Acculturation and health outcomes among vietnamese immigrant women in taiwan

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,

Acculturation and Health Outcomes Among

Vietnamese Immigrant Women

In Taiwan

Yung Mei Yang

Queensland University of Technology

School of Nursing

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

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:………

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)

Health Related Quality of Life (HRQOL)

The Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA) The Demand of Immigration Specific Distress Scale (DIS)

Classification and Regression Trees (CART)

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 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 whose generosity in providing the scholarship helped me to counter the economic difficulties and encouraged me to complete my PhD study

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

Acculturation and Health Outcomes Among

Vietnamese Immigrant Women

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

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

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

TABLE OF CONTENTS

CHAPTER 1 INTRODUCTION………1

I NTRODUCTION 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

I NTRODUCTION 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

2.3.2 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

I NTRODUCTION 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

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

I NTRODUCTION …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

I NTRODUCTION 121

6.1 Characteristics of the sample 122

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

I NTRODUCTION 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

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

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

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

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

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

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

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 Taiwan

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

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

1.2 Purpose of this study

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

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

1.2.3 The Research Hypotheses

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

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)

This figure is not available online

Please consult the hardcopy thesis available from the QUT Library

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

Figure 1.2 The hypothesized model of this study

process

Health outcomes

Ethnic identity

Daily habits

Perceived discrimination

Physical wellbeing

1.4 Research Significance

1.4.1 The Scope of Acculturation and Nursing Research

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

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

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

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

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

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

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

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

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

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,

of intermarried couples has sharply increased the number of foreign brides married to Taiwanese men The overwhelming economic differences betweenTaiwan 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