The role of employment and occupation in the adjustment
of psychological distress for immigrants has been well documented (Meleis et
al., 1998; Aroian et al., 1998; 2003). The explanation of this result may
indicated that occupation and employment may mean that not only does work
have monetary value to support the family expanse, but gives a sense of
purpose, accomplishment, and gains respect in the family. The employed
were significantly less distressed than were the unemployed (Aroian et al,
1998).
Although, according to the Department of Immigration of Taiwan, the
government’s policy forbids marriage immigrant women to work legally until
they become citizens (MOI, 2005). Some Vietnamese immigrant women work
illegally, seeing the irrelevance of their former jobs. Most of the participants
have studied about 9 years of formal education before migration. Some of
them have semi-professional occupations in their original country before they
came to Taiwan. In spite of their education and profession, these participants
have realized that it is difficult to get work related to their work experience. It is
extremely difficult to argue unfairness with the Taiwanese employer who
intends to exploit them with long hours and low-paid work. Even though
people have a prejudice against them in the workplace, they still endeavour to
find a job.
Participants strongly expressed their desire to find jobs, so that they could
supplement family income, and not be viewed as freeloaders. Yet lack of
professional skill forces them to perform mainly low-paid housework, laundry
and cooking, babysitting or menial work; lack of legal citizenship status
magnifies their difficulty in finding work. Almost all participants considered the
economic problem as the single most stressful and worrisome problem they
faced at that moment.
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These Southeast Asian foreign brides usually marry Taiwanese men of lower
socio-economic status, with lower incomes, whose chief purpose for the
marriage is continuing the family bloodline (Liu, Chung & Hsu, 2001; Chang,
1999; Yang & Wang, 2003). It is not surprising that many Vietnamese
immigrant women are housewives, experiencing financial dependency on their
husband, loss of autonomy and lack of support from their extended family
structure; combined with language difficulties, this may leave them with
psychological distress.
Thus, poverty and low income are other issues in life faced by Vietnamese
immigrant women and their families. Previous findings support the significant
correlation between economic distress and psychological health (Yang &
Wang, 2003). Research has correlated socioeconomic status with health
conditions, and the health problems that emanate from poverty, such as
unsuitable living conditions, inability to afford and/or obtain medical services,
malnutrition and poor mental condition (Benjamin & Hartman, 1996).
With this association between income and health, there is found a strong
relationship between unemployment and poor health. Although such causal
links are sometime disputed, in terms of whether illness leads to lack of
employment or vice versa, there is no doubt that unemployment is associated
with a wide range of mental health issues. Problems arising include higher
risks of psychological disorders (e.g. anxiety, depression, neurotic disorders,
sleeping problems and poor self-esteem), poor physical health, and high
mortality. In conclusion, Vietnamese immigrant women experience more
poverty, lower income, higher levels of unemployment, higher levels of shift
work and poorer security rights than do Taiwanese women (Yang & Wang,
2003).
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6.7.4 Loss
The concept of loss elicits information about longing, and unresolved
attachment to people, places, and things in the homeland (Aroian et al.,
2003). Findings are confirmed by researchers (Hill, Lipson & Meleis, 2003;
Mirdal, 1984; Meleis, 2003; Bhugra 2004; Takeuchi et al., 2007) that
immigrant women confront the multiple stressors of loss in the transition
process, such as loss of familiar networks, support systems, known symbols,
and identifiable resources. Bhugra (2004) stated that depression occurs
amongst migrants; the psychoanalytic concept of loss and melancholia may
well explain some of this. Loss of specific objects may be complicated by loss
of status, and loss of social support, which are the problems most commonly
reported among Asian immigrants, and problems associated with loss of
status and loss of self-esteem (Takeuchi et al., 2007). Yang and Wang (2003)
report that Indonesian immigrant women experienced the breaking of ties to
family and friends in their country of origin, thus resulting in feelings of loss
and loneliness.
6.7.5 Novelty
Novelty is about newness, unfamiliarity, or information deficits related to living
in the new country, for example: needing advice from people to know how to
live in Taiwan, having to learn how certain tasks are handled, such as renting
an apartment, depending on other people to show or teach, always facing
new situations and circumstances. Previous research has shown that
stressors associated with immigrants, such as language difficulties and
novelty, are strongly correlated with distress in immigrants (Aroian et al.,
1998; Miller & Chandler, 2002; Heilemann et al., 2004). Heilemann and
colleagues (2004) found that a poor sense of mastery is a risk factor that is
related to depression symptoms among Mexican immigrant women in United
States.
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Many of these risk factors are usually more prevalent in immigrant women
than in men; immigrant women’s education tends to be at a lower level, and
they are more likely to be unemployed or to have a low income job. Aroian’s
(2001) review of research published in the 1990s showed that, comparing
gender differences, psychological distress was greater in immigrant women
(Kim, 1999; Aroian, 2003).
As this was an initial prediction of an acculturation and health model, the
number of variables in the model was modest. Because our research
questions did not focus on the quality of the partner relationship or the stress
associated with marital discord, it remains unclear whether particular aspects
of marriage relationships might make a difference in levels of acculturative
distress and psychological well being among Vietnamese immigrant women in
Taiwan. Future research could involve additional variables that might
contribute to prediction of successful acculturation and psychological well
being. For example, some researchers (Shaffer & Harrison, 2001; James,
Hunsley Navara & Malnnie, 2004) are also beginning to include marital
satisfaction or spousal factor variables as well as personality variables in the
predicting model.
6.8 The Holistic View of Immigrant Women’s Health
Women’s health research historically has been focused on disease and
conditions affecting the reproductive organs. The last quarter of the 20th
century, however, has seen an explosion of action and extension of scientific
inquiries from those limited largely to women’s reproductive organs to those
encompassing all organ systems and behaviour, as well as the interactions
between them (Brisling & Lucas, 2003). Dan, Bernhard and Wester, (1980)
defining women's health as involving women's emotional, social, cultural,
spiritual and physical well-being and being determined by the social, political
and economic context of women's lives (p. 545).
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As well, Meleis (2003) has stated that existing models of women’s health tend
to neglect the integration between cultural value and norms and structural
facilitators and constraints in women’s lives that shape their responses and
experiences. It is vital to view the focus of women’s health as now moving
beyond reproductive health to encompass overall health and quality of life
throughout the lifespan (Anderson, 2003). In the context of women’s health,
the definition includes everything about women’s lives, including their physical
political, economic, spiritual, emotional, and social dimensions.
No matter what reason individuals have for moving to a new society, many
immigrant women find themselves dealing with a life of economic struggle and
hardship, marginalized in their new society (Anderson,1990; Meleis,1991). Im
and Yang (2006) have described three existing theories of immigration and
health: selective migration, negative effects of immigration, and acculturation.
They indicated that acculturation and stress showed a strong relationship with
depression. The results of this study suggest that immigrant women’s health
should be considered within a framework that acknowledges women’s health,
the acculturation process, and the developmental life stage.
Immigrant women are a substantial subgroup of women; they have the same
experiences as resident women. At the same time, they encounter additional
unique problems in obtaining access to the receiving country’s services. The
burden of this function is an even greater challenge for immigrant women,
many of whom face multiple barriers to acculturation to the new society. In
Taiwan, the issue of transnational marriage, like international migration, is
about stresses in life. This particular group of immigrant women are more
highly susceptible and vulnerable to health problems. These single and alone
SEA immigrant women find themselves dealing with resettlement struggle and
hardship, and are marginalized in the Taiwanese society.
As Melies (2003) proposes, the provision of quality care for women cross-
culturally requires a framework that is driven by well-examined acculturation
assumptions and careful attention to multidimensionality of health. The result
of this study demonstrates a holistic view of immigrant women’s health and
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well-being. The effects of acculturation influences on women’s health include:
the physical dimension (body pain); the psychological dimension (mental
health and vitality); the social dimension (poor social functioning, isolation,
and occupational disadvantage); the emotional dimension (loss and
alienation); and the cultural dimension (language barrier, novelty, and
discrimination). These findings provided a more holistic approach to viewing
SEA immigrant women’s health.
6.9 Conceptual Framework for Acculturation and Heal th
The conceptual framework developed here is based on an exploration of the
relationship between acculturation variables and health outcomes. The
evidence collected from the finding of this research, support the model derived
from the literature review in Chapter One (Figure1.1). The conceptual
framework that has been modified in this research was based on Berry’s
Acculturative Stress Model (1987), which has offered a comprehensive
conceptual framework for the study of immigration, acculturation, and well-
being.
The results of this study suggest that level of acculturation does significantly
correlate with socio-demographic variables and negatively correlates with
acculturative distress, high acculturative distress, reduced vitality, social
functioning, mental health and increased bodily pain. The result shows that
five risk factors: alienation, occupational adjustment, loss, language
accommodation, and novelty, were significant predictors of physical and
psychological distress among Vietnamese immigrant women in Taiwan.
In addition, the framework acknowledges that immigrant women’s health is
influenced by multiple factors; including their pre- and post-immigration status,
level of acculturation, factors of acculturation, and a number of demographic,
social, and psychological characteristics of individual members. The
conceptual framework of acculturation and health identifies the cultural and
psychological factors that govern the relationship between acculturation and
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mental health. We have assumed that mental health problems often do arise
during acculturation.
Individual Acculturation Process Health Outcomes
AcculturationFactors
LanguageSocial supportDaily habitEthnic identityDiscrimination
AcculturationFactors
LanguageSocial supportDaily habitEthnic identityDiscrimination
Physical &
PsychologicalHealth
Physical &
PsychologicalHealth
Pre-migration
Age, Education,ReligiousEthnicity
Pre-migration
Age, Educat ion,ReligiousEthnicity
Post-migrationYears in Taiwan
Marital status
OccupationSpouse’s SES
religion
children
Post-migrationYears in Taiwan
Marital status
OccupationSpouse’s SES
religion
children
Physical DistressBP.
PsychologicalDistress
VT.SF.MH
Physical DistressBP.
PsychologicalDistress
VT.SF.MH
AssimilationIntegration
SeparationMarginalization
Acculturation Strategies
High
Risk FactorsAlienationLanguage
OccupationLoss
Novelty
Risk FactorsAlienationLanguage
OccupationLoss
NoveltyLow
Figure 6.1 The conceptual framework of this study
6.10 Summary
The cross-culture comparisons indicated that Vietnamese immigrant women
show a general lower mean score of HRQOL than Taiwanese women.
Acculturation for Vietnamese immigrant women in Taiwan indicated moderate
levels of acculturation, as well as biculturalism or integration of their
acculturative mode, which means that the participants had kept Vietnamese
their ethnic identity and cultural traditions while also adapting to the
Taiwanese society.
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The years of residency in Taiwan, number of children, marital status, level of
education, religion of spouse, and employment of spouse have positively
influenced the level of acculturation among Vietnamese immigrant women in
Taiwan.
In addition, a higher level of acculturation corresponding to “integration or
assimilation” can be associated with a higher level of mental health whereas
with the level of acculturation decrease associated with marginalization or
separation, mental health and well-being would decrease, assuming that the
marginalized or separation participant might be led to poor mental health
outcomes and psychological distress.
Acculturative stress had a significant negative direct effect on: bodily pain,
vitality, social functioning, and mental health. Elevated acculturative stress
was significantly associated with higher depression and anxiety. The
Vietnamese immigrant women who have higher levels of acculturative stress
also have complaints of bodily pain, less vitality, less energy and feel fatigued
in everyday life. The interpretation of this finding may be related with
somatization. Vietnamese immigrant women who have higher level of
acculturative stress also have a higher level of difficulties in social functioning
with others. The language barriers may increase Vietnamese immigrant
women’s social isolation, and reduce their social functioning and make them
feel lonelier. Alienation, occupational adjustment, loss, language
accommodation, and novelty were significant predictors of physical and
psychological distress among Vietnamese immigrant women in Taiwan.
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Chapter 7 Conclusion
Introduction
This study investigated Health Related Quality of Life, psychological impacts
of acculturative distress and levels of acculturation among Vietnamese
immigrant women in Taiwan. Its findings will not only provide evidence-based
data to help health care professionals to understand these immigrant women’s
health and their physical and psychological acculturative distress, but will also
improve health professionals’ effectiveness in meeting the specific health
needs of this unique population in Taiwan. The chapter first presents the
implications of the study and recommendations on various aspects of nursing
practice, research, and policy making that are supported by this research;
then presents the limitations of this study; and, finally, suggestions are made
for future research.
7.1. Advocacy for Immigrant Women’s Health
7.1.1 Disadvantaged Population
It has been estimated that the combined total of South East Asian wives in
Taiwan was more than 100,000 in 2007; this is expected to rise in the future.
These women are often colloquially called, “foreign brides” or “alien brides”,
terms that carry negative stigmata. Most Vietnamese brides are products of
the marriage trade; their marriages are arranged by marriage brokers and
hence these relationships are built on fragile grounds. Some Vietnamese
women are seen as being sold for profit by their families; this perception
stemming from common Taiwanese perceptions of their home country as a
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backward land, a labour supplier to Taiwan. This, plus negative and superficial
media coverage of trans-national marriages produces a stereotyped picture of
a distorted family life, runaway brides, marriage fraud and prostitution, which
has led to disrespect of such wives by household members and to gossip
among neighbours. These kinds of international marriages are described by
the mass media as a “marriage trade for money”. In summary, they and their
family have undergone commercialisation, stigmatisation, discrimination and
marginalisation by Taiwanese society and by the health care system. They
are one of a group of disadvantaged population in Taiwanese society.
7.1.2 Health Advocacy for Disadvantaged Immigrant W omen
The community nurses or midwifes or other health providers for these
immigrant women can be an effective advocate for individual women and can
play an important role as a participant in community advocacy organizations,
or may serve as a voice for the needs of immigration women within
community or the health care system. McElmurry, Park, and Buseh (2003)
proposed partnership roles between nurses and community health advocates
in primary health care delivery. Their community nurse advocate team was an
effective strategy for promoting immigrant women’s health care needs.
The findings of this study can not only explore the current situations and
influencing factors around acculturation distress and health outcomes among
Vietnamese immigrant women, but also advocates the rights to health care of
SEA disadvantaged immigrant women and their family. Nurse professionals
have increasing responsibilities as the expansion of the scope of their clinical
and academic work is resulting in more clearly defined professional roles,
continuously emphasizing the importance of well-being and identifying and
developing immigrant women’s health needs and strengths in practice, theory,
research and health policy.
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7.2. Implications and Recommendations
7.2.1. Nursing Practice
Today, in the new century, nurses face greater challenges with regard to
providing culturally competent care to diverse immigrant populations
(Leininger, 1995; Meleis & et al, 1998). Nurse professionals and other health
care providers encounter immigrants in hospitals, community health centres,
clinics, schools and workplaces. Specifically, community and public health
nurses are in the front line of the health care delivery system, and are
seriously challenged to explore the health problems and provide for health
intervention for a diverse range of immigrant women.
Immigrant women form a substantial subgroup, and have the same
experiences as resident women. Traditionally women have been and still are
the family health-givers, as well as the brokers and protectors of their family’s
health. They use health care services more frequently than men, particularly
during their childbearing years. At the same time, they encounter unique
additional problems in obtaining access to the country’s services. The burden
of this function is an even greater challenge for immigrant women, many of
whom face multiple barriers to adaptation in the new society. As health care
providers, we are frequently thwarted in our efforts to provide adequate,
effective, and culturally competent care to the immigrant women in our
communities.
As these SEA immigrant women become part of Taiwanese communities and
society, the need becomes apparent to understand how they acculturate to
Taiwan and to the health status they acquire. Providing cultural appropriate
primary care to SEA immigrant women is a challenge to the Taiwan health
care system. It will be facing an ever-increasing rate of change as the
character of Taiwan’s population continues to include a higher proportion of
SEA immigrant women, and as it continues to strive to improve the nursing
care of this increasingly vulnerable group and their families. The findings of
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this study have contributed to nursing practice, and provide solid research
evidence.
The present study has shown that acculturative distress among these
Vietnamese immigrant women included social isolation, language inadequacy
ethnic discrimination and cultural prejudice and economic distress. In nursing
practice, nurses should understand the factors influencing immigrant women’s
health and well being. Immigrant women are often isolated at home; home
visiting can be arranged by community nurses for those immigrant women
who need more health care and health information.
Health Promotion Strategies
The results are significant for nurses who need to focus on health promotion
activities for populations such as immigrant Vietnamese. A primary health
care approach to improving immigrant women’s health requires
acknowledgement of the many factors that can affect women’s health. The
health promotion of immigrant women’s health requires that nurses use a
social view of health, as opposed to a medical model, to ensure that the
psychological, social and physical needs of women are taken into account
(Anderson, 2004).
This research recommends that health promotion strategies and interventions
should be designed to improve immigrant women’ health by developing
programs to increase social participation, developing initiatives to reduce
stress and isolation and to provide outreach health screening, providing
culturally acceptable midwifery service for high-risk women and organizing
health education programs (parenthood education classes, hospital antenatal
classes, breastfeeding education programs). Primary care centres could offer
counselling and support groups to immigrant women, increasing the women’
social participation through women-to-women discussion groups in an
atmosphere of confidence and trust, and enabling them to make informed
health choices while reducing their acculturative distress and isolation.
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A primary health service plays an integral role in multidisciplinary approaches
for immigrant women’s health promotion strategies. The research results
show that novelty is related to immigration distress and impacts on
psychological health. Therefore, we suggest that researchers, public health
nurses, health educators, and social workers collaborate on interventions that
include immigrant adjustment classes, home visiting, motherhood preparation
classes, driving license classes, and language classes. These interventions
should be evaluated for effectiveness in relation to women‘s sense of mastery,
and would decrease the sense of novelty among Vietnamese immigrant
women in Taiwan.
Informing Vietnamese immigrant women about accessible, affordable health
care insurance and social welfare programs is one of the important aspects of
health promotion practices that can help to reduce economic distress.
Because the spouses of immigrants are not well educated, it is more difficult
for them to obtain information on National Health Insurance (NHI) and
immigrant welfare.
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Figure 7.1 Health promotion for immigrant women
Health promotion for immigrant women - Nursing practice
Women migrating from SEA countries can be disadvantaged by:
social isolation; language barriers; discrimination and cultural prejudice;
economic distress.
Health promotion strategies among SEA immigrant women:
• primary health care and community orientation
• increased community participation
• providing health education: culturally oriented midwifery health
service and health education programs
• multidisciplinary approaches: home visiting and classes for language,
immigrant adjustment, motherhood preparation, and driving license
• accessible, affordable health insurance
• comprehensive health assessment
• aware of mental health problems.
Language Issues
The present study has emphasized that the language gap and cultural
differences play an important role in health care among these immigrant
women. Nurses have the responsibility to provide culturally sensitive and
centred nursing practice in the health care setting. In order to reduce the
language barrier, the study suggests that health care institutions should
examine more carefully how they serve clients with limited Chinese
proficiency (LCP). Wilson (1995) provides suggestions for health care
providers to improve the health of immigrant women. Education is the primary
intervention that should be used; the women need information regarding
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resources available in the community that provide health care services at
minimal or no cost.
Some useful strategies could be suggested to decrease the language barrier;
formal or non-professional interpreters could be trained and hired for health
care facilities or the community; their role would be like that of volunteers and
family and friends. Telephone interpretation services should be established at
hospitals or primary care centres.
Our study found that, for Vietnamese immigrant women, reading or writing
Chinese was more difficult than listening and speaking. Therefore, health care
organizations could develop comprehensive translated health information
media, either printed materials, such as discharge instructions, informed
consent sheets for operations or treatment, medication instructions and a
variety of health education pamphlets, brochures, booklets, or films and DVDs
to improve access and quality of health care. In addition, special clinics could
be set up to provide language services, such as Immigrant screening clinics,
or Immigrant women’s clinics.
Assessment Tools
Our results show a high prevalence of psychological distress among
Vietnamese immigrant women, especially women just arrived, in their first
year in Taiwan. This research provides information for physicians, nurse
practitioners, social workers, and public health nurses, who are the health
care professionals in a prime position to assess immigrant women’s health.
We recommend that strategies for assessment, screening, and diagnosis of
mental health problems be included in routine nursing assessment. Given that
levels of acculturation and acculturative distress were significantly related to
mental health, this information should be included in health assessment of
immigrants. More especially, the DIS scale and SF-36 can be used as
screening tools to identify those immigrants who may need assistance with
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dealing with immigration demands. The information from the assessment or
screening can be shared with primary care providers, or high-risk women
could be referred to mental health evaluation, or further interventions.
Awareness of Mental Health Problems
It is important that professional nurses are able to identify immigrant women
who feel psychological distress during the first year of their residence in
Taiwan. Community health nurses and school nurses work with the families
and observe the immigrant women. As nurses become acquainted with these
women, they are able to identify those high-risk individuals. The findings of the
study show that women who perceived higher acculturative stress will have
complaints of bodily pain, less vitality, less energy and feelings of fatigue in
everyday life. It is important, and helpful and enlightening, for a clinician to
elicit women’s and families’ understanding of the aetiology of her emotional
symptoms related to immigrant distress. Health care professionals need to be
aware of the variables that influence the acculturation process to identify
potential stressors and to educate individuals and families to enable them to
develop healthy patterns of immigrant adaptation, and to ensure early
identification of cases of mental health problems in the community.
7.2.2. Implications for Nursing Research
The present study has filled a gap in research on immigrant women’s health in
Taiwan, and conceptualised a theoretical framework for understanding
immigrant women’s health. This knowledge will not only enhance the
capability of health professionals to deal with immigrant women’s mental
health, but will ultimately improve the quality of health care of these unique
populations. Today, health professionals are in a position where they can
make a difference and help those women who find themselves in this life
transition period (Meleis & Lipson, 2003).
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Reviewing the previous studies, there is limited information on the association
between acculturation and health status of Vietnamese immigrant women in
Taiwan. This research bridges the knowledge gap by examining the
relationships among demographic characteristics, acculturation variables, and
health outcomes among Vietnamese immigrant women. Thus, the results of
this research will contribute to nursing research on immigrant women’s health
and will help to develop a body of knowledge of people who are marginalized
in our societies (Melies & Im, 1999).
In addition, achieving scientific parsimony by replication and using similar
populations or a population in another geographic area may help to verify the
conceptual model and its generalization. Polit and Beck (2004) recommend
the development of a stronger knowledge base through multiple, confirmatory
strategies. Confirmation is usually needed through the deliberate replication of
studies with different clients in a different clinical setting, to ensure that they
are robust. Replication in different ethnic groups of women is especially
important, because the primary setting for health care delivery is shifting from
inpatient hospitals to the community and homes. The study also recommends
another confirmatory strategy, the conduct of multiple ethnic group
investigations by research.
7.2.3 Implications for Health Policy
The growing number of SEA women immigrating to Taiwan has become a
significant part of the social and public health structure of the region. In 2007,
the SEA immigrant women population was 131,000. These SEA female
immigrants’ impact on pubic health is important in influencing policy regarding
what health and social welfare benefits will be offered. Understanding of these
conceptualisations and of acculturation is an important aspect of the
knowledge to be used in formulating health promotion strategies and health
policies that are relevant and appropriate for this population
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From the government’s point of view, it is vital to monitor their health quality
and health care needs, as their health issues and concerns may differ from
those of people born in Taiwan. The health policy for immigrants more
typically focuses on quarantine regulation, disease prevention (HIV, STD),
reproductive health, health insurance, and health care utilization.
The present study can inform the government which references to use in
making appropriate health policies for these SEA immigrant women, and in
shaping a comprehensive immigrant health-promoting policy including health
insurance policy, health promotion programs, women’s health empowerment
programs and Chinese-language education courses for these SEA immigrant
women and their families. In addition, the health care system could develop
strategies or regulations to ensure the mental health of SEA immigrant
women; the health service could be applied to access and promote positive
coping strategies, including a program designed to support and assist
immigrant women in adjusting to Taiwan social and cultural norms, developing
social network skills and improving language communication.
Furthermore, the present study suggests that multidisciplinary collaboration is
an important aspect of health care practice; an immigrant health department
could be established to manage and merge useful resources of the health
service, the social welfare system, and the education system to tackle and
serve the increasing numbers of SEA immigrant women.
7.3 Suggestions for Future Research
The study has attempted to provide an overview of the health outcomes of
SEA immigrant women. The limitations of this review only heighten the
importance for more research to be conducted on SEA immigrant women in
Taiwan.
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As SEA immigrant women become part of Taiwanese communities and
society, the need becomes apparent to understand how they adapt to Taiwan
and the problems that they encounter. The findings of this study suggest
several important areas for further study in order to address the unique health
issues encountered by SEA immigrant women in Taiwan. For instance, the
researcher is continuing to conduct a 2-year research project on “participatory
action research (PAR) into acculturation and health promotion strategies
among SEA new immigrant women (IW),” which will described at the end of
this section.
First, we recommend that the approach can be extended further to other
subgroups of immigrant with greater cultural distance in Taiwan In order to
improve the health care of this increasingly vulnerable SEA population and
their families; the present study was focused only on Vietnamese women, the
largest immigrant group in the period 1994 to 2007. Further research could be
designed to investigate the immigrant women who come from other Southeast
Asian subgroup of countries, such as Indonesia, the Philippines, Thailand,
Malaysia, Myanmar and Cambodia. Analysis of comparative differences in
acculturation, immigrant distress, and HRQOL will be needed to form a
comprehensive understanding of these SEA groups. As the work on
acculturation was modified and developed with one language group only
(Vietnamese), and as there may be acculturation difference for other ethnic
populations, further work with other immigrants group, such as Indonesians, is
needed to further validate the scale; for example, different migrants might
place more emphasis on food or on particular religious ceremonies.
Secondly, the results of this study also suggest a need for a culturally effective
intervention program and outreach for SEA immigrant women. Thus, future
research may be needed to develop culture-centred and culture-specific
health promotion strategies and to explore their effectiveness, so as to better
serve this growing population in Taiwan.
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Moreover, this study was designed to examine the relationship between
acculturation and health outcomes, providing a preliminary health survey
dataset for immigrant women. The result of this study showed that
acculturation has direct effect on mental health among Vietnamese immigrant
women in Taiwan. Continued research could systematically focus on gaining a
more comprehensive understanding of acculturative stressors and their
relationships with other immigrant related health variables. Further research
may deepen understanding of psychological impacts and mental health
issues, such us anxiety, depression, substance abuse, alcoholism, and
domestic violence among these immigrant women.
In addition, more culturally specific questionnaires are needed to assess the
SEA population. Further validation of the measurement of acculturation is
necessary, since the measure is relatively new, and has not been used in
many studies to date. The ACC scale, DIS scale, and HRQOF should also
receive further validation and reliability testing on other South East Asian
ethnic groups. Future research should include more questions regarding
acculturation in order to obtain a better assessment of this area.
Finally, longitudinal cohort studies may be another recommended research
direction for comparing and examining acculturation and well being for these
populations over time. In a cross-sequential design, two or more age cohorts
are studied longitudinally, so that both changes over time and cohort
differences can be detected. However, more research is needed to further this
knowledge base.
Continued Research Project
Future research, based on the knowledge of this study: “Participatory action
research (PAR) of acculturation and health promotion strategies among SEA
new immigrant women in Taiwan” is being conducted sequentially, funded and
sponsored by the National Science Council of Taiwan (NSC 96 -26 28-B-037-
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041-MY2). This 2-year research project will develop a culture-centred and
culture-specific health promotion strategy and health empowerment model
among SEA new immigrant women in Taiwan, and will evaluate the
effectiveness and efficiency of the health promotion strategies and health
empowerment model of the project.
The research methods are based on community participation in incorporating
health with social welfare resources. The PAR (Hart ＆ Bond, 1995; Holter &
Schwartz-Barcott, 1993) will be used with a sequential mixed method
combining quantitative and qualitative study, to develop a program: “Health
Empowerment Model among SEA New Immigrant Women.” This program will
focus on physical, psychological, cultural, and social dimensions, including
reproductive health, disease prevention, utilization of healthcare systems,
cultural competence, special health issues, and mental health. Two
communities in Pingdong and Kaohsiung counties will be selected for the
experiment on PAR.
In the second year, feedback and evaluation methods, including formative and
summative evaluation (Scriven, 1991) will be conducted to evaluate the
effectiveness and efficiency of the “Acculturation and Health Promotion
Empowerment Program for SEA New Immigrant Women.” The FORECAST
system (Goodman & Wanderman, 1994) will be applied for formative
evaluation to describe the development, process, and outcome of the two
techniques, while summative evaluation will be employed, including focus
groups and a quantitative questionnaire survey to evaluate the changes of
health knowledge, attitude, and behaviour in SEA new immigrant women in
Taiwan. This project can not only provide a culture-centred and culture-
specific health promotion and health empowerment care model of new
immigrant women in Taiwan for the healthcare professionals, but also the
application of the outcomes of this project will contribute to the health and well
being of thousands of immigrant women and their families.
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54
The Health of Southeast Asian Marriage Trading Women in Taiwan
PhDQuantitative
ResearchSurvey n=213
Post-doctoralAction
ResearchInterventions
NSC Grant 2Acculturation and PAR of health promotion strategies among SEA new immigrant women
in Taiwan.
MasterQualitative Research
Ethnography n=15
2001-2003 2007-2009
NSC Grant 1Health concerns of
Indonesian Immigrant women
in Taiwan
Figure 7.2 Continued Research Project
7.4 Limitations of This Study
Several limitations of the present study are worth noting. Barriers specific to
recruiting and retaining ethnic minorities include: (a) the language barrier, (b)
cultural differences, (c) family and community gatekeepers, and (d) mistrust
about exploitation and ethnic stereotyping (Aroian, 2006). Although rigorous
translation methods were used in this study, the main limitations of this
research were the language barriers. There was no doubt that trying to get
messages across to participants from different cultures and languages may
create misunderstandings or communication breakdowns.
In order to decrease language barriers and increase the awareness of culture
differences, the following strategies were undertaken in the study: (1)
providing a Vietnamese language version of the questionnaire to Vietnamese
participants, and (2) the use of trained bilingual research assistants to
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facilitate the data collection. We called on three Vietnamese immigrant women
who lived or worked in the local community to collect data for us from the
participants. Their goal was to earn additional income during after-work hours,
which coincided with times when the participants were accessible. In addition,
these bilingual research assistants have interpersonal skills and a reputation
for being trustworthy.
This study had challenges in sample recruitment and retention. Because
Vietnamese immigrant women are usually isolated at home with fewer
opportunities to interact with the community, this isolation made it difficult to
access and recruit the sample. In order to increase accessibility to these
immigrant women, the following strategies were undertaken in the study.
First, using female Vietnamese bilingual community workers and community
linkages to build trust and maintain cultural sensitivity; this is a common
approach for recruiting and retaining ethnic minorities in research studies.
Secondly, the snowball technique of sampling was a useful strategy to solve
problems occurring when the participants were difficult to approach directly.
Using phone contact rather than mail for confirmation, this purposefully
avoided written language barriers and cultural norms for men to mediate their
wives’ relationship with the outside world; the husband often handles incoming
mail in Taiwan. Husbands or mothers in law acted as family gatekeepers,
some participants wanted to seek their husbands’ or mother-in-law’s
permission before committing to participation in this study. The main concerns
among husbands or mothers-in-law were about disclosing personal details
about the family. The researcher fully accepted participants’ wishes. In
addition, the researcher not only encouraged the participating women to take
the time to seek permission, but also offered to talk with husbands or mothers-
in-law about their potential concerns.
Finally, incentive gifts were used to increase the response rate. In
appreciation for participant’s time and cooperation, after the interview,
participants received a gift valued at AUSD $4 from the researcher as the
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major incentive for their participation. This information should be useful to
other researchers to avoid the time and costs of trying unsuccessful strategies
with this study population.
It should also be noted that results of this study were restricted to an
employee convenience, non-random sample, and used snowball techniques
to collect the data, which could have resulted in a selection bias, which may
have influenced the outcomes. The small sample size limited the number of
variables that could be included in the regression analysis. The inability of the
present study to identify any predictors of the eight-domain quality of life may
be due to the small sample size causing a type II statistical error. Based on
the conceptual framework and theory assumption, our study focus was on
understanding how those Vietnamese immigrant women acculturate to a new
society that impacted on their health related quality of life; however, the
findings of this research were still consistent with the aforementioned studies.
Despite these limitations, the finding of this study offer a direction for future
areas of enquiry, especially for those into immigrant women’s health in
Taiwan.
7.5 Conclusion
The aim of this research was to explore the physical and psychological
impacts of the acculturation process and to examine the relationships
between acculturative stress and health outcomes among Vietnamese
immigrant women in Taiwan. In conclusion, the present study filled a gap in
research on immigrant women’s health and evidence-based Health Related
Quality of Life in Taiwan. But additional studies are needed to document more
aspects of the health issues of SEA immigrant women in Taiwan. Continued
research systematically focusing deeply on SEA immigrant women’s mental
health issues, domestic violence, and health experience can contribute to both
quality of life and quality of health. Despite the limitations described in the
paragraph above, this study contributes to a strong evidence-based
knowledge and literature on immigrant women’s health. Moreover, the study
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provides specific strategies and concretised approaches for nursing practice,
research, and will assist the Taiwanese government to formulate appropriate
immigrant health policies for these SEA immigrant women. Finally, the
application of this research will positively contribute to the health and well
being of thousands of immigrant women and their families.
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Appendix 1: Ethical approval
Date: Thu 3 Nov 16:18:09 EST 2005
From: Wendy Heffernan <[email protected]
Subject: Confirmation of Level 1 ethical clearance - 4290H
Dear Yung-Mei
I write further to the application for ethical clearance for your project, "Acculturative
stress and psychological well-being among Indonesian transnational marriage
women in Taiwan" (QUT Ref No 4290H).On behalf of the Chair, University Human
Research Ethics Committee (UHREC), I wish to confirm that the project qualifies for
Level 1 (Low Risk) ethical clearance.This is subject to: provision of copies of all the
data collection instruments (questionnaire, survey and interview questions); and
provision of an information sheet and consent form for the interviews and a cover
sheet for the questionnaire and survey in accordance with the University Human
Research Ethics Manual (see attached templates). However, you are authorised to
immediately commence your project on this basis. This authorisation is provided
on the strict understanding that the above information is provided to the Research
Ethics Office prior to the commencement of data collection.
The decision is subject to ratification at the 29 November 2005 meeting of UHREC. I
will only contact you again in relation to this matter if the Committee raises any
additional questions or concerns in regard to the clearance.
The University requires its researchers to comply with: the University’s research
ethics arrangements and the QUT Code of Conduct for Research;
• the standard conditions of ethical clearance;
• any additional conditions prescribed by the UHREC;
• any relevant State / Territory or Commonwealth legislation;
• the policies and guidelines issued by the NHMRC and AVCC (including the
National Statement on Ethical Conduct in Research Involving Humans).
Please do not hesitate to contact me further if you have any queries regarding
this matter.Regards
Wendy
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Appendix 3: Informed consent
Study information sheet
“Acculturation and Health Outcomes among Vietnamese
Immigrant Women in Taiwan Chief Investigator: Yung-Mei Yang PhD student RN QUT Ph: (+617)3864-3880
Principle supervisor: Dr Debra Anderson QUT Ph: (+617)3864-3881
Faculty of Nursing, QUT Kelvin Grove Campus. Victoria Road, Kelvin Grove,
Brisbane, Queensland, Australia.
Description of the project
The purpose of this project is to investigate factors influencing immigrant women‘s
psychological well-being. The project is being conducted through QUT and is the
basis of a degree of Doctor of Philosophy at Queensland University of Technology
(QUT). The research will be performed by Yung-Mei Yang under the guidance of Dr
Debra Anderson. The name and contact details of the research team are list above.
Please call Yung-Mei Yang for all initial inquiries.
Your involvement
Your involvement in the project would include giving a written consent to participate.
You will participate in a survey by completing an anonymous questionnaire that
contains questions about your health in general and briefly about your immigrant
adjustment. It will take about twenty minutes to complete the survey.
Expected benefits
Your involvement in this project will not have any direct benefit to you. However, it is
expected that this project will benefit you and your family. In addition, the result of this
research will provide an evidence data base of immigrant health which may be useful
for policy regulation in Taiwan. The outcome of this research may improve the
knowledge and strategies of immigrant women’s adaptation.
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Risks
There are no risks associated with your participation in this project.
Confidentiality
All comments and responses are anonymous and will be treated confidentially. The
names of individual persons are not required in any of the responses. Your name and
contact details will be recorded on a computer database and you will be assigned a
participant number. This number will be used instead of your name on all documents in
the research. Only the researchers have access to the computer data base. All
information you supply for the project will be treated in confidence and securely stored
during the study period and five years afterwards, until which the data is destroyed.
When the project is finished, the results will be published. However, no information will
be published that can identify you or the place where you live.
Voluntary participation
Your participation in this project is entirely voluntary. If you do agree to participate, you
can withdraw from participation at any time during the project without comment or
penalty. This study has been approved by the Ethics Committee of QUT.
Questions / further information
Please contact the researchers if you require further information about the project, or to
have any questions answered.
Concerns / complaints
Please contact the Research Ethics Officer on (+617)38642340 or
[email protected] if you have any concerns or complaints about the ethical conduct
of the project.
I would appreciate it very much if you would take part in this survey. Without your
help it will not be possible to have an accurate understanding of wellbeing in
immigrant women. I thank you for the time you took to read this, and in anticipation of
your help.
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Study Consent Sheet
“Acculturation and Health Outcomes among Vietnamese Immigrant Women in Taiwan
Chief Investigator: Yung-Mei Yang PhD student RN QUT Ph: (+617)3864-3880
Principle supervisor: Dr Debra Anderson QUT Ph: (+617)3864-3881
School of Nursing, QUT Kelvin Grove Campus. Victoria Road, Kelvin Grove,
Brisbane, Queensland, Australia.
Statement of consent
By signing below, you are indicating the following:
• I have read and understood the information sheet about this project;
• I have had any questions answered to my satisfaction;
• I understand that if I have any additional questions I can contact the research
team;
• I understand that I am free to withdraw at any time, without comment or
penalty;
• I understand that I can contact the research team if I have any questions
about the project, or the Research Ethics Officer on 3864 2340 or
[email protected] if I have concerns about the ethical conduct of the
project;
• I agree to participate in the project.
Name
Signature
Date / /
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Appendix 4: Permission from SL-ASIA Scale
Date: Tue 24 Jan 09:16:40 EST 2006
From: Richard Suinn <[email protected]> Add To Address Book | This is
Spam
Subject: Re: SL-ASIA Scale
To: "<[email protected]>" <[email protected]>
SUINN-LEW ASIAN SELF-IDENTITY ACCULTURATION SCALE
(SL-ASIA)
This document provides formal permission to anyone whishing to use
the SL-ASIA scale. The scale is duplicated in the last section . Also
discussed are some practical research design suggestions as well as
some theoretical issues. Finally some potential new items are
described for those researchers who may wish to extend the scale.
(The same information is duplicated under separate links in the web
site: http://www.awong.com/~randy/dad/index.htm
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Appendix 5: Permission from DIS Scale
Date: Wed 31 Aug 11:57:32 EST 2005
From: "KAREN J. AROIAN" <[email protected]> Add To Address Book | This
is Spam
Subject: Re: Demands of Immigration Scale
Hello and thank you for your interest in my work. Sorry for
my delay in getting back to you. Your original request came
when I was on vacation and then the start-up of the semester
was consuming all of my time. Attached is a copy of the
DIS. There is no fee for using it but I ask that (1) I be
informed of how you intend to use it, including your study
population and the language of administration (2) that you
properly cite it as my scale, both when you administer it
and in any publications or presentations and (3) that you
inform me of the psychometrics you obtain with your study
sample. #3 allows me communicate this important information
with other researchers who are also interested in using it.
It is available in Russian, English, Spanish, and Arabic. If you
want to use it in another language, it should be translated
and back translated as a validity check or translated by a
committee that discusses and resolves differences about the
translation. If you want one of these already established
alternate language versions, let me know and I'll get you a
copy. I look forward to hearing the details of your
research and how you intend to use the measure. Best wishes,
Karen J. Aroian
College of Nursing
Wayne State University
Attachment: Demands of Immigration Scale.doc (61k bytes) Open
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Appendix 6: Permission from SF-36 survey
Date: Wed 8 Mar 06:50:41 EST 2006 From: "Lynda LaPlante" <[email protected]> Add To Address Book | This is Spam Subject: Survey Forms for License #F1-013106-25288 To: <[email protected]> Dear Yung Mei,
Thank you for returning the signed agreement and payment to license version 2 of
the SF-36™, 4-week (standard) Health Survey(s). Please find attached Microsoft
Word and Adobe Acrobat files for the language(s) you have requested to license.
NOTE: If you have licensed other languages besides US English, please print a hard
copy of the Adobe Acrobat file for each translation. We would like to ask that you
compare the Microsoft Word file against the Adobe Acrobat file before administering
the surveys to your patients. If you do not have Adobe Acrobat Reader installed on
your computer, you can download a FREE copy at
http://www.adobe.com/support/downloads/main.html The reason for this verification
is your computer may not have all the fonts installed to open up the Microsoft Word
document correctly.
Please do not hesitate to contact me with questions.
www.qualitymetric.com - information about our products, consulting services and licensing our surveys www.sf-36.org - information about our surveys www.iqola.org - information about the validation of our surveys Kind Regards,
MIchelle Koch Account Executive Direct Line (401) 642-9258 Fax (401) 334-8770 Email: [email protected] QualityMetric Incorporated 640 George Washington Highway Suite 201 Lincoln, RI 02865 Office: (401) 334-8800 Toll Free: 1-800-572-9394 The information contained in this e-mail is confidential and privileged. Any unauthorized disclosure, copying, distribution or taking of any action based on the contents of this material is strictly prohibited. If you have received this e-mail in error please notify the sender and delete this email immediately.
- 197 -
Appendix 7: Questionnaire (Vietnamese version)
BẢN THĂM DÒ SỰ THÍCH NGHI V Ề VĂN HOÁ VÀ VẤN ðỀ SỨC
KHOẺCỦA PHỤ NỮ VIỆT NAM TẠI ðÀI LOAN
Số thứ tự:___________
Ngàààày thááááng năm:_________ Kính chào quí vị : Hoan nghênh quí vị ñến với ðài loan ! Chúng tôi rất coi trọng vấn ñề sức khoẻ và và sự hài lòng về cuộc sống của quí vị. ðề
án nghiên cứu này do nghiên cứu sinh Yung-Mei Yang, thuộc Viện ðại học Kỹ thuật
Queensland - Australia thực hiện. Mục ñích là ñể tìm ra các nhân tố có ảnh hưởng
ñến sức khoẻ và sự hoà nhập văn hoá của phụ nữ ðông nam á tại ðài loan. Sự ñóng
góp ý kiến của qúi vị rất có giá trị và chính xác cho kết quả nghiên cứu của chúng tôi.
ðồng thời cũng là nguồn tư liệu hữu ích, ñể cung cấp cho chính phủ ðài loan tham
khảo trong việc phát triển và sửa ñổi chính sách dành cho người nhập cư mới. Nhằm
hỗ trợ về sự thích nghi về văn hoá và sức khoẻ của càng nhiều chị em ñến từ khu vực
ðông nam á. Mọi thông tin sẽ ñược giữ kín và bảo quản an toàn trong suốt thời gian
nghiên cứu. Xin quí vị vui lòng căn cứ theo kinh nghiệm thực tế của mình ñể trả lời
bản câu hỏi, rất cảm ơn sự hỗ trợ của quí vị.
Nếu quí vị bằng lòng tham gia, xin hãy ký tên vào khoảng trống phía bên dưới, chúng tôi sẽ dành riêng một phần quà nhỏ tặng quí vị.
Kính chúc an khang thịnh vượng, vạn sự như ý!
Nghiên cứu sinh Yung-Mei Yang-Học viện ðại học Kỷ thuật Queensland Tiến sĩ Debra Anderson- Học viện ðại học Kỷ thuật Queensland Giáo sư Hsiu-Hung Wang - Học viện Chăm sóc và bảo vệ sức khoẻ ðại học Y khoa Cao hùng
ðồng kính Người tham gia ký tên:_______________ Ngày tháng năm:______________ Nếu quí vị có thắc mắc gì, xin liên hệ với Yung-Mei Yang ðại chỉ: Học viện Y học Cao hùng; Số 100, ñường Thập toàn, TP. Cao hùng ðiện thoại: 07-3121101 xin số 2624; Fax: 07-3218364; Di ñộng: 0926910606 Email: [email protected]
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(I)Phần Một: Lý L ịch Cá Nhân
1. Tuổi:_____(Năm sinh: 19____) 2. Quốc tịch gốc: □ 1 Việt Nam □ 2 Indonesia □ 3 Thái Lan □ 4
Khác:________
3. Tình trạng hôn nhân: □1 Có gia ñình □2 Ly dị □3 ðộc thân □4 Goá □5 Khác: _______
4. Tôn giáo: □1 Hồi giáo □2 Tin lành/Thiên Chúa giáo □3 Phật giáo/ðạogiáo
□4 Tôn giáo khác:______________ □5 Không
5. Quí vị có phải là người Vi ệt gốc Hoa không: □1 Phải □2 Không phải 6. Trình ñộ học vấn ở Việt nam: □1 Không □2 Tiểu học □3 Cấp 2 □4 Cấp 3
□5 ðại học hoặc chuyên khoa □6 ðại học trở lên
7. Thời gian cư trú tại ðài Loan: ____năm ____tháng
8. Nghề nghiệp tại Vi ệt Nam: __________________
9. Nghề nghiệp tại ðài Loan:___________________
10. Tình trạng công việc tại ðài Loan: □1 Không □2 Toàn thời □3 Bán
thời
11. Trình ñộ học vấn của chồng: □1 Không □2 Tiểu học □3 Cấp 2 □4 Cấp 3 □5 ðaị học hoặc chuyên khoa □6 ðại học trở
lên
12. Tuổi cuả chồng:_______( Trung hoa Dân quốc năm:____)
13. Nghề nghiệp của chồng:___________________
14. Tình trạng công việc của chồng : □1 Không □2 Toàn thời □3 Bán thời
15. Tôn giáo của chồng: □1 Hồi giáo □2 Tin lành/Thiên Chúa giáo□3 Phật giáo/ ðạogiáo □4 Tôn giáo khác:_________ □5 Không
16. Tình trạng sức khỏe của chồng: □1 Không tốt □2 Bình thường □3 Tốt 17. Tính cho ñến nay, bác sĩ có nói sức khoẻ chồng của quí vị có vấn ñề gì không?
□1 Không □2 có:______________
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18. Số con cái: ________
19. Mô hình gia ñình: □1 Tiểu gia ñình (gồm chồng, vợ và con cái) □2 Gia ñình
chỉ có bố hoặc mẹ □3 Cả 3 ñời cùng chung sống (ông bà, cha mẹ, con cái)□
4 khác:_____
20. Quí vị có cảm thấy mình không ñược khoẻ sau khi ñến ðài loan không? □1 Không □2 Có, triệu chứng: _______
21. Sau khi ñến ðài loan, bác sĩ có nói sức khoẻ của qúi vị có vấn ñề gì không? □1 Không □2 Có :___________
(II) Phần Hai: Vấn ñề Hội Nhập Văn Hoá
Phần này hỏi về sinh hoạt thường ngày, quan hệ xã hội, sử dụng ngôn ngữ và cảm nhận của quí vị, xin hãy chọn một câu trả lời thích hợp nhất.
1. Sinh hoạt thường ngày
1. Loại nhạc nào quý vị thích nghe?
□ 1.Chỉ nhạc Việt □ 2.Hầu hết là nhạc Việt □ 3.Thích nghe cả nhạc Việt và nhạc ðài Loan □ 4.Hầu hết là nhạc ðài Loan □ 5.Chỉ nhạc ðài Loan
2. Chương trình truy ền hình nào quý vị thích xem?
□ 1.Chương trình tiếng Việt □ 2.Hầu hết là chương trình tiếng Việt □ 3.Thích xem cả chương trình tiếng Việt và tiếng ðài Loan □ 4.Hầu hết là chương trình tiếng ðài Loan
3. Loại thức ăn nào quý vị thích hơn (ở nhà) ?
□ 1.Chỉ thức ăn Việt □ 2.Hầu hết là thức ăn Việt □ 3.Thích cả thức ăn Việt và ðài Loan □ 4.Hầu hết là thức ăn ðài Loan □ 5.Chỉ thức ăn ðài Loan
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4. Loại thức ăn nào quý vị thích hơn (ở nhà hàng)?
□ 1.Chỉ thích thức ăn Việt □ 2.Hầu hết là thức ăn Việt □ 3.Thích cả thức ăn Việt và ðài Loan □ 4.Hầu hết là thức ăn ðài Loan □ 5.Chỉ thích thức ăn ðài Loan
5. ðánh giá mức ñộ thích nghi của quý vị về thức ăn ðài Loan ?
□1 Rất không thích nghi □ 2 Không thích nghi □ 3 Bình thường □ 4 Thích nghi □ 5 Rất thích nghi.
Nguyên nhân không thích nghi: □1 Chủng loại thức ăn □2 Cách chế biến □ 3 Do tôn giáo □ 4 Lý do khác :_________
2, Quan hệ xã hội
6. Các bạn hữu hoặc ñồng nghiệp của quý vị thuộc nhóm người nào? □ 1. Toàn là người Vi ệt □ 2. Phần lớn là người Vi ệt □ 3. Cả bạn người Vi ệt lẫn người ðài Loan □ 4. Phần lớn là người ðài Loan □ 5. Toàn là người ðài Loan □ 6. Nhóm người khác :_____________
7. Hiện tại quý vị thường giao thiệp với nhóm người nào trong cộng ñồng? □ 1. Toàn với người Vi ệt □ 2. Phần lớn là với người Vi ệt □ 3. Cả người Vi ệt lẫn người ðài Loan □ 4. Phần lớn là với người ðài Loan □ 5. Toàn với người ðài Loan
8. Ai thường nâng ñỡ quý vị về mặt tinh th ần?
□ 1. Không ai cả □ 2. Hầu hết là người Vi ệt □ 3. Cả người Vi ệt lẫn người ðài Loan □ 4. Hầu hết là người ðài Loan □ 5. Chỉ có người ðài Loan
9. Ai cố vấn và giúp ñỡ quý vị khi gặp những sự cố ( khó khăn)?
□ 1. Không ai cả □ 2. Hầu hết là người Vi ệt Nam □ 3. Cả người Vi ệt lẫn người ðài Loan □ 4. Hầu hết là người ðài Loan
□ 5. Chỉ có người ðài Loan
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10. Quý vị thường giao tiếp và ñi mua sắm với ai? □ 1. Không với ai cả □ 2. Hầu hết là với người Vi ệt Nam □ 3. Cả với người Vi ệt lẫn người ðài Loan □ 4. Hầu hết là với người ðài Loan □5. Chỉ với người ðài Loan
11. Nếu có thể chọn lựa, quý vị thích giao thiệp với nhóm người nào trong cộng ñồng hơn?
□ 1. Toàn với người Vi ệt □ 2. Phần lớn là với người Vi ệt □ 3. Cả với người Vi ệt lẫn người ðài Loan □ 4. Phần lớn là với người ðài Loan □ 5. Chỉ với người ðài Loan □ 6. Nhóm người khác:____________________
12. Xin ñánh giá sự giúp ñỡ mà quý vị nhận ñược từ các bạn hữu Việt Nam
□1 Không có □2 ðôi lúc □3 Thường xuyên □4 Nhiều □5 Rất nhiều
13. Xin ñánh giá sự giúp ñỡ mà quý vị nhận ñược từ các bạn hữu ðài Loan
□1 Không có □2 ðôi lúc □3 Thường xuyên □4 Nhiều □5 Rất nhiều
14. Xin ñánh giá sự giúp ñỡ mà quý vị nhận ñược từ người chồng
□1 Không có □2 ðôi lúc □3 Thường xuyên □4 Nhiều □5 Rất nhiều
15. Quý vị giữ liên lạc với Vi ệt Nam như thế nào?
□1. Trở về thăm Việt Nam ít nhất mỗi năm một lần □2. Không về thăm Việt Nam mỗi năm □3. Thỉnh thoảng trở về thăm Việt Nam □4. Thỉnh thoảng liên lạc (thư từ, ñiện thoại v.v..) với thân hữu tại Vi ệt Nam □5. Không có tiếp xúc hoặc liên lạc với thân hữu tại Vi ệt Nam
3, Sử dụng ngôn ngữ
16. Quý vị nói ñược những ngôn ngữ nào?
□1. Chỉ tiếng Việt □2. Tiếng Việt và một ít tiếng Hoa/ ðài loan □3. Cả tiếng Việt lẫn tiếng Hoa/ ðài loan □4. Tiếng Hoa/ ðài Loan, thỉnh thoảng mới nói tiếng Việt
□5. Chỉ tiếng Hoa/ ðài Loan
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17. Quí vị ñọc ñược những ngôn ngữ nào? □1. Chỉ chữ Việt □2. Chữ Việt khá hơn chữ Hoa □3. Cả chữ Việt lẫn chữ Hoa □4. Chữ Hoa khá hơn chữ Việt □5. Chỉ chữ Hoa
18. Quí vị viết ñược những ngôn ngữ nào?
□1. Chỉ chữ Việt □2. Chữ Việt và một ít chữ Hoa □3. Cả chữ Việt lẫn chữ Hoa □4. Chữ Hoa khá hơn chữ Việt □5. Chỉ chữ Hoa
19. Ngôn ngữ nào quý vị thường dùng tại nhà hơn?
□1. Chỉ tiếng Việt □2. Hầu hết tiếng Việt, một ít tiếng Hoa/ ðài Loan □3. Cả tiếng Việt lẫn tiếng Hoa/ðài Loan □4. Hầu hết tiếng Hoa/ ðài Loan, một ít tiếng Việt □5. Chỉ tiếng Hoa/ ðài Loan
20. Xin ñánh giá về khả năng nói tiếng Hoa/ ðài Loan của quý vị
□1 Không biết □2 Một ít □3 Trung bình □4 Khá □5 Tốt
21. Xin ñánh giá về khả năng nghe và hiểu tiếng Hoa/ ðài Loan của quý vị □1 Không hiểu □2 Hiểu một ít □3 Trung bình □4 Khá □5 Tốt
22. Xin ñánh giá về khả năng ñọc chữ Hoa/ ðài Loan của quý vị
□1 Không hiểu □2 Một ít □3 Trung bình □4 Khá □5 Tốt
23. Xin ñánh giá về khả năng viết chữ Hoa/ ðài Loan của quý vị □1 Không biết □2 Một ít □3 Trung bình □4 Khá □5 Tốt
4, Bản sắc văn hoá
24. Quý vị tự nhận mình là người gì?
□1 Là người ðông phương □2 Là người Vi ệt □3 Là người Hoa ở châu Á □4 Là người Hoa gốc Việt □5 Là người Hoa hoặc ðài Loan
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25. Những giá trị văn hoá nào quý vị dùng ñể giáo dục con cái? □1 ðông phương □2 Việt Nam □3 Trung Hoa Á châu □4 Hoa - Việt □5 Hoa hoặc ðài Loan
26. Nếu quý vị tự cho rằng mình là người Vi ệt, xin hãy cho biết niềm tự hào của quý vị khi mình là một người Vi ệt.
□1 Rất tự hào □2 Tự hào □3 Có một chút □4 Không tự hào nhưng không có cách nhìn tiêu cực ñối với nhóm này □5 Không tự hào và có cách nhìn tiêu cực ñối với nhóm người này
27. Quý vị tự nhận về mình như thế nào? □1 Rất là Việt Nam □2 Gần như Việt - Hoa □3 Song văn hoá (cả Việt và Hoa) □4 Gần như là người Hoa □5 Rất là người Hoa
28. Quý vị có tham dự những ngày hội hè, lễ nghỉ, và những ngày lễ truy ền
thống Việt Nam không? □1 Gần như tham dự tất cả □2 Tham dự phần nhiều □3 Tham dự một số lần □4 Ít tham dự □5 Không bao giờ tham dự
29. Xin hãy ñánh giá sự tin tưởng của quí về giá trị văn hoá Việt Nam (trên phương diện: hôn nhân, gia ñình, giáo dục, nghề nghiệp.v.v..)
□1 Không tin tưởng □2 Một ít □3 Bình thường □4 Tin tưởng □5 Rất tin tưởng
30. Xin hãy ñánh giá sự tin tưởng của quí vị về giá trị văn hoá ðài Loan (trên phương diện: hôn nhân, gia ñình, giáo dục, nghề nghiệp.v.v..)
□1 Không tin tưởng □2 Một ít □3 Bình thường □4 Tin tưởng □5 Rất tin tưởng
31. Xin ñánh giá sự hoà ñồng giữa quý vị và những người Vi ệt khác □1 Không hoà ñồng □2 Một ít □3 Bình thường □4 Hoà ñồng □5 Rất hoà ñồng
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32. Xin ñánh giá sự hoà ñồng giữa quý vị và người ðài Loan □1 Không hoà ñồng□2 Một ít □ Bình thường □4 Hoà ñồng □5 Rất hoà ñồng
33. Mỗi người ñều có một quan ñiểm riêng, câu nào sau ñây diễn tả thích hợp nhất quan ñiểm của quý vị về chính mình?
□1. Tôi cho rằng tôi là người Vi ệt Nam. Mặc dù ñang sống và có gia ñình ở ðài Loan, nhưng tôi vẫn xem tôi là người Vi ệt Nam.
□2. Tôi cho rằng tôi là người Hoa. Mặc dù tôi có những ñặc ñiểm riêng và sinh ra Việt Nam, nhưng tôi vẫn xem tôi là người Hoa.
□3. Tôi cho rằng tôi là người Hoa gốc Việt, nhưng trong thâm tâm tôi biết mình là người Vi ệt.
□4. Tôi cho rằng tôi là Hoa gốc Việt, nhưng trong thâm tâm trước tiên tôi nghĩ rằng mình là người Hoa.
□5. Tôi cho rằng tôi là người Hoa gốc Việt. Tôi có những ñặc ñiểm của cả người Vi ệt và người Hoa, và tôi xem mình là một sự pha trộn giữa cả hai.
5. Cảm nhận về xã hội
Rất không ñồng ý
Không ñồng ý
Bình thường
ðồng ý
Rất ñồng
ý 34. Vì tôi là người Vi ệt Nam, nên
tôi phải làm công việc gấp ñôi.
1 2 3 4 5
35. Người ta có giọng kẻ cả với tôi, vì tôi là người Vi ệt Nam
1 2 3 4 5
36. Những trò ñùa cợt có tính cách kỳ thị chủng tộc thường nhắm vào tôi, trong gia ñình hoặc nơi làm việc của tôi.
1 2 3 4 5
37. Vì tôi là người Vi ệt Nam, nên tôi thường bị phân công vào những việc không ai muốn làm.
1 2 3 4 5
38. Ở ðài loan, người ta coi thường và thiếu tôn trọng khi cư xử với tôi
1 2 3 4 5
39. Tôi ñã từng bị từ chối hay bỏ bê khi nhập bệnh viện hoặc ñiều trị
1 2 3 4 5
40. Các cơ quan y tế lơ là không phục vụ tôi, hoặc dành ưu tiên cho người ñịa phương
1 2 3 4 5
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(III) Ph ần ba: Cảm nhận về tâm lý Xin hãy chọn và khoanh tròn câu trả lời diễn tả phù hợp nhất với cảm nhận của quí vị trong vòng 3 tháng gần ñây. (Nếu quí vị làm công việc nội tr ợ, thì có thể không cần trả lời câu số 6, 11, 19, 21) Rất
không ñồng ý
Không ñồng ý
ðồng ý
Rất ñồng ý
1. Người ðài Loan nghe không hiểu giọng nói của tôi.
0 1 2 3
2. Khi nghĩ tới qúa khứ, tôi có rất nhiều cảm xúc và hoài niệm.
0 1 2 3
3. Tuy sống ở ñây, nhưng tôi không cảm thấy ðài Loan là ñất nước của tôi.
0 1 2 3
4. Tôi cần ý kiến của những người có kinh nghiệm hướng dẫn tôi cách sống ở ñây.
0 1 2 3
5. Tôi thấy rất khó tìm ñược một công việc tốt.
0 1 2 3
6. Cấp bậc trong công việc hoặc ñiạ vị xã hội của tôi không bằng trước ñây.
0 1 2 3
7. Vì là người di dân, tôi cảm thấy mình bị coi như là người công dân cấp hai.
0 1 2 3
8 Ngay khi làm những việc bình thường, tôi vẫn cảm thấy khó khăn do trở ngại về ngôn ngữ.
0 1 2 3
9. Người ðài Loan không nghĩ tôi là một thành viên của nước họ.
0 1 2 3
10. Tôi nhớ những người thân ở quê nhà.
0 1 2 3
11. Tôi có ít cơ hội ñể phát triển nghề nghiêp ở ðài Loan.
0 1 2 3
12. Tôi phải rất cố gắng và tốn nhiều thời gian ñể học nói tiếng Phổ thông hoặc ðài Loan.
0 1 2 3
13. Người ðài Loan xem tôi như người ngoài nước.
0 1 2 3
14. Tôi phải học cách xử lý một số việc, chẳng hạn như ñi thuê nhà hoặc thi bằng lái xe.
0 1 2 3
15 Tôi không cảm thấy ðài loan thật sự là ngôi nhà của tôi.
0 1 2 3
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16. Tôi phải lệ thuộc vào người khác ñể hướng dẫn tôi cách làm một số việc.
0 1 2 3
17. Tôi không cảm thấy như ñang ở nhà.
0 1 2 3
18. Tôi cảm thấy buồn, khi nghĩ tới những nơi ñặc biệt ở quê nhà.
0 1 2 3
19. Trong công việc, tôi không thể cạnh tranh với người ðài Loan.
0 1 2 3
20. Ở ðài loan, người có giọng nói ngoại quốc hầu như không ñược tôn trọng.
0 1 2 3
21. Kinh nghiệm làm việc hoặc bằng cấp ở Việt nam, ở ðài loan không ñược chấp nhận.
0 1 2 3
22. Tôi luôn phải ñối mặt với những tình huống và hoàn cảnh mới.
0 1 2 3
23. Tôi thường rơi lệ khi nghĩ tới quê hương.
0 1 2 3
(IV) Phần bốn: Tình tr ạng sức khoẻ
Muc ñích phần câu hỏi này là ñể tìm hiểu cách nhìn nhận của quí vị về sức khoẻ
của mình. Phần thông tin sau ñây sẽ hỗ trợ ghi chép lại sự cảm nhận, và khả năng
ñiều khiển trong sinh hoạt thường ngày của qúi vị. Cảm ơn sự hợp tác của quí vị,
xin hãy chọn một tr ả lời thích hợp nhất và ñánh dấu ����vào ô trống����.(ví dụ:����)
1. Thông thường mà nói, quí vị cho rằng tình hình sức khoẻ hiện tại của qúi vị là
1� Vô cùng khỏe 2�Rất khoẻ 3�Khoẻ 4� Bình thường 5� Không khoẻ
2. So với một năm trước, quí vị cho rằng tình hình sức khoẻ hiện tại là
1� Khoẻ hơn rất nhiều 2� Khỏe hơn 3� Khoẻ 4�Tệ hơn 5� Tệ hơn rất nhiều.
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3. Sau ñây là các câu hỏi có liên quan ñến sinh hoạt thường ngày, xin hỏi tình hình sức khoẻ hiện tại có hạn chế ñến sinh hoạt hàng ngày của qúi vị không?
Hạn chế
rất nhiều Hạn chế một số
Không bị hạn chế
a. Hoat ñộng tốn sức, như chạy bộ, xách vật nặng, vận ñộng kịch liệt.
�1 �2 �3
b. Các hoạt ñộng mức ñộ trung bình như: khiêng bàn, lau nhà, chơi bóng bo-ling hoặc ñánh thái cực quyền.
�1 �2 �3
c. Xách hoặc mang một số thực phẩm (như: ñi chợ mua thức ăn)
�1 �2 �3
d. Leo cầu thang nhiều tầng lầu
�1 �2 �2
e. Leo cầu thang một tầng lầu
�1 �2 �2
f. Khom lưng, quì gối, ngồi xổm
�1 �2 �3
g. ði bộ hơn 1 km
�1 �2 �3
h. ði bộ vài trăm mét
�1 �2 �3
i. ði bộ một trăm mét
�1 �2 �3
j. Có bị hạn chế khi tắm hoặc thay quần áo không? nếu có thì mức ñộ là:
�1 �2 �3
4. Trong vòng 4 tuần qua, có bao giờ do vấn ñề sức khoẻ, nên trong công việc
hoặc các hoạt ñộng thường ngày cuả quí vị có vấn ñề nào sau ñây? Hầu
như Phần lớn
ðôi lúc
Rất ít
Không bao giờ
a. Giảm bớt thời gian làm việc hoặc các hoạt ñộng khác
�1 �2 �3 �4 �5
b. Công việc hoàn thành ít hơn so với quí vị mong muốn
�1 �2 �3 �4 �5
c. Một số công việc hoặc hoạt ñộng bị hạn chế
�1 �2 �3 �4 �5
d. Gặp khó khăn (ví dụ: bỏ ra càng nhiều công sức) khi làm việc hoặc các hoạt ñộng khác
�1 �2 �3 �4 �5
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5. Trong vòng 4 tuần qua, có bao giờ do nỗi buồn bực (víííí dụ: cảm thấy buồn
phiền, hoặc lo nghĩ), dẫn ñến công việc hoặc các hoạt ñộng thường ngày của quí vị gặp phải các vấn ñề sau?
Hầu
như Phần lớn
ðôi lúc
Rất ít Không bao giờ
a. Giảm bớt thời gian làm việc hoặc các hoạt ñộng khác
� � � � �
b. Lượng công việc hoàn thành ít hơn so với qúi vị mong muốn
� � � � �
c. Cẩn thận hơn trong lúc làm việc hoặc hoạt ñộng
� � � � �
6. Trong vòng 4 tuần qua, do vấn ñề sức khoẻ hoặc do buồn bực, ñã làm trở
ngại ñến hoạt ñộng thường ngày giữa qúi vị với người nhà hoặc bạn bè, hàng xóm, ñoàn thể xã hội như thề nào?
Hoàn toàn không
Có một chút
Mức ñộ trung bình
Thường xuyên
Vô cùng trở ngại
�1
�2 �3 �4 �5
7. Trong vòng 4 tuần qua, sự ñau nhức về thân thể cuả quí vị nghiêm trọng ñến
mức ñộ nào? Hoàn toàn không
Cực kỳ ít
Có một chút
Mức ñộ trung bình
Nghiêm trọng
Rất nghiêm trọng
�1
�2 �3 �4 �5 �6
8. Tròng vòng 4 tuần qua, do sự ñau nhức về thân thể ñã làm trở ngại ñến công
việc thường ngày( cả việc nhà và ñi làm) của quí vị như thế nào?
Hoàn toàn không
Có một chút
Mức ñộ trung bình
Thường xuyên Vô cùng trở ngại
�1
�2 �3 �4 �5
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9. Sau ñây là các vấn ñề có liên quan ñến cảm giác của và cảm nhận trong vòng
4 tuần qua của qúi vị ñối với môi trường xung quanh. Xin hãy chọn một câu
tr ả lời diễn tả thích hợp nhất với cảm giác gần ñây của qúi vị. Trong vòng
bốn tuần qua, có bao giờ ….
Hầu
như Phần lớn
ðôi lúc Rất ít Không bao giờ
a. Qúi vị cảm thấy mình tràn ñầy sức sống?
�1 �2 �3 �4 �5
b. Quí vị là một người rất dễ bị căng thẳng?
�1 �2 �3 �4 �5
c. Cảm thấy rất buồn phiền, không có ñiều gì làm qúi vị có thể vui lên ñược?
�1 �2 �3 �4 �5
d. Quí vị cảm thấy lòng mình thanh thản?
�1 �2 �3 �4 �5
e. Quí vị sức lực dồi dào?
�1 �2 �3 �4 �5
f. Quí vị cảm thấy buồn phiền lo lắng và không vui?
�1 �2 �3 �4 �5
g. Quí vị cảm thấy sức tàn lực kịêt?
�1 �2 �3 �4 �5
h. Qúi vị là một người hoạt bát, vui vẻ?
�1 �2 �3 �4 �5
i. Quí vị cảm thấy mệt mỏi?
�1 �2 �3 �4 �5
10. Trong vòng 4 tuần qua, có bao giờ do vấn ñề sức khoẻ và nỗi buồn bực ñã
làm trở ngại ñến các hoạt ñộng xã giao của qúi vị( như: thăm viếng thân hữu)?
Hầu như Phần lớn ðôi lúc Rất ít Không bao giờ �1
�2 �3 �4 �5
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11. ðối với quí vị mà nói, thì mức ñộ chính xác về sự trình bày của mỗi câu sau
ñây là :
Hoàn toàn chính xác
Hầu như
Không biết
Phần lớn không chính xác
Hoàn toàn không chính xác
a. Hình như tôi dễ bị bệnh hơn so với người khác
�1 �2 �3 �4 �5
b. Tôi và tất cả bạn bè quen biết ñều khoẻ mạnh như nhau
�1 �2 �3 �4 �5
c. Tôi cảm thấy sức khoẻ của mình càng ngày càng xấu ñi (càng tuột dốc)
�1 �2 �3 �4 �5
d. Tình hình sức khoẻ cả tôi rất tốt .
�1 �2 �3 �4 �5
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Appendix 8: Questionnaire (Chinese version)
新移民婦女文化適應與身心健康問卷新移民婦女文化適應與身心健康問卷新移民婦女文化適應與身心健康問卷新移民婦女文化適應與身心健康問卷
編號編號編號編號：＿＿＿＿＿：＿＿＿＿＿：＿＿＿＿＿：＿＿＿＿＿日期日期日期日期：＿＿＿＿＿：＿＿＿＿＿：＿＿＿＿＿：＿＿＿＿＿
親愛的南洋姐妹們：
您好!歡迎您來到台灣
您的健康及滿意的生活是我們所重視的。本研究為澳洲昆士蘭理工大學博士候選人楊詠
梅，所執行的研究計畫”，用以調查影響東南亞移民婦女文化適應及身心健康的因素。
研究的結果將提供政府發展移民健康政策的參考，間接將促進南洋移民姐妹們健康與適
應。您寶貴的意見將是我們珍貴的資源，本問卷不具名以維護您個人隱私及權利且僅供
學術研究之用，我們會妥善保管此份資料並做最適切的運用，請您依據您個人的經驗及
實際的想法作答，謝謝您的協助。
如果您願意協助這份問卷的填答，請在下面空白處簽名，我們將致贈精美的禮物一份，再
次謝謝您寶貴的時間及資料。
敬祝 健康平安 事事順利
澳洲昆士蘭理工大學護理學院 博士候選人 楊詠梅 澳洲昆士蘭理工大學護理學院 Dr Debra Anderson
高雄醫學大學護理學院王秀紅教授
參與者簽名:_____________________ 日期:＿＿＿＿＿＿
如有任何疑問請聯絡： 楊詠梅講師
地址： 高雄市十全一路 100 號 護理學院 Email: [email protected]
電話: (07) 3121101-2624 傳真：07-3218364
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第第第第一一一一部份部份部份部份:::: 基本資料基本資料基本資料基本資料
1. 年齡：_____(出生西元:19______)
2. 原國籍： □1 越南 □2 印尼 □3 泰國 □4 其他:_______
3. 婚姻狀況：□1 已婚 □2 離婚 □3 未婚 □4 寡居 □5 其他：＿＿＿
4. 宗教信仰： □1 回教 □2 基督教∕天主教 □3 佛教/道教 □4 其他:___
□5 無
5. 您是否為華裔（中國血統）： □1 是 □ 2 否
6. 教育程度(母國)：□1 未受教育 □2 小學 □3 中學 □4 高中 □5 大學
或專科 □6 大學或專科以上
7. 定居於台灣的時間多長： _______年 _____月
8. 在母國的職業：________________
9. 您目前在台灣的職業(性質與職稱)：_________________
10. 您目前在台灣的受雇情形： □1 無 □2 全職 □3 兼職
11. 丈夫的教育：□1 未受教育 □2 小學 □3 中學 □4 高中 □5 大學或
專科 □6 大學或專科以上
12. 丈夫年齡：＿＿＿＿＿＿(出生民國:______)
13. 丈夫的職業： ______________
14. 丈夫目前受雇情形： □1 無 □2 全職 □3 兼職
15. 丈夫的宗教： □1 回教 □2 基督教∕天主教 □3 佛教/道教 □4 其他
_____ □5 無
16. 丈夫的的健康狀況：□1 不佳 □2 尚可 □3 佳
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17. 丈夫是否有經醫師診斷的健康問題? □1 無 □2 有:________
18. 目前子女數：___________
19. 家庭型態：□1 小家庭（夫妻及子女） □2 單親家庭 □3 大家庭（三代同
堂） □4 其他：＿＿＿＿＿＿＿
20.您來台後是否有身體不適? □1 無 □2 有 什麼問題:____________ 21.您來台後是否有經醫師診斷的健康問題? □1 無 □2:__________
第第第第二二二二部分部分部分部分: 文化適應問題文化適應問題文化適應問題文化適應問題 此部份將詢問您關於在台灣的日常生活、社交活動、語言使用與社會感受等問題，請勾選一個您認為描述最適切的答案
Part 1: 日常生活日常生活日常生活日常生活
1. 您偏愛聽的音樂為何您偏愛聽的音樂為何您偏愛聽的音樂為何您偏愛聽的音樂為何？？？？
□1. 只聽母國的音樂 □2. 大部分是聽母國的音樂 □3. 母國的音樂及台灣的音樂都會聽 □4. 大部分聽台灣的音樂 □5. 只聽台灣的音樂
2. 您偏愛看的電視節目為何您偏愛看的電視節目為何您偏愛看的電視節目為何您偏愛看的電視節目為何？？？？
□1. 只看母國的電視節目 □2. 大部分是看母國的電視節目 □3. 母國及台灣的電視節目都會看 □4. 大部分是看台灣的電視節目 □5. 只看台灣的電視節目
3. 您在家中偏好的食物為何您在家中偏好的食物為何您在家中偏好的食物為何您在家中偏好的食物為何？？？？ □1. 只偏好母國的食物 □2. 大部分偏好母國的食物，只吃一點台灣食物 □3. 母國及台灣的食物偏好程度差不多 □4. 大部分偏好台灣的食物 □5. 只偏好台灣的食物
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4. 在餐館中您偏好的食物為何在餐館中您偏好的食物為何在餐館中您偏好的食物為何在餐館中您偏好的食物為何？？？？ □1. 只偏好母國的食物 □2. 大部分偏好母國的食物，只吃一點台灣食物 □3. 母國及台灣的食物偏好程度差不多 □4. 大部分偏好台灣的食物 □5. 只偏好台灣的食物
5. 您對台灣飲食的適應程度您對台灣飲食的適應程度您對台灣飲食的適應程度您對台灣飲食的適應程度????
□1 非常不適應 □2 不適應 □3 普通 □ 4適應 □5 非常適應 不適應的原因為: □1 食物種類 □2 烹調方式 □3 宗教因素 □4 其他:_____
Part 2: 社交活動社交活動社交活動社交活動
6. 您的朋友或同事是屬於哪一國家您的朋友或同事是屬於哪一國家您的朋友或同事是屬於哪一國家您的朋友或同事是屬於哪一國家？？？？
□1. 幾乎所有的朋友都是與您屬同一個國家 □2. 大部分的朋友與您屬同一個國家
□3. 與您屬同一國家種族的朋友以及台灣的朋友數量相當 □4. 大部分朋友都是台灣人
□5. 幾乎所有的朋友都是台灣人
7.7.7.7.最近新認識的朋友是哪裡人最近新認識的朋友是哪裡人最近新認識的朋友是哪裡人最近新認識的朋友是哪裡人???? □1. 幾乎所有的朋友都是與您屬同一個國家 □2. 大部分的朋友與您屬同一個國家
□3. 與您屬同一國家種族的朋友以及台灣的朋友數量相當 □4. 大部分朋友都是台灣人
□5. 幾乎所有的朋友都是台灣人
8. 誰給予您情感上的支持誰給予您情感上的支持誰給予您情感上的支持誰給予您情感上的支持？？？？
□1. 沒有 □2. 大部分是與您屬同一國家種族的人 □3. 有與您屬同一國家種族的人，也有台灣人 □4. 大部分是台灣人 □5. 幾乎都是台灣人
- 215 -
9. 對於一些特殊的問題您會向誰尋求建議及協助對於一些特殊的問題您會向誰尋求建議及協助對於一些特殊的問題您會向誰尋求建議及協助對於一些特殊的問題您會向誰尋求建議及協助？？？？ □1. 沒有 □2. 大部分是與您屬同一國家種族的人 □3. 有與您屬同一國家種族的人，也有台灣人 □4. 大部分是台灣人 □5. 幾乎都是台灣人
10. 您都跟誰一起聊天您都跟誰一起聊天您都跟誰一起聊天您都跟誰一起聊天、、、、逛街購物逛街購物逛街購物逛街購物？？？？
□1. 沒有人 □2. 大部分是與您屬同一國家種族的人 □3. 有與您屬同一國家種族的人，也有台灣人 □4. 大部分是台灣人 □5. 完完全是台灣人
11 假如您可以選擇假如您可以選擇假如您可以選擇假如您可以選擇，，，，您在社區中會想與誰聯絡交流您在社區中會想與誰聯絡交流您在社區中會想與誰聯絡交流您在社區中會想與誰聯絡交流？？？？ □1. 幾乎只聯絡與您同一母國的人 □2. 大部分是與您同一母國的人
□3. 與您同一母國的人和台灣人，您都會想與之聯絡交流
□4. 大部分是台灣人 □5. 完全是台灣人
12.您從同一母國的朋友處得到的支持您從同一母國的朋友處得到的支持您從同一母國的朋友處得到的支持您從同一母國的朋友處得到的支持與幫助為與幫助為與幫助為與幫助為？？？？
□1 沒有 □2 一點點 □3 普通 □ 4多 □5 很多
13 您從台灣的朋友處得到的支持您從台灣的朋友處得到的支持您從台灣的朋友處得到的支持您從台灣的朋友處得到的支持幫助程度幫助程度幫助程度幫助程度為為為為？？？？
□1 沒有 □2 一點點 □3 普通 □ 4多 □5 很多
14 您從配偶處得到的支持您從配偶處得到的支持您從配偶處得到的支持您從配偶處得到的支持與幫助程度與幫助程度與幫助程度與幫助程度為為為為？？？？
□1 沒有 □2 一點點 □3 普通 □ 4多 □5 很多
15 您與母國您與母國您與母國您與母國聯繫的狀況為何聯繫的狀況為何聯繫的狀況為何聯繫的狀況為何？？？？
□1. 至少一年會回去母國一次 □2. 回母國的次數一年不到一次 □3. 偶爾才回母國拜訪
□4. 偶爾才與住在母國的朋友或家人聯絡（信件、電話等） □5. 從未與住在母國的朋友或家人聯絡
- 216 -
Part 3: 語言語言語言語言使用使用使用使用
16.您會說哪一種語言您會說哪一種語言您會說哪一種語言您會說哪一種語言？？？？ □1. 只會說母語
□2. 大部分講母語，只會講一國/台語
□3. 母語和國/台語都會 □4. 大部分講國/台語，偶爾講一點母語
□5. 只講國/台語
17777 您會讀哪一種語言您會讀哪一種語言您會讀哪一種語言您會讀哪一種語言
□1. 只會讀母國文字
□2. 母國文字讀的比中文好 □3. 母國文字和中文讀的一樣好
□4. 中文讀的比母國文字好
□5. 只會讀中文
18. 您會寫哪一種語言您會寫哪一種語言您會寫哪一種語言您會寫哪一種語言
□1. 只會寫母國文字
□2. 母國文字寫的比中文字好 □3. 母國文字和中文字寫的一樣好
□4. 中文字寫的比母國文字好
□5. 只會寫中文字
19 您在家較常用哪一種語言您在家較常用哪一種語言您在家較常用哪一種語言您在家較常用哪一種語言？？？？
□1. 在家只講母語
□2. 大部分是講母語，有時候講華語或是台語
□3. 母語和華語或是台語都會講 □4. 大部分是講華語或是台語，有時候講母語
□5. 在家只講華語或是台語
20 請評分您請評分您請評分您請評分您，，，，口說口說口說口說國國國國語語語語（（（（或台或台或台或台語語語語））））的程度的程度的程度的程度
□1 不會 □2 一點點 □3 普通 □ 4好 □5 很流利
21111. 請評分您請評分您請評分您請評分您，，，，聽聽聽聽華語或是台語的程度華語或是台語的程度華語或是台語的程度華語或是台語的程度
□1 不懂 □2 一點點 □3 普通 □ 4好 □5 完全了解
22. 請評分您請評分您請評分您請評分您，，，，閱讀閱讀閱讀閱讀中文的程度中文的程度中文的程度中文的程度
□1 不懂 □2 一點點 □3 普通 □ 4好 □5 完全了解
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23. 請評分您請評分您請評分您請評分您，，，，書寫書寫書寫書寫中文字的程度中文字的程度中文字的程度中文字的程度
□1 不懂 □2 一點點 □3 尚可 □ 4好 □5 很流利
Part 4: 文化認同文化認同文化認同文化認同
24. 您如何認定自己您如何認定自己您如何認定自己您如何認定自己 ？？？？
□1. 東方人
□2. 印尼∕越南人 □3. 亞裔華人 □4. 印尼（越南）裔華人
□5. 華人或是台灣人
25. 您教導您的孩子何種價值觀及信仰您教導您的孩子何種價值觀及信仰您教導您的孩子何種價值觀及信仰您教導您的孩子何種價值觀及信仰？？？？ □1. 東方人
□2. 印尼∕越南人 □3. 亞裔華人 □4. 印尼（越南）裔華人
□5. 華人或是台灣人
26. 假如您認同您自己是印尼假如您認同您自己是印尼假如您認同您自己是印尼假如您認同您自己是印尼（（（（越南越南越南越南））））人人人人，，，，您感覺有多自傲您是一位您感覺有多自傲您是一位您感覺有多自傲您是一位您感覺有多自傲您是一位印尼印尼印尼印尼（（（（越越越越 南南南南））））人人人人？？？？
□1. 非常自傲
□2. 普通自傲 □3. 一點點 □4. 不覺得自傲，但對於印尼（越南）人不會有負向的看法
□5. 不覺得自傲且對於印尼（越南）人有負向的看法
27. 您自己是屬於您自己是屬於您自己是屬於您自己是屬於？？？？
□1. 完全是印尼∕越南人 □2. 主要是印尼（越南）裔華人
□3. 雙文化的 □4. 主要是華人 □5. 完全是華人
28. 您會參加母國的活動您會參加母國的活動您會參加母國的活動您會參加母國的活動、、、、節慶節慶節慶節慶、、、、傳統等嗎傳統等嗎傳統等嗎傳統等嗎？？？？ □1. 幾乎都會參加
□2. 大部分會參加 □3. 有一些會參加
□4. 很少參加
□5. 都不參加
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29. 請評分您對於母國文化請評分您對於母國文化請評分您對於母國文化請評分您對於母國文化的價值的價值的價值的價值（（（（例如婚姻例如婚姻例如婚姻例如婚姻、、、、家庭家庭家庭家庭、、、、教育教育教育教育、、、、工作等工作等工作等工作等））））與信念與信念與信念與信念 的程度為何的程度為何的程度為何的程度為何
□1 不相信 □2 一點點 □3 尚可 □ 4相信 □5 非常相信
30. 請評分您對於華人文化的價值與信念的程度為何請評分您對於華人文化的價值與信念的程度為何請評分您對於華人文化的價值與信念的程度為何請評分您對於華人文化的價值與信念的程度為何
□1 不相信 □2 一點點 □3 尚可 □ 4相信 □5 非常相信
31. 現在現在現在現在您與母國的人相處的切合度您與母國的人相處的切合度您與母國的人相處的切合度您與母國的人相處的切合度（（（（相處是否相處是否相處是否相處是否合合合合得來得來得來得來）？）？）？）？ □1 合不來 □2 一點點 □3 普通 □ 4 合得來 □5 相處融洽
32. 您與華人您與華人您與華人您與華人（（（（台灣人台灣人台灣人台灣人））））相處的切合度相處的切合度相處的切合度相處的切合度（（（（相處是否相處是否相處是否相處是否合合合合得來得來得來得來）？）？）？）？
□1 合不來 □2 一點點 □3 普通 □ 4 合得來 □5 相處融洽
33. 每個人對於自己的看法都不同每個人對於自己的看法都不同每個人對於自己的看法都不同每個人對於自己的看法都不同，，，，下列哪一句話最貼近您對自己的描述下列哪一句話最貼近您對自己的描述下列哪一句話最貼近您對自己的描述下列哪一句話最貼近您對自己的描述？？？？
□1. 我認為自己是印尼∕越南人。雖然我嫁到台灣並住在這裡， 但我仍然認為自己是印尼∕越南人
□2. 我認為自己是華人。雖然我有母國的出生背景及特色，但我仍然認為 自己是華人
□3. 我認為自己是印尼∕越南裔華人，但在內心深處我知道我是一個印尼∕越南人 □4. 我認為自己是印尼∕越南裔華人，但在內心深處我還是會先想到我是一個華人 □5. 我認為自己是印尼∕越南裔華人，我有印尼∕越南人和華人的特色，並且我認為
自己是兩者的混合
Part 5: 社會社會社會社會接受接受接受接受
.
非常非常非常非常
不贊同不贊同不贊同不贊同
不贊同不贊同不贊同不贊同
普通普通普通普通
贊同贊同贊同贊同
非常非常非常非常
贊同贊同贊同贊同
34. 因為我是印尼∕越南人，所以在工作上我要比別人加倍努力
1 2 3 4 5
35. 別人會用高高在上的態度跟我說話，因為我是印尼∕越南人
1 2 3 4 5
36. 在家中或是在工作場所，別人會對我開帶有種族色彩的笑話
1 2 3 4 5
37. 因為我是印尼∕越南人，所以我被派去做其他人不願意做的工作
1 2 3 4 5
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38. 在台灣，我並未得到應有的尊重 1 2 3 4 5
39. 我曾被醫療人員忽視或拒絕治療
1 2 3 4 5
40. 醫療人員不理會我或是先為當地人服務 1 2 3 4 5
第三部份第三部份第三部份第三部份::::心理感受心理感受心理感受心理感受 請針對每一個問題，思考是否符合您最近（近三個月內）的感受，請圈選適合您的答案 非常
不同意
不同意
同意 非常同意
1. 台灣人聽不懂我的口音 0 1 2 3
2. 當我想起以前的生活，我會變得感傷與懷念
0 1 2 3
3. 雖然我住在這裡，但仍感覺這裡不是我的國家
0 1 2 3
4. 我需要有經驗的人敎我如何在此生活 0 1 2 3
5. 我很難得到一份好的工作 0 1 2 3
6. 我在工作上的階級比以前低 0 1 2 3
7. 如同一位移民者，我覺得我是二等公民 0 1 2 3
8. 因為語言問題，我在做普通的工作都覺得困難
0 1 2 3
9. 台灣人不認為我是他們國家的一份子 0 1 2 3
10. 我思念我家鄉的人 0 1 2 3
11. 在台灣，我的工作機會比較少 0 1 2 3
12. 講國語或台語都需要花時間努力與學習 0 1 2 3
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13. 台灣人對待我像是一個外人 0 1 2 3
14. 在台灣，我必須學習去處理一些事務，例如租房子或拿到駕照
0 1 2 3
15. 我覺得台灣不是我真正的家 0 1 2 3
16. 我需要依賴其他人指導我如何去做一些事 0 1 2 3
17. 我不覺得像是在家的感覺 0 1 2 3
18. 當我想到家鄉某些特別的地方，我會覺得感傷
0 1 2 3
19. 在我的工作上，我無法和台灣人競爭 0 1 2 3
20. 在台灣，有外國口音的人總是較不被尊重 0 1 2 3
21. 我在母國家鄉的履歷和工作經驗，在台灣是不被接受的
0 1 2 3
22. 到台灣後，我總是在面對新的情況和環境 0 1 2 3
23. 當我想到我的家鄉時，我會流淚
0 1 2 3
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Appendix 9: Questionnaire (Backward Translation)
Part 2: Choose the one answer which best suitable for you
Domain1: daily activity
1. What is your musical preference? □1. Only my home country music □2. Mostly home country music □3. Equally my home country and Taiwanese music □4. Mostly Taiwanese music □5. Taiwanese only 2. What is your TV preference? □1. Only my home country TV □2. Mostly my home country □3. Equally my home country and Taiwanese TV □4. Mostly Taiwanese TV □5. Only Taiwanese TV 3. What is your food preference at home? □1. Only Vietnamese food □2. Mostly Vietnamese food, some Chinese □3. About equally Vietnamese and Chinese □4. Mostly Chinese food □5. Only Chinese food 4. What is your food preference in restaurants? □1. Exclusively Vietnamese food □2. Mostly Vietnamese food, some Chinese □3. About equally Vietnamese and Chinese □4. Mostly Chinese food □5. Only Chinese food 5. Circle your satisfaction in Taiwanese or Chinese food □1 very dissatisfied □2.dissatisfied □3.moderate □ 4. satisfied □5 strongly satisfied
Domain 2: social relationships
6. What is your friends‘ ethnic origin? □1. Exclusively Vietnamese □2. Mostly Vietnamese □3. About equally Vietnamese groups and Taiwanese groups □4. Mostly Taiwanese □5. Only Taiwanese 7. With whom do you now associate in the neiberhood? □1. Only Vietnamese □2. Mostly Vietnamese □3. About equally Vietnamese groups and Taiwanese groups □4. Mostly Taiwanese □5. Only Taiwanese
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8. From whom do you receive emotional support? □1. None □2. Mostly Vietnamese □3. About equally Vietnamese groups and Taiwanese groups □4. Mostly Taiwanese □5. Only Taiwanese
9. From whom do you get advice and help for specific problems you need? □1. Nobody □2. Mostly Vietnamese □3. About equally Vietnamese groups and Taiwanese groups □4. Mostly Taiwanese □5. Only Taiwanese 10. With whom do you socialize and go shopping with? □1. Nobody □2. Mostly Vietnamese □3. About equally Vietnamese groups and Taiwanese groups □4. Mostly Taiwanese □5. Only Taiwanese
11. If you could choose, who would you prefer to associate with in the community? □1. Almost exclusively Vietnamese □2. Mostly Vietnamese □3. About equally Vietnamese groups and Taiwanese groups □4. Mostly Taiwanese □5. Only Taiwanese
12. Please rate the support of your Vietnamese friends? □1 none □2. a little □3 moderate □ 4 a lot □5 highly
13. Please rate the support of your Taiwanese Friends? □1 none □2. a little □3 moderate □ 4 a lot □5 highly
14. Please rate the support of your spouse? □1 none □2. a little □3 moderate □ 4 a lot □5 highly
15. What contact do you have with your Vietnamese families? □1. Travel at least once a year □2. Travel less than once a year to Vietnam □3. Occasional visits to Vietnam □4. Occasional communications (letters, phone calls, etc.) with people in Vietnam □5. No exposure or communications with people in Vietnamese
Domain 3: language
16. What language do you speak in the house? □1. Only Vietnamese □2. Mostly Vietnamese, some Mandarin □3. Equally well (bilingual) Vietnamese and Mandarin □4. Mostly Mandarin, some Vietnamese □5. Only Mandarin
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17. Can you read? □1. Only Vietnamese □2. Vietnamese better than Chinese □3. Both Vietnamese and Chinese equally well □4. Chinese better than Vietnamese □5. Only Chinese 18. Can you write? □1. Only Vietnamese □2. Vietnamese better than Chinese □3. Both Vietnamese and Chinese equally well □4. Chinese better than Vietnamese □5. Only Chinese 19. What language do you prefer to speak at the house ? □1. Only Vietnamese □2. Vietnamese better than Chinese □3. Both Vietnamese and Chinese equally well □4. Chinese better than Vietnamese □5. Only Chinese 20. Please rate your speaking confidence in Mandarin or Taiwanese dialect. □1.unconfident □2.a little confident □3. moderately confident □ 4.confident □5.strongly
21. Please rate your listening confidence in Mandarin or Taiwanese dialect □1.unconfident □2.a little confident □3. moderately confident □ 4.confident □5.strongly
22. Please rate your reading confidence in Chinese □1.unconfident □2.a little confident □3. moderately confident □ 4.confident □5.strongly
23. Please rate your writing confidence in Chinese □1.unconfident □2.a little confident □3. moderately confident □ 4.confident □5.strongly
Domain: cultural identity
24. How do you think of yourself? □1. I am Vietnamese □2. I am mostly Vietnamese □3. I am Asian -Chinese or Taiwanese □4. I am Vietnamese -Chinese □5. I am Chinese/ Taiwanese 25. What kind of values and beliefs, will you teach your children? □1. Only Vietnamese □2. Most Vietnamese and a little Taiwanese □3. Equal Vietnamese and Taiwanese □4. Most Taiwanese and a little Vietnamese □5. Only Taiwanese 26. If you belong to a Vietnamese group, how much pride do you have? □1. Extremely proud □2. Moderately proud □3. Little proud □4. Have no feelings of pride □5. Have negative feelings
- 224 -
27. How would you rate yourself? □1. Very Vietnamese □2. Mostly Vietnamese, a little Chinese □3. Bicultural □4. Mostly Chinese □5. Very Chinese 28. Do you participate in Vietnamese occasions, holidays, traditions, etc.? □1. Nearly always □2. Most always □3. Sometimes □4. Occasionally □5. Not at all 29. Measure yourself on how much you believe in Vietnamese values (e.g., about marriage, families, education, work): □1 do not believe □2 a little bit □3. moderate □ 4.very much □5 strongly believe
30. Rate your self on how much you believe in Chinese values: □1 do not believe □2 a little bit □3. moderate □ 4 very much □5 strongly believe 31. Rate yourself on how well you fit when with other Vietnamese friends. □1 do not fit in □2 a little bit □3. moderate □ 4 very much □5 fit in very well 32. Rate yourself on how well you fit when with other Chinese friends. □1 do not fit in □2 a little bit □3. moderate □ 4 very much □5 fit in very well
33. Which one of the following most closely describes how you view yourself? □1. Even though I live and married in Taiwan, I still view myself basically as a Vietnamese
person. □2. I think myself basically as a Chinese person. Even though I have a Vietnamese background
and characteristics, I still view myself as Chinese. □3. I think myself as a Vietnamese -Chinese, although deep down I always know I am a
Vietnamese person. □4. I think myself as a Vietnamese -Chinese, although deep down, I view myself as a Chinese
person first. □5. I think myself as a Vietnamese-Chinese, I have both Vietnamese and Chinese characteristics,
and I view myself as a blend of both.
Domain 5: perceived discrimination
.
None
A
little
Mode- rate
Very much
Most of the time
34. Because I am Vietnamese, I have to work very hard 1 2 3 4 5
35. People show less respect because I am Vietnamese 1 2 3 4 5
36. Ethnic jokes or interferences are placed on me which happened at home or at the workplace.
1 2 3 4 5
37. Because I am Vietnamese, I am assigned a job that no one else wanted to do
1 2 3 4 5
38. I am treated with less respect and disregard than I should be.
1 2 3 4 5
39. I have been denied hospitalization or medical care facilities.
1 2 3 4 5
40. Medical providers ignore me and service local people first 1 2 3 4 5
- 225 -
Part 3: Your immigrant experience
Demands of Immigration Scale (DIS)
(Back Translation)
Directions: This questionnaire contains 23 items about your personal immigrant experience in Taiwan. Please respond to each item as accurately as possible which will indicate the experience most suited to you (recent three months.) 0= no and never 1= a little 2= more than a little 3= most of the time 1. Taiwanese have difficulty in understanding my accent 0 1 2 3 2. When I remember the past in home country, I feel affected
and become emotional 0 1 2 3
3. Even when I live in Taiwan, it does not feel like my home country
0 1 2 3
4. I need suggestions from other people who are more experienced than me, to show me how to live here.
0 1 2 3
5. It is difficult to find a good job in Taiwan 0 1 2 3 6. My work status is lower than it used to be 0 1 2 3 7. Being an immigrant, I feel I am a second class citizen in
Taiwan 0 1 2 3
8. Because of the language barrier, I feel difficulty in doing common tasks.
0 1 2 3
9. Taiwanese don’t think I really belong in their country 0 1 2 3 10. I miss the people in Vietnam. 0 1 2 3 11. I have a little chance in developing my career in Taiwan 0 1 2 3 12. Talking in Mandarin or Taiwanese takes a lot of effort. 0 1 2 3 13. Taiwanese people treat me as an outsider 0 1 2 3 14. I need to learn new things, such as obtaining a motorbike
license. 0 1 2 3
15. I feel that here is not my real home. 0 1 2 3 16. I need to rely on some friends to teach me or show me how
things are done here 0 1 2 3
17. I do not feel at home 0 1 2 3 18. I feel sorrow when I think of special places back home 0 1 2 3 19. I can not compete with Taiwanese for work in my workplace. 0 1 2 3 20. People with SEA accents will treat me with less respect in
Taiwan 0 1 2 3
21. Taiwanese employers don’t accept my Vietnamese education and previous work experience in Vietnam
0 1 2 3
22. I am always facing new situations and conditions. 0 1 2 3
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23. When I think of Vietnam my homeland, I cry 0 1 2 3
Part 4: Your Health
The purpose of this questionnaire is to view the extent your health. This information recorded how you feel about your health and your ability to deal with your daily activities. Thank you very much for your answering the questions. Please circle the number which suits you most.
1. In general, How about your health
1= Excellent 2=Very good 3=Good 4=Fair 5=Poor
2. Compare to one year ago, how do you feel about your health now?
1= better 2= a little better 3= still the same 4= a little bit worse 5= very poor
3. Below we are asking about your daily activities. According to your health,
how will this limit your ability to perform tasks, if so, how much? 1=always 2=most of the time 3=sometimes 4= a little of the time 5= no, not at all
a. Hard working, such as running fast, lifting very heavy stuff, harsh sport b. Moderate activities, such as moving a desk, playing bowls or Tai-Chi c. Carrying groceries d. Climbing several floors of stairs e. Climbing one floor of stairs f. Bending, kneeling, stooping g. Walking more than one kilo meter h. Walk several hundred meters i. Walking one hundred meters j. Take bath or clothe myself
4. During the past four weeks, how often has your health influenced your work
or daily activities?
1=always 2=most of the time 3=sometimes 4= little of the time 5= no, not at all
a. Cut down on the amount of time you spent on work or other activities b. Completed less than you thought c. Were limited in the type of work or activities d. Had difficulty to do the job or activities, such as needing more effort to
complete it
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5. During the past four weeks, how often has emotional problems (such as
anxiety or depression) influenced your work or other activities
1=always 2=most of the time 3=sometimes 4= little of the time 5= no, not at all
a. Cut down on the amount of time you spent on work or other activities b. Completed less than you thought c. Do work or activities less than usual. During the past four weeks, how
often has your health or emotional problems influenced your relationship with your family, neighbours, or friends?
1= not at all 2=a little bit 3=moderately 4=very much 5=extremely 7. During the past four weeks, how much body pain have you felt?
1= no body pain 2= slightly pain 3= a little bit 4=moderate pain 5=quite a bit of pain 6=very painful
8. During the past four weeks, how much body pain disturbs your daily
activities or work?
1=not at all 2= a little bit 3= moderately 4= quite a bit of pain 5= very much 9. The following questionnaire is about how your feelings and experiences during
the past four weeks.
1= All of the time 2= Most of the time 3= Sometimes 4= A little bit 5=Never
a. I feel full of life b. I am a very nervous person c. I feel very upset, nothing can make me happy d. I feel calm e. I feel I have a lot of energy f. I feel unhappy and depressed g. I feel exhausted h. I am a happy person i. I always feel tried
10. During the past four weeks, how much time has your physical or emotional
problems influenced your social activities (such as visiting friends)?
1=All of the time 2=Most of the time 3=Sometimes 4= a little of the time 5= No, not at all
- 228 -
11 Does one of the following statements below describe you accurately, if so, do you think it is correct or not?
1= completely correct 2= mostly correct 3= don’t know 4= partially incorrect 5=completely incorrect
a. I seem to get sick more frequently than the others b. Compared to the other people, my health is as good as them c. I think my health will become worse and worse d. I have good health
- 299 -
Appendix 10: Timeline for complet ion of PhD Program-Yung-Mei Yang
2005 2006 2007 2008
Schedule of Activities Feb-Apr
May-Jul
Aug-Oct
Nov-Jan
Feb-Apr
May-Jul
Aug-Oct
Nov-Jan
Feb-Apr
May-Jul
Aug-Oct
Nov-Dec
Jan-Feb
Mar- Apr
Enrollment Stage 2 proposal Progress reports Course work Ethics approval: QUT Stage 2 Seminar Submit Confirmation document Confirmation seminar Conduct research: Phase 1 study Phase 2 study Write-up of thesis Title & Abstract Literature Review Methodology Data analysis Results Discussion Conclusion Outputs Publication (1)- (2)- (3)- International Conference Editing draft of thesis Submit thesis to panel Final seminar External examination
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Graduation Ceremony Citation
Yung Mei Yang
RN,BS,MS
Thesis title:
Acculturation and Health Outcomes among Vietnamese immigrant women in Taiwan
Supervisors
Dr Debra Anderson, (Principle)
Dr Jennieffer Barr, (Associate)
Dr Hsiu-Hung Wang, Taiwan. ROC (External)
Citation:
This thesis is a cross-sectional investigation of acculturation stress and health related
quality of life among Vietnamese marriage migrant women in Taiwan. This
dissertation reflects an excellent report on a very significant new phenomenon that is
driven by globalization. These young immigrants are highly susceptible and
vulnerable to health problems. The study revealed that the Vietnamese migrant
women showed a lower score than Taiwanese women in health related quality of life,
and had higher acculturation stress impact on vitality, social functioning, and mental
health. In addition, the psychological distress included: alienation, occupation
adjustment, loss of social support, language accommodation, and novelty among
Vietnamese immigrant women in Taiwan
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