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Pacific Islands Families Study: psychological distress among mothers of Pacific children living in New Zealand

Pacific Islands Families Study: psychological distress among mothers of Pacific children living... (NZ) are ethnically heterogeneous P(Sāmoan, 49%; Cook Islands Māori, Objective: This study investigated: 1) the prevalence of psychological distress among a cohort 21%; Tongan, 20%; and Niuean, 8%), rapidly of mothers of Pacific children; and 2) the socio-demographic and lifestyle variables associated growing, youthful and highly urbanised. with psychological distress. However, Pacific people suffer from an excess Method: The Pacific Islands Families (PIF) Study is a longitudinal investigation of a cohort of of social, health and economic deprivation. Pacific children born in Auckland, New Zealand, and their mothers and fathers. The 12-item The low socioeconomic status of Pacific General Health Questionnaire (GHQ12) was used to assess psychological distress among people and experiences of rapid acculturation mothers (N=851) at about 11 years postpartum. and sociocultural change have been linked Results: Current psychological distress was reported by 19% of mothers, and six explanatory to concerns about mental illness and risk- variables were significantly associated with maternal psychological distress: stressful life events, taking behaviors among Pacific people. postnatal depression, marital status, maternal education, ethnicity and cultural alignment. Two national surveys carried out in the past Conclusion: These findings suggest that the mental health of Pacific people varies by particular decade have described the relatively high ethnic group and cultural alignment. This highlights the need for culturally appropriate prevalence of Pacific mental health disorder evaluation and treatment for at-risk Pacific mothers that will break down psychological, cultural in comparison to other NZ groups. However, and economic barriers to accessing help for psychological distress. there is a scarcity of data that considers the Implications: By learning about factors that are potentially modifiable we can begin to identify risk and protective factors across the lifespan the most appropriate ways to address their impact on psychological distress among Pacific that lead to psychological distress among women. Pacific adults living in NZ. Key words: psychological distress, Pacific women, general health questionnaire In 2004, Te Rau Hinengaro: The New Zealand Mental Health Survey investigated the 12-month prevalence of DSM-IV disorders experience of symptoms such as anxiety, In terms of risk factors for psychological in NZ. The DSM-IV covers anxiety and mood confused emotions, depression or rage. In this distress, international research has shown that disorders, phobias and substance abuse. The 7 8,9 national survey it was revealed that 6% of NZ poor living standards, income inequality, researchers found that the prevalence of 10 11 adult men and 7% of adult women reported previous depression, stressful life events, any mental disorder in the past 12 months experiencing psychological distress over the and social adversity have been associated was higher in Pacific people (25%) than for past four weeks. Thirteen per cent of Pacific with high rates of psychological distress, and the general population (21%). This national adults reported psychological distress, which physical and social morbidity. survey found that gender, educational was 2.1 times higher than non-Pacific adults This paper is based on the Pacific Islands qualifications and household income had in NZ. The prevalence rate was 12% for Pacific 13 Families (PIF) Study, a birth cohort study no significant impact on the prevalence or men and 13.3% for Pacific women, although that is a longitudinal investigation of Pacific severity of mental disorder for Pacific people. these rates were not significantly different. infants born in South Auckland, NZ, in 2000 In 2013, the Ministry of Health’s NZ Health International studies have used the GHQ12 to (n=1,398) and their mothers and fathers. Survey examined psychological distress in NZ measure psychological distress and revealed Children and their families have been visited adults using the 10-question Kessler Scale. prevalence rates for women in England (15%), when the children were aged six weeks, and Psychological distress is defined as a person’s Scotland (17%) and Northern Ireland (21%). one, two, four, six, nine and 11 years. In the 1. National Institute for Public Health and Mental Health Research, Auckland University of Technology, New Zealand Correspondence to: Professor Janis Paterson, Public Health & Psychosocial Studies, Auckland University of Technology, 90 Akoranga Drive, Northcote, Auckland 0627, New Zealand; e-mail: janis.paterson@aut.ac.nz Submitted: April 2015; Revision requested: July 2015; Accepted: September 2015 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2016; 40:110-4; doi: 10.1111/1753-6405.12491 110 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 2 © 2015 Public Health Association of Australia Mothers and Children Psychological distress among mothers PIF Study, the General Health Questionnaire your difficulties?”; “ Have you recently been able depression, but a score of above 12 is widely (GHQ) was used to measure psychological to enjoy your normal day-to-day activities?”; used to indicate depressive symptoms. The distress. We found prevalence rates for “Have you recently felt capable about making sensitivity, specificity and predictive validity maternal psychological distress of 12.2% decisions about things?” Each item was of the EPDS have been established in a variety at one year postpartum and 9.5% at two recorded on a four-point Likert scale, such of populations. years postpartum. This investigation of as from “not at all” up to “much more[less] Life events: A 23-item scale was used with the prevalence of psychological distress is than usual”, and were assigned values 0 maternal participants to examine stressful focused on the cohort of mothers of Pacific to 3. The extent of psychological distress events at the 11-year data point. The Social children at 11 years postpartum, and explores was measured using GHQ12 scores, which Readjustment Rating Scale determines predictors of such distress. were derived by summing the 12 numeric the number of stressful events (e.g. serious responses, thereby giving a range of possible arguments with partner; death of a close scores from zero to 36. Up to one missing friend or relative; serious financial problems) Method response was replaced by that participant’s experienced by the family in the past median response; participants with two or 21 Participants 12 months. The number of events was more missing values were excluded. Mothers categorized as zero, one, two, and three or The PIF Study is following a cohort of Pacific with three or more responses having values more. High internal consistency ranging from children born in Auckland, NZ in 2000. All 2 or 3 (a common ‘binary’ method of scoring) 22 0.89 to 0.96 has been reported. potential participants from one hospital were were referred to in this study as symptomatic selected from births where at least one parent Socio-demographic characteristics: Socio- (of psychological distress). High validity identified as being of a Pacific ethnicity demographic variables included age, coefficients for the GHQ12 of between 0.83 and was a NZ permanent resident. Initial ethnicity, marital status, highest educational and 0.93 have been reported in a number of information about the study was provided at qualification and maternal report of personal settings. Using Cronbach’s alpha, we found the hospital and consent was sought to make income. that the internal consistency of the maternal a home visit. The original cohort included Smoking status: Maternal smoking was GHQ scores in the PIF Study were 0.87, 1,376 mothers of 1,398 Pacific infants assessed using the question “Over the past 0.85, 0.83, 0.84 at ages two, four, six and 11 (including 44 twins). Compared with data week, how many cigarettes on average did you years, respectively. Any interviews that were available from Statistics NZ’s 1996 and 2001 smoke a day?” Participants who answered zero incomplete or inconsistent were excluded censuses, the inception cohort was broadly cigarettes were defined as ‘non-smokers’, and from the analysis. representative of the Pacific census figures at those replying with one or more cigarettes Acculturation: The General Ethnicity the time of recruitment. Participants have were classified as ‘smokers’. Questionnaire (GEQ) measures cultural been followed up about every two years with Alcohol consumption: Any alcohol orientation and is based on the concept of 1,029 maternal participants interviewed at 11 consumption was assessed by the Alcohol acculturation, the process of change that years postpartum. Use Disorders Identification Test (AUDIT). groups and individuals undergo when they Consumption was categorised into binary come into contact with another culture. This Procedures ‘drinking’ and ‘non-drinking’ categories. measure has been used at all data points Individual interviews were carried out with Migration status: Migration status was with maternal participants. It is based on maternal participants in their homes. Once determined by maternal report of country of four different varieties of acculturation: informed consent was obtained, mothers birth and years lived in NZ. assimilation (replacing Pacific with NZ participated in interviews concerning their culture), integration (identification with both Data were coded and entered into an individual health, family functioning and the cultures), separation (maintaining only Pacific electronic database (SPSS Data Entry Builder health and development of their child. Within culture), and marginalisation (withdrawal 4.0) that employed comprehensive data the context of the wider interview, issues from both cultures). For the specific purposes validation and checking rules. All analyses of maternal health were investigated using of the PIF Study, the scale was shortened were conducted using R 3.1.0. various screening tools. Details of recruitment and slightly modified thereby developing and procedures are available elsewhere. the Pacific (PI Acculturation) and NZ (NZ Data analysis Acculturation) versions of the GEQ. The Measures The mean response of GHQ12 scores was internal consistency of the measure was analysed using linear multiple regression Maternal mental health: The 12-item General examined using Cronbach’s alpha (α), and was 14 models. Because this study’s aim was to Health Questionnaire is widely used to found to be acceptable (α = 0.81 and 0.83 for assess associations with the extent (rather identify current psychological distress in the NZ Acculturation and PI Acculturation, than the presence) of distress, we used a adults at a particular point in time and respectively). linear approach to GHQ-12 scores rather than has been used with maternal participants Postnatal depression: The Edinburgh Postnatal the traditional dichotomous method. There at every PIF data point. It screens for Depression Scale (EPDS) was used only is some support for treating the GHQ-12 as symptoms common to any non-psychotic in the baseline interviews, about six weeks a continuous variable that measures one disorders and focuses on two major areas, after the birth of the cohort child in 2000. underlying dimension on a continuum from the inability to carry out normal functions It is an instrument focusing on cognitive mental illness to mental wellbeing (Stewart- and the appearance of new and distressing and affective symptoms of depression. The Brown, 2013). An initial model was derived psychological phenomena. Items include: scale does not provide a clinical diagnosis of including all explanatory variables: ethnicity, “Have you recently felt you couldn’t overcome 2016 vol . 40 no . 2 Australian and New Zealand Journal of Public Health 111 © 2015 Public Health Association of Australia Paterson et al. Article migration, current age band, marital status, Likewise, there were some significant Table 2. Variations in mean GHQ12 score within postnatal depression, smoking status, alcohol variations by acculturation category, with subsets of the sample, derived from a linear usage, highest education, personal income, higher distress among separators compared multiple regression model. life events and acculturation. To produce to assimilators (p=0.004). No other significant Variable and subgroup Difference (95% CI) a simplified model aimed at avoiding the associations were found, i.e. with the variables Ethnicity problem of over-fitting, variables were age, migration status, smoking, alcohol and Sāmoan (ref ) (-0.85, 0.85) eliminated in a stepwise manner based on income (Table 2). Cook Islands 0.00 (-1.68, -0.13)* Akaike’s information criterion with small Tongan -0.90 (-1.02, 1.35) sample correction (AICc). Thus a final model Other Pacific 0.16 (-2.16, 0.19) Discussion was derived to estimate associations of some Non-Pacific -0.98 variables (those that contribute to improving This paper aimed to describe the prevalence Postnatal depressive symptoms the model fit based on AICc) with the of maternal psychological distress and No (ref ) outcome. Model diagnostics were performed examine predictors of such distress. Using Yes 0.88 (0.07, 1.69)* on the final model, including tests for good 14 the GHQ screening tool we found that Marital status fit, multicollinearity and independence of 19% of PIF cohort mothers reported current Partnered (ref ) residuals. Tests for interactions among pairs of symptoms that scored at, or above, the cut- Non-partnered 1.45 (0.73, 2.17)*** explanatory variables were not considered. off for psychological distress. The different Highest education Occasional missing values in covariates were measurement tools used in the previous Beyond secondary (ref ) found for 21 participants, amounting to a tiny national NZ studies makes it difficult to Up to secondary 1.15 (0.55, 1.76)*** fraction (0.2%) of covariate values. To retain compare prevalence rates with PIF findings. Life events these participants in the model, missing The 25% rate of mental disorder found in the None (ref ) values in categorical varables were simply Te Rau Hinengaro survey was based on a One 0.55 (-0.45, 1.54) imputed with the most common value. No more in-depth measurement (DSM-IV criteria) Two 1.62 (0.63, 2.61)** numeric variables required imputation. The and over a 12-month period that would Three or more 2.49 (1.60, 3.37)*** final model refitted on complete cases only capture more distress than the screening tool Acculturation showed almost identical results. (GHQ12) used in the PIF Study. The Ministry Assimilator (ref ) of Health NZ Mental Health Survey used a Separator 1.24 (0.41, 2.07)** screening tool but with a longer time period Integrator 1.02 (-0.05, 2.10) Results (four weeks), and found that 13.3% of Pacific Marginalizor -0.14 (-0.97, 0.68) women reported psychological distress. The A total of 851 participants completed the Notes: * p<0.05; ** p<0.01; ***p<0.001 GHQ12 questions and 19% of mothers scored Table 1. Sample characteristics (N=851). in the symptomatic range using the binary Variable n % Variable n % method of scoring. Sample characteristics are GHQ case Smoker presented in Table 1. The mean GHQ12 score Non-symptomatic 689 81% No 564 66% was 9.5 (SD=4.5) and showed some variations Symptomatic 162 19% Yes 287 34% among subgroups. Six explanatory variables Ethnicity Alcohol (any) were retained by the AICc criterion in the Sāmoan 349 41% No 523 62% final model: ethnicity, postnatal depression, Cook Islands 160 19% Yes 326 38% marital status, highest education, life events Highest education Tongan 208 24% and acculturation. Model diagnostic tests for Beyond secondary 425 50% Other Pacific 64 8% the final model all suggested that the model 2 Non-Pacific 70 8% Up to secondary 418 50% was a good fit. The model had an adjusted R Migration Personal weekly income of 8.3% suggesting that the model explains NZ born 328 39% Up to $250 201 24% some of the variation but that further Child migrant 119 14% $251–$500 351 41% research is required. Teenage migrant 92 11% Over $500 269 32% The regression model revealed that mothers Adult migrant 309 36% Unknown 30 4% who had indicated postnatal depressive Postnatal depression Life events symptoms six weeks after the birth of No 705 83% None 125 15% the cohort child had significantly greater 21% Yes 141 17% One 178 distress (p=0.034), as had unpartnered Current age Two 178 21% mothers (p<0.001) and mothers without Up to 35 271 32% Three or more 370 43% post-secondary education (p<0.001). The 36–45 413 49% Acculturation occurrence of stressful life events was highly 46 and over 167 20% Assimilator 371 44% predictive of psychological distress (p<0.001) Marital status Separator 219 26% with a clear increasing trend up to three or Partnered 660 78% Integrator 81 10% more such events. Some ethnic variations Non-partnered 190 22% were evident with lower distress among Marginalizor 174 21% Note: where subtotals are less than 851, some missing values were encountered. Tongans compared to Sāmoans (p=0.02). 112 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 2 © 2015 Public Health Association of Australia Mothers and Children Psychological distress among mothers prevalence rate (19%) from the PIF Study is national Te Rau Hinengaro survey found Within the NZ context, Pacific leaders have more comparable with international studies no significant link between education and called for more culturally appropriate mental that have also used the GHQ12 to measure DSM-IV disorders. This may be due to the health services that are based on Pacific current psychological distress. considerable differences between the two providers and models of care. studies, with the national study focusing We found that six factors were significantly We found that ethnic identity had a on mental health disorder rather than associated with psychological distress (high significant impact on maternal psychological psychological distress and also using a current life stress, postnatal depressive distress with Tongan mothers reporting different measure of education. symptoms, separated or single marital status, significantly less psychological distress than low maternal education, cultural orientation Strong links to cultural homelands in the Sāmoan mothers. This is in line with findings and ethnic group). In line with other studies, Pacific islands can influence beliefs about from the Te Rau Hinengaro survey, which we found that current life stress had a health and illness, and access and use found that Tongans had the lowest 12-month significant effect on maternal psychological of health services in NZ. We found that prevalence of mental health disorder and distress. Relationships between psychological mothers who described themselves as the lowest prevalence of suicidal behaviour distress and current life stress are commonly having closer ties to their home islands, by compared to Sāmoans, Cook Islands Maori 26,27 found in adult women. There is some maintaining only their traditional Pacific and ‘Other Pacific’. Further explanation, evidence that this is due to changing culture (separators) or by maintaining cultural through qualitative methods, is warranted to social roles, parenting stress and marital links with Pacific and NZ culture (integrators), gather more in-depth data on the factors that difficulties. The presence of stressful events reported higher psychological distress than facilitate psychological wellbeing in Tongan and the perception by the individual that mothers who were aligned to the dominant adults. such problems are stressful or non-stressful NZ culture (assimilators) or to neither culture The high rates of psychological distress 19 35,36 may lead to differences in the way women (marginalizors). A number of researchers 5 among women may be due to the chronic cope with particular situations and affect the have emphasised the central role of the stress associated with traditional female development of psychological distress. individual’s maintenance of his/her ethnic 24 roles, the social acceptability of revealing culture in the cultural orientation that s/he 25 Earlier PIF findings revealed that 16.4% of psychological symptoms, and/or the adopts in the new country, and the effect 26 mothers reported postnatal depressive tendency to dwell on problems. This is that this has on the individual’s self-esteem symptoms at the six-week measurement an important issue as the psychological 29 and on psychological distress. Within NZ, gift point and in this analysis we found that health and wellbeing of mothers plays a giving to family and church is an important mothers who reported postnatal depression significant role in family health. Research has part of traditional expectations. It is reported significantly more psychological consistently shown that children of mothers possible that mothers with strong traditional distress after 11 years. This finding is who show evidence of depressive symptoms/ alignment may be struggling to meet these supported by other studies that have psychological distress are at increased risk for financial commitments. Previous findings in 27 found that women with prior mental health the development of psychopathology. the PIF Study showed that 59% of mothers problems tend to suffer more psychological reported that traditional gift giving brought distress than those who have no such Strengths and limitations 30 significant financial stress on the family. history. A significant strength of the PIF Study is the In addition, strong traditional Pacific beliefs Consistent with previous PIF findings, strong representation of Pacific researchers around mental illness can lead to feelings of marital status was significantly associated and maternal interviewers on the team stigmatisation towards the affected individual with psychological distress, with those who that heightens the cultural sensitivity of from within the family and community. were separated or single reporting greater our methods and procedures. Cultural Research has demonstrated that Pacific psychological distress. A number of studies appropriateness of the study is supported peoples’ experience of health care can be have found that, compared to adults in a by the independent Pacific People’s Advisory influenced by cultural beliefs and values stable marriage, separated and single adults Board, composed of senior Pacific community that can create barriers to the access and are likely to experience more social isolation representatives, established to guide the 40,41 31 use of services across the health system. and poorer physical and mental health. In PIF management team in the scientific and Pacific researchers call for service delivery addition, women have reported difficulties cultural directions of the research. to be culturally competent so that it is more with childrearing, career planning and It is important to recognise that this analysis acceptable to a wider spectrum of Pacific finances. These are significant stressors that is constrained by the nature of large 32 individuals and families. Those mothers who are likely to affect psychological distress. longitudinal studies, with multidisciplinary maintain their Pacific ethnic identity may be As reported in other studies, we also found questionnaires resulting in lesser opportunity more likely to be the recipients of prejudice, that low maternal education was significantly to drill down into multifaceted issues. This stereotyping, and discrimination from within associated with maternal psychological limits the degree to which the specific role the western dominated mental health system. distress. Limited education is likely to result of Pacific subcultures and their elements This is in line with International research in difficulties associated with attaining can be elucidated. The findings are based that has shown that minority ethnic groups meaningful employment and the cumulative on a robust birth cohort with the island- are often treated in a stereotypical way and adverse effects of being disadvantaged in specific distributions being approximately experience inappropriate assessment and socioeconomic terms throughout life are representative of the ethnic distribution of treatment procedures that are not based likely to impact on wellbeing. However, the the Pacific population in NZ. Some evidence 43,44 on traditional mental health processes. 2016 vol . 40 no . 2 Australian and New Zealand Journal of Public Health 113 © 2015 Public Health Association of Australia Paterson et al. Article 23. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, of differential attrition has previously been References Grant M. Development of the Alcohol Use Disorders reported in the PIF Study; however, there Identification Test (AUDIT): WHO collaborative project 1. 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Berkshire (UK): (NZ): New Zealand Ministry of Health; 2006. p. 178-208. However, it is acknowledged that mothers McGraw-Hill and Open University Press; 2013. p. 33-41. 4. Ministry of Health. The Health of New Zealand Adults may under-report their own behaviours, 26. Mirowsky J, Ross CE. Social Causes of Psychological 2013/2014: Key Findings of the New Zealand Health Distress. New York (NY): Aldine De Gruyter; 1989. Survey. Wellington (NZ): Government of New Zealand; which could be related to issues around the 27. Nolen-Hoeksema S. Sex Differences in Depression . Palo social acceptability of revealing psychological Alto )CA): Stanford University Press; 1990. 5. Kessler RC. Epidemiology of women and depression. J 28. Rabkin JG, Struening EL. Life events, stress, and illness. Affect Disord. 2003;74(1):5-13. symptoms. These limitations are recognised Science. 1976;194(4269):1013-20. 6. Bromley C, Skelton N. Scottish Health Survey: UK but in large scale studies such as the PIF 29. Abbott MW, Williams MM. Postnatal depressive Comparisons. Edinburgh (SCO): Government of symptoms among Pacific mothers in Auckland: Study, self-report is usually the most feasible Scotland; 2010. Prevalence and risk factors. Aust N Z J Psychiatry. 7. Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The option for measurement. 2006;40(3):230-8. prevalence and distribution of major depression in a 30. Kuh D, Hardy R, Rodgers B, Wadsworth MEJ. Lifetime risk national community sample: The National Comorbidity The PIF Study adds to the literature factors for women’s psychological distress in midlife. Soc Survey. Am J Psychiatry. 1994;151(7):979-86. documenting psychological distress in Sci Med. 2002;55(11):1957-73. 8. Kaplan GA, Pamuk ER, Lynch JW, Cohen RD, Balfour 31. Amato J. The consequences of divorce for adults and minority populations. The factors that JL. Inequality in income and mortality in the United children. J Marriage Fam. 2000;62:1269-87. States: Analysis of mortality and potential pathways. significantly affected the risk of psychological 32. Garvin V, Kalter N, Hansell J. Divorced women: Factors BMJ. 1996;312(7037):999-1003. distress during adulthood were from across contributing to resiliency and vulnerability. J Divorce 9. Lynch JW, Smith GD, Kaplan GA, House JS. Income Remarriage. 1994;21(1-2):21-40. inequality and mortality: Importance to health of the lifespan. Marital breakdown, stressful life 33. Mayberry LJ, Horowitz JA, Declercq E. Depression individual income, psychosocial environment, or events, maternal education, and previous symptom prevalence and demographic risk factors material conditions. BMJ. 2000;320(7243):1200-4. among U.S. women during the first 2 years postpartum. 10. Horowitz JA, Goodman J. A longitudinal study of depression exerted significant effects on J Obstet Gynecol Neonatal Nurs. 2007;36(6):542-9. maternal postpartum depression symptoms. Res Theory maternal psychological distress. By learning 34. Ministry of Health and Ministry of Pacific Island Affairs. Nurs Pract. 2004;18(2-3):149-63. Ala Mo’ui: Pathways to Pacific Health and Wellbeing. about factors that are potentially modifiable 11. Kessler RC. The effects of stressful life events on Wellington (NZ): Government of New Zealand; 2010. depression. Annu Rev Psychol. 1997;48(1):191-214. we can begin to identify the most appropriate 35. Nesdale D, Rooney R, Smith L. Migrant ethnic identity 12. Dohrenwend BP. The role of adversity and stress in ways to address their role in maternal and psychological distress. J Cross Cult Psychol. psychopathology: Some evidence and its implications 1997;28(5):569-88. for theory and research. J Health Soc Behav. 2000;41(1): psychological distress among Pacific women. 36. Phinney JS, Chavira V, Tate JD. The effect of ethnic threat 1-19. on ethnic self-concept and own-group ratings. J Soc The findings related to ethnic identity and 13. Paterson J, Percival T, Schluter P , Sundborn G, Abbott M, Psychol. 1993;133(4):469-78. Carter S, et al. Cohort Profile: The Pacific Islands Families cultural orientation suggest that particular 37. Mulitalo-Lauto PTMT III. Fa’asamao and Social Work (PIF) Study. Int J Epidemiol. 2008;37(2):273-9. issues exist for Pacific peoples that need to Within the New Zealand Context. Palmerston North (NZ): 14. Goldberg D, Williams P. A User’s Guide to the GHQ. Dunmore Press; 2000. Windsor (UK): NFER-Nelson; 1998. be considered carefully in terms of support 38. Cowley ET, Paterson J, Williams M. Traditional gift giving 15. Gao W, Paterson J, Abbott M, et al. Maternal mental and appropriate interventions. More in-depth among Pacific families in New Zealand. J Fam Econ health and child behavior problems at 2 years: n fi dings Issues. 2004;25(3):431-44. from the Pacific Islands Families Study. Aust N Z J qualitative research, using these quantitative 39. Vaeau F. An Investigation of Pasifika Access to the Child Psychiatry. 2007;41:885–95. findings, is needed to clarify the way these and Adolescent Mental Health Service within Counties 16. Makowska Z, Merecz D, Moscicka A, Kolasa W. The Manukau District Health Board – The Influence of Health factors impact on psychological distress and validity of general health questionnaires, GHQ-12 and Beliefs and Attitudes [Masters Thesis]. Auckland (NZ): GHQ-28, in mental health studies of working people. Int to guide the design of effective strategies that Auckland University of Technology; 2013. J Occup Med Environ Health. 2002;15(4):353-62. minimise their effect on Pacific women living 40. Ministry of Health. Looking Upstream: Cause of Death- 17. Tsai JL, Ying Y-W, Lee PA. The meaning of “Being classified by Risk and Condition 1997 . Wellington (NZ): Chinese” and “Being American”: Variation among in NZ. The current PIF findings highlight the Government of New Zealand; 2004. 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Gerst MS, Grant I, Yager J, Sweetwood H. The reliability of the social readjustment rating scale: Moderate and long-term stability. J Psychosom Res. 1978;22(6):519-23. 114 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 2 © 2015 Public Health Association of Australia http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Pacific Islands Families Study: psychological distress among mothers of Pacific children living in New Zealand

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Wiley
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© 2016 Public Health Association of Australia
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1326-0200
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1753-6405
DOI
10.1111/1753-6405.12491
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26713675
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Abstract

(NZ) are ethnically heterogeneous P(Sāmoan, 49%; Cook Islands Māori, Objective: This study investigated: 1) the prevalence of psychological distress among a cohort 21%; Tongan, 20%; and Niuean, 8%), rapidly of mothers of Pacific children; and 2) the socio-demographic and lifestyle variables associated growing, youthful and highly urbanised. with psychological distress. However, Pacific people suffer from an excess Method: The Pacific Islands Families (PIF) Study is a longitudinal investigation of a cohort of of social, health and economic deprivation. Pacific children born in Auckland, New Zealand, and their mothers and fathers. The 12-item The low socioeconomic status of Pacific General Health Questionnaire (GHQ12) was used to assess psychological distress among people and experiences of rapid acculturation mothers (N=851) at about 11 years postpartum. and sociocultural change have been linked Results: Current psychological distress was reported by 19% of mothers, and six explanatory to concerns about mental illness and risk- variables were significantly associated with maternal psychological distress: stressful life events, taking behaviors among Pacific people. postnatal depression, marital status, maternal education, ethnicity and cultural alignment. Two national surveys carried out in the past Conclusion: These findings suggest that the mental health of Pacific people varies by particular decade have described the relatively high ethnic group and cultural alignment. This highlights the need for culturally appropriate prevalence of Pacific mental health disorder evaluation and treatment for at-risk Pacific mothers that will break down psychological, cultural in comparison to other NZ groups. However, and economic barriers to accessing help for psychological distress. there is a scarcity of data that considers the Implications: By learning about factors that are potentially modifiable we can begin to identify risk and protective factors across the lifespan the most appropriate ways to address their impact on psychological distress among Pacific that lead to psychological distress among women. Pacific adults living in NZ. Key words: psychological distress, Pacific women, general health questionnaire In 2004, Te Rau Hinengaro: The New Zealand Mental Health Survey investigated the 12-month prevalence of DSM-IV disorders experience of symptoms such as anxiety, In terms of risk factors for psychological in NZ. The DSM-IV covers anxiety and mood confused emotions, depression or rage. In this distress, international research has shown that disorders, phobias and substance abuse. The 7 8,9 national survey it was revealed that 6% of NZ poor living standards, income inequality, researchers found that the prevalence of 10 11 adult men and 7% of adult women reported previous depression, stressful life events, any mental disorder in the past 12 months experiencing psychological distress over the and social adversity have been associated was higher in Pacific people (25%) than for past four weeks. Thirteen per cent of Pacific with high rates of psychological distress, and the general population (21%). This national adults reported psychological distress, which physical and social morbidity. survey found that gender, educational was 2.1 times higher than non-Pacific adults This paper is based on the Pacific Islands qualifications and household income had in NZ. The prevalence rate was 12% for Pacific 13 Families (PIF) Study, a birth cohort study no significant impact on the prevalence or men and 13.3% for Pacific women, although that is a longitudinal investigation of Pacific severity of mental disorder for Pacific people. these rates were not significantly different. infants born in South Auckland, NZ, in 2000 In 2013, the Ministry of Health’s NZ Health International studies have used the GHQ12 to (n=1,398) and their mothers and fathers. Survey examined psychological distress in NZ measure psychological distress and revealed Children and their families have been visited adults using the 10-question Kessler Scale. prevalence rates for women in England (15%), when the children were aged six weeks, and Psychological distress is defined as a person’s Scotland (17%) and Northern Ireland (21%). one, two, four, six, nine and 11 years. In the 1. National Institute for Public Health and Mental Health Research, Auckland University of Technology, New Zealand Correspondence to: Professor Janis Paterson, Public Health & Psychosocial Studies, Auckland University of Technology, 90 Akoranga Drive, Northcote, Auckland 0627, New Zealand; e-mail: janis.paterson@aut.ac.nz Submitted: April 2015; Revision requested: July 2015; Accepted: September 2015 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2016; 40:110-4; doi: 10.1111/1753-6405.12491 110 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 2 © 2015 Public Health Association of Australia Mothers and Children Psychological distress among mothers PIF Study, the General Health Questionnaire your difficulties?”; “ Have you recently been able depression, but a score of above 12 is widely (GHQ) was used to measure psychological to enjoy your normal day-to-day activities?”; used to indicate depressive symptoms. The distress. We found prevalence rates for “Have you recently felt capable about making sensitivity, specificity and predictive validity maternal psychological distress of 12.2% decisions about things?” Each item was of the EPDS have been established in a variety at one year postpartum and 9.5% at two recorded on a four-point Likert scale, such of populations. years postpartum. This investigation of as from “not at all” up to “much more[less] Life events: A 23-item scale was used with the prevalence of psychological distress is than usual”, and were assigned values 0 maternal participants to examine stressful focused on the cohort of mothers of Pacific to 3. The extent of psychological distress events at the 11-year data point. The Social children at 11 years postpartum, and explores was measured using GHQ12 scores, which Readjustment Rating Scale determines predictors of such distress. were derived by summing the 12 numeric the number of stressful events (e.g. serious responses, thereby giving a range of possible arguments with partner; death of a close scores from zero to 36. Up to one missing friend or relative; serious financial problems) Method response was replaced by that participant’s experienced by the family in the past median response; participants with two or 21 Participants 12 months. The number of events was more missing values were excluded. Mothers categorized as zero, one, two, and three or The PIF Study is following a cohort of Pacific with three or more responses having values more. High internal consistency ranging from children born in Auckland, NZ in 2000. All 2 or 3 (a common ‘binary’ method of scoring) 22 0.89 to 0.96 has been reported. potential participants from one hospital were were referred to in this study as symptomatic selected from births where at least one parent Socio-demographic characteristics: Socio- (of psychological distress). High validity identified as being of a Pacific ethnicity demographic variables included age, coefficients for the GHQ12 of between 0.83 and was a NZ permanent resident. Initial ethnicity, marital status, highest educational and 0.93 have been reported in a number of information about the study was provided at qualification and maternal report of personal settings. Using Cronbach’s alpha, we found the hospital and consent was sought to make income. that the internal consistency of the maternal a home visit. The original cohort included Smoking status: Maternal smoking was GHQ scores in the PIF Study were 0.87, 1,376 mothers of 1,398 Pacific infants assessed using the question “Over the past 0.85, 0.83, 0.84 at ages two, four, six and 11 (including 44 twins). Compared with data week, how many cigarettes on average did you years, respectively. Any interviews that were available from Statistics NZ’s 1996 and 2001 smoke a day?” Participants who answered zero incomplete or inconsistent were excluded censuses, the inception cohort was broadly cigarettes were defined as ‘non-smokers’, and from the analysis. representative of the Pacific census figures at those replying with one or more cigarettes Acculturation: The General Ethnicity the time of recruitment. Participants have were classified as ‘smokers’. Questionnaire (GEQ) measures cultural been followed up about every two years with Alcohol consumption: Any alcohol orientation and is based on the concept of 1,029 maternal participants interviewed at 11 consumption was assessed by the Alcohol acculturation, the process of change that years postpartum. Use Disorders Identification Test (AUDIT). groups and individuals undergo when they Consumption was categorised into binary come into contact with another culture. This Procedures ‘drinking’ and ‘non-drinking’ categories. measure has been used at all data points Individual interviews were carried out with Migration status: Migration status was with maternal participants. It is based on maternal participants in their homes. Once determined by maternal report of country of four different varieties of acculturation: informed consent was obtained, mothers birth and years lived in NZ. assimilation (replacing Pacific with NZ participated in interviews concerning their culture), integration (identification with both Data were coded and entered into an individual health, family functioning and the cultures), separation (maintaining only Pacific electronic database (SPSS Data Entry Builder health and development of their child. Within culture), and marginalisation (withdrawal 4.0) that employed comprehensive data the context of the wider interview, issues from both cultures). For the specific purposes validation and checking rules. All analyses of maternal health were investigated using of the PIF Study, the scale was shortened were conducted using R 3.1.0. various screening tools. Details of recruitment and slightly modified thereby developing and procedures are available elsewhere. the Pacific (PI Acculturation) and NZ (NZ Data analysis Acculturation) versions of the GEQ. The Measures The mean response of GHQ12 scores was internal consistency of the measure was analysed using linear multiple regression Maternal mental health: The 12-item General examined using Cronbach’s alpha (α), and was 14 models. Because this study’s aim was to Health Questionnaire is widely used to found to be acceptable (α = 0.81 and 0.83 for assess associations with the extent (rather identify current psychological distress in the NZ Acculturation and PI Acculturation, than the presence) of distress, we used a adults at a particular point in time and respectively). linear approach to GHQ-12 scores rather than has been used with maternal participants Postnatal depression: The Edinburgh Postnatal the traditional dichotomous method. There at every PIF data point. It screens for Depression Scale (EPDS) was used only is some support for treating the GHQ-12 as symptoms common to any non-psychotic in the baseline interviews, about six weeks a continuous variable that measures one disorders and focuses on two major areas, after the birth of the cohort child in 2000. underlying dimension on a continuum from the inability to carry out normal functions It is an instrument focusing on cognitive mental illness to mental wellbeing (Stewart- and the appearance of new and distressing and affective symptoms of depression. The Brown, 2013). An initial model was derived psychological phenomena. Items include: scale does not provide a clinical diagnosis of including all explanatory variables: ethnicity, “Have you recently felt you couldn’t overcome 2016 vol . 40 no . 2 Australian and New Zealand Journal of Public Health 111 © 2015 Public Health Association of Australia Paterson et al. Article migration, current age band, marital status, Likewise, there were some significant Table 2. Variations in mean GHQ12 score within postnatal depression, smoking status, alcohol variations by acculturation category, with subsets of the sample, derived from a linear usage, highest education, personal income, higher distress among separators compared multiple regression model. life events and acculturation. To produce to assimilators (p=0.004). No other significant Variable and subgroup Difference (95% CI) a simplified model aimed at avoiding the associations were found, i.e. with the variables Ethnicity problem of over-fitting, variables were age, migration status, smoking, alcohol and Sāmoan (ref ) (-0.85, 0.85) eliminated in a stepwise manner based on income (Table 2). Cook Islands 0.00 (-1.68, -0.13)* Akaike’s information criterion with small Tongan -0.90 (-1.02, 1.35) sample correction (AICc). Thus a final model Other Pacific 0.16 (-2.16, 0.19) Discussion was derived to estimate associations of some Non-Pacific -0.98 variables (those that contribute to improving This paper aimed to describe the prevalence Postnatal depressive symptoms the model fit based on AICc) with the of maternal psychological distress and No (ref ) outcome. Model diagnostics were performed examine predictors of such distress. Using Yes 0.88 (0.07, 1.69)* on the final model, including tests for good 14 the GHQ screening tool we found that Marital status fit, multicollinearity and independence of 19% of PIF cohort mothers reported current Partnered (ref ) residuals. Tests for interactions among pairs of symptoms that scored at, or above, the cut- Non-partnered 1.45 (0.73, 2.17)*** explanatory variables were not considered. off for psychological distress. The different Highest education Occasional missing values in covariates were measurement tools used in the previous Beyond secondary (ref ) found for 21 participants, amounting to a tiny national NZ studies makes it difficult to Up to secondary 1.15 (0.55, 1.76)*** fraction (0.2%) of covariate values. To retain compare prevalence rates with PIF findings. Life events these participants in the model, missing The 25% rate of mental disorder found in the None (ref ) values in categorical varables were simply Te Rau Hinengaro survey was based on a One 0.55 (-0.45, 1.54) imputed with the most common value. No more in-depth measurement (DSM-IV criteria) Two 1.62 (0.63, 2.61)** numeric variables required imputation. The and over a 12-month period that would Three or more 2.49 (1.60, 3.37)*** final model refitted on complete cases only capture more distress than the screening tool Acculturation showed almost identical results. (GHQ12) used in the PIF Study. The Ministry Assimilator (ref ) of Health NZ Mental Health Survey used a Separator 1.24 (0.41, 2.07)** screening tool but with a longer time period Integrator 1.02 (-0.05, 2.10) Results (four weeks), and found that 13.3% of Pacific Marginalizor -0.14 (-0.97, 0.68) women reported psychological distress. The A total of 851 participants completed the Notes: * p<0.05; ** p<0.01; ***p<0.001 GHQ12 questions and 19% of mothers scored Table 1. Sample characteristics (N=851). in the symptomatic range using the binary Variable n % Variable n % method of scoring. Sample characteristics are GHQ case Smoker presented in Table 1. The mean GHQ12 score Non-symptomatic 689 81% No 564 66% was 9.5 (SD=4.5) and showed some variations Symptomatic 162 19% Yes 287 34% among subgroups. Six explanatory variables Ethnicity Alcohol (any) were retained by the AICc criterion in the Sāmoan 349 41% No 523 62% final model: ethnicity, postnatal depression, Cook Islands 160 19% Yes 326 38% marital status, highest education, life events Highest education Tongan 208 24% and acculturation. Model diagnostic tests for Beyond secondary 425 50% Other Pacific 64 8% the final model all suggested that the model 2 Non-Pacific 70 8% Up to secondary 418 50% was a good fit. The model had an adjusted R Migration Personal weekly income of 8.3% suggesting that the model explains NZ born 328 39% Up to $250 201 24% some of the variation but that further Child migrant 119 14% $251–$500 351 41% research is required. Teenage migrant 92 11% Over $500 269 32% The regression model revealed that mothers Adult migrant 309 36% Unknown 30 4% who had indicated postnatal depressive Postnatal depression Life events symptoms six weeks after the birth of No 705 83% None 125 15% the cohort child had significantly greater 21% Yes 141 17% One 178 distress (p=0.034), as had unpartnered Current age Two 178 21% mothers (p<0.001) and mothers without Up to 35 271 32% Three or more 370 43% post-secondary education (p<0.001). The 36–45 413 49% Acculturation occurrence of stressful life events was highly 46 and over 167 20% Assimilator 371 44% predictive of psychological distress (p<0.001) Marital status Separator 219 26% with a clear increasing trend up to three or Partnered 660 78% Integrator 81 10% more such events. Some ethnic variations Non-partnered 190 22% were evident with lower distress among Marginalizor 174 21% Note: where subtotals are less than 851, some missing values were encountered. Tongans compared to Sāmoans (p=0.02). 112 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 2 © 2015 Public Health Association of Australia Mothers and Children Psychological distress among mothers prevalence rate (19%) from the PIF Study is national Te Rau Hinengaro survey found Within the NZ context, Pacific leaders have more comparable with international studies no significant link between education and called for more culturally appropriate mental that have also used the GHQ12 to measure DSM-IV disorders. This may be due to the health services that are based on Pacific current psychological distress. considerable differences between the two providers and models of care. studies, with the national study focusing We found that six factors were significantly We found that ethnic identity had a on mental health disorder rather than associated with psychological distress (high significant impact on maternal psychological psychological distress and also using a current life stress, postnatal depressive distress with Tongan mothers reporting different measure of education. symptoms, separated or single marital status, significantly less psychological distress than low maternal education, cultural orientation Strong links to cultural homelands in the Sāmoan mothers. This is in line with findings and ethnic group). In line with other studies, Pacific islands can influence beliefs about from the Te Rau Hinengaro survey, which we found that current life stress had a health and illness, and access and use found that Tongans had the lowest 12-month significant effect on maternal psychological of health services in NZ. We found that prevalence of mental health disorder and distress. Relationships between psychological mothers who described themselves as the lowest prevalence of suicidal behaviour distress and current life stress are commonly having closer ties to their home islands, by compared to Sāmoans, Cook Islands Maori 26,27 found in adult women. There is some maintaining only their traditional Pacific and ‘Other Pacific’. Further explanation, evidence that this is due to changing culture (separators) or by maintaining cultural through qualitative methods, is warranted to social roles, parenting stress and marital links with Pacific and NZ culture (integrators), gather more in-depth data on the factors that difficulties. The presence of stressful events reported higher psychological distress than facilitate psychological wellbeing in Tongan and the perception by the individual that mothers who were aligned to the dominant adults. such problems are stressful or non-stressful NZ culture (assimilators) or to neither culture The high rates of psychological distress 19 35,36 may lead to differences in the way women (marginalizors). A number of researchers 5 among women may be due to the chronic cope with particular situations and affect the have emphasised the central role of the stress associated with traditional female development of psychological distress. individual’s maintenance of his/her ethnic 24 roles, the social acceptability of revealing culture in the cultural orientation that s/he 25 Earlier PIF findings revealed that 16.4% of psychological symptoms, and/or the adopts in the new country, and the effect 26 mothers reported postnatal depressive tendency to dwell on problems. This is that this has on the individual’s self-esteem symptoms at the six-week measurement an important issue as the psychological 29 and on psychological distress. Within NZ, gift point and in this analysis we found that health and wellbeing of mothers plays a giving to family and church is an important mothers who reported postnatal depression significant role in family health. Research has part of traditional expectations. It is reported significantly more psychological consistently shown that children of mothers possible that mothers with strong traditional distress after 11 years. This finding is who show evidence of depressive symptoms/ alignment may be struggling to meet these supported by other studies that have psychological distress are at increased risk for financial commitments. Previous findings in 27 found that women with prior mental health the development of psychopathology. the PIF Study showed that 59% of mothers problems tend to suffer more psychological reported that traditional gift giving brought distress than those who have no such Strengths and limitations 30 significant financial stress on the family. history. A significant strength of the PIF Study is the In addition, strong traditional Pacific beliefs Consistent with previous PIF findings, strong representation of Pacific researchers around mental illness can lead to feelings of marital status was significantly associated and maternal interviewers on the team stigmatisation towards the affected individual with psychological distress, with those who that heightens the cultural sensitivity of from within the family and community. were separated or single reporting greater our methods and procedures. Cultural Research has demonstrated that Pacific psychological distress. A number of studies appropriateness of the study is supported peoples’ experience of health care can be have found that, compared to adults in a by the independent Pacific People’s Advisory influenced by cultural beliefs and values stable marriage, separated and single adults Board, composed of senior Pacific community that can create barriers to the access and are likely to experience more social isolation representatives, established to guide the 40,41 31 use of services across the health system. and poorer physical and mental health. In PIF management team in the scientific and Pacific researchers call for service delivery addition, women have reported difficulties cultural directions of the research. to be culturally competent so that it is more with childrearing, career planning and It is important to recognise that this analysis acceptable to a wider spectrum of Pacific finances. These are significant stressors that is constrained by the nature of large 32 individuals and families. Those mothers who are likely to affect psychological distress. longitudinal studies, with multidisciplinary maintain their Pacific ethnic identity may be As reported in other studies, we also found questionnaires resulting in lesser opportunity more likely to be the recipients of prejudice, that low maternal education was significantly to drill down into multifaceted issues. This stereotyping, and discrimination from within associated with maternal psychological limits the degree to which the specific role the western dominated mental health system. distress. Limited education is likely to result of Pacific subcultures and their elements This is in line with International research in difficulties associated with attaining can be elucidated. The findings are based that has shown that minority ethnic groups meaningful employment and the cumulative on a robust birth cohort with the island- are often treated in a stereotypical way and adverse effects of being disadvantaged in specific distributions being approximately experience inappropriate assessment and socioeconomic terms throughout life are representative of the ethnic distribution of treatment procedures that are not based likely to impact on wellbeing. However, the the Pacific population in NZ. Some evidence 43,44 on traditional mental health processes. 2016 vol . 40 no . 2 Australian and New Zealand Journal of Public Health 113 © 2015 Public Health Association of Australia Paterson et al. Article 23. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, of differential attrition has previously been References Grant M. Development of the Alcohol Use Disorders reported in the PIF Study; however, there Identification Test (AUDIT): WHO collaborative project 1. 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Gerst MS, Grant I, Yager J, Sweetwood H. The reliability of the social readjustment rating scale: Moderate and long-term stability. J Psychosom Res. 1978;22(6):519-23. 114 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 2 © 2015 Public Health Association of Australia

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