The Impact of Migration Status on Adolescents’ Mental Health during COVID-19
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Migration Status, Restrictions, and Remote Schooling in Austria
2.3. Measures
2.3.1. Well-Being (WHO-5)
2.3.2. Depressive Symptoms (PHQ-9)
2.3.3. Anxiety Symptoms (GAD-7)
2.3.4. Sleep Quality (ISI)
2.3.5. Stress (PSS-10)
2.3.6. Eating Attitudes Test (EAT-8)
2.4. Statistical Analyses
2.4.1. Matched-Pair Analysis
2.4.2. Whole Sample Analysis
3. Results
3.1. Matched-Pairs Analysis (N = 958)
3.2. Whole Sample Analysis (N = 3052)
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- WHO/Europe|Publications—Spotlight on Adolescent Health and Well-Being. Findings from the 2017/2018 Health Behaviour in School-Aged Children (HBSC) Survey in Europe and Canada. International Report. Volume 1. Key Findings. Available online: https://www.euro.who.int/en/publications/abstracts/spotlight-on-adolescent-health-and-well-being.-findings-from-the-20172018-health-behaviour-in-school-aged-children-hbsc-survey-in-europe-and-canada.-international-report.-volume-1.-key-findings (accessed on 14 May 2021).
- Duinhof, E.L.; Smid, S.C.; Vollebergh, W.A.M.; Stevens, G.W.J.M. Immigration Background and Adolescent Mental Health Problems: The Role of Family Affluence, Adolescent Educational Level and Gender. Soc. Psychiatry Psychiatr. Epidemiol. 2020, 55, 435–445. [Google Scholar] [CrossRef] [Green Version]
- Shi, L.; Chen, W.; Bouey, J.H.; Lin, Y.; Ling, L. Impact of Acculturation and Psychological Adjustment on Mental Health among Migrant Adolescents in Guangzhou, China: A Cross-Sectional Questionnaire Study. BMJ Open 2019, 9, e022712. [Google Scholar] [CrossRef] [Green Version]
- Delaruelle, K.; Walsh, S.D.; Dierckens, M.; Deforche, B.; Kern, M.R.; Currie, C.; Maldonado, C.M.; Cosma, A.; Stevens, G.W.J.M. Mental Health in Adolescents with a Migration Background in 29 European Countries: The Buffering Role of Social Capital. J. Youth Adolesc. 2021, 50, 855–871. [Google Scholar] [CrossRef]
- Gutmann, M.T.; Aysel, M.; Özlü-Erkilic, Z.; Popow, C.; Akkaya-Kalayci, T. Mental Health Problems of Children and Adolescents, with and without Migration Background, Living in Vienna, Austria. Child Adolesc. Psychiatry Ment. Health 2019, 13, 35. [Google Scholar] [CrossRef] [PubMed]
- Schouler-Ocak, M.; Graef-Calliess, I.T.; Bajbouj, M.; Plener, P.L. Psychische Störungen bei MigrantInnen. Z. Für Kinder- Jugendpsychiatrie Psychother. 2020, 48, 453–457. [Google Scholar] [CrossRef] [PubMed]
- Dimitrova, R.; Chasiotis, A.; van de Vijver, F. Adjustment Outcomes of Immigrant Children and Youth in Europe: A Meta-Analysis. Eur. Psychol. 2016, 21, 150–162. [Google Scholar] [CrossRef]
- Belhadj Kouider, E.; Koglin, U.; Petermann, F. Emotional and Behavioral Problems in Migrant Children and Adolescents in Europe: A Systematic Review. Eur. Child Adolesc. Psychiatry 2014, 23, 373–391. [Google Scholar] [CrossRef]
- Mood, C.; Jonsson, J.O.; Låftman, S.B. Immigrant Integration and Youth Mental Health in Four European Countries. Eur. Sociol. Rev. 2016, 32, 716–729. [Google Scholar] [CrossRef]
- Emerging Trends in the Social and Behavioral Sciences: An Interdisciplinary, Searchable, and Linkable Resource, 1st ed.; Scott, R.A.; Kosslyn, S.M. (Eds.) Wiley: Hoboken, NJ, USA, 2015; ISBN 978-1-118-90077-2. [Google Scholar]
- Coll, C.G.; Patton, F.; Kerivan Marks, A.; Dimitrova, R.; Yang, R.; Suarez, G.A.; Patrico, A. Understanding the Immigrant Paradox in Youth. In Realizing the Potential of Immigrant Youth; Masten, A.S., Liebkind, K., Hernandez, D.J., Eds.; Cambridge University Press: Cambridge, UK, 2012; pp. 159–180. ISBN 978-1-139-09469-6. [Google Scholar]
- Van Geel, M.; Vedder, P. The Role of Family Obligations and School Adjustment in Explaining the Immigrant Paradox. J. Youth Adolesc. 2011, 40, 187–196. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Banati, P.; Jones, N.; Youssef, S. Intersecting Vulnerabilities: The Impacts of COVID-19 on the Psycho-Emotional Lives of Young People in Low- and Middle-Income Countries. Eur. J. Dev. Res. 2020, 32, 1613–1638. [Google Scholar] [CrossRef]
- Duan, L.; Shao, X.; Wang, Y.; Huang, Y.; Miao, J.; Yang, X.; Zhu, G. An Investigation of Mental Health Status of Children and Adolescents in China during the Outbreak of COVID-19. J. Affect. Disord. 2020, 275, 112–118. [Google Scholar] [CrossRef] [PubMed]
- Fegert, J.M.; Vitiello, B.; Plener, P.L.; Clemens, V. Challenges and Burden of the Coronavirus 2019 (COVID-19) Pandemic for Child and Adolescent Mental Health: A Narrative Review to Highlight Clinical and Research Needs in the Acute Phase and the Long Return to Normality. Child Adolesc. Psychiatry Ment. Health 2020, 14, 20. [Google Scholar] [CrossRef]
- Pierce, M.; Hope, H.; Ford, T.; Hatch, S.; Hotopf, M.; John, A.; Kontopantelis, E.; Webb, R.; Wessely, S.; McManus, S.; et al. Mental Health before and during the COVID-19 Pandemic: A Longitudinal Probability Sample Survey of the UK Population. Lancet Psychiatry 2020, 7, 883–892. [Google Scholar] [CrossRef]
- Porter, C.; Favara, M.; Hittmeyer, A.; Scott, D.; Sánchez Jiménez, A.; Ellanki, R.; Woldehanna, T.; Duc, L.T.; Craske, M.G.; Stein, A. Impact of the COVID-19 Pandemic on Anxiety and Depression Symptoms of Young People in the Global South: Evidence from a Four-Country Cohort Study. BMJ Open 2021, 11, e049653. [Google Scholar] [CrossRef]
- Pieh, C.; Plener, P.L.; Probst, T.; Dale, R.; Humer, E. Assessment of Mental Health of High School Students during Social Distancing and Remote Schooling during the COVID-19 Pandemic in Austria. JAMA Netw. Open 2021, 4, e2114866. [Google Scholar] [CrossRef] [PubMed]
- Gibson, B.; Schneider, J.; Talamonti, D.; Forshaw, M. The Impact of Inequality on Mental Health Outcomes during the COVID-19 Pandemic: A Systematic Review. Can. Psychol. Can. 2021, 62, 101–126. [Google Scholar] [CrossRef]
- Liu, C.H.; Zhang, E.; Wong, G.T.F.; Hyun, S.; Hahm, H. “Chris” Factors Associated with Depression, Anxiety, and PTSD Symptomatology during the COVID-19 Pandemic: Clinical Implications for U.S. Young Adult Mental Health. Psychiatry Res. 2020, 290, 113172. [Google Scholar] [CrossRef]
- Akkaya-Kalayci, T.; Kothgassner, O.D.; Wenzel, T.; Goreis, A.; Chen, A.; Ceri, V.; Özlü-Erkilic, Z. The Impact of the COVID-19 Pandemic on Mental Health and Psychological Well-Being of Young People Living in Austria and Turkey: A Multicenter Study. Int. J. Environ. Res. Public. Health 2020, 17, 9111. [Google Scholar] [CrossRef]
- Harris, P.A.; Taylor, R.; Minor, B.L.; Elliott, V.; Fernandez, M.; O’Neal, L.; McLeod, L.; Delacqua, G.; Delacqua, F.; Kirby, J.; et al. The REDCap Consortium: Building an International Community of Software Platform Partners. J. Biomed. Inform. 2019, 95, 103208. [Google Scholar] [CrossRef] [PubMed]
- Brähler, E.; Mühlan, H.; Albani, C.; Schmidt, S. Teststatistische Prüfung Und Normierung Der Deutschen Versionen Des EUROHIS-QOL Lebensqualität-Index Und Des WHO-5 Wohlbefindens-Index. Diagnostica 2007, 53, 83–96. [Google Scholar] [CrossRef]
- Allgaier, A.K.; Pietsch, K.; Frühe, B.; Prast, E.; Sigl-Glöckner, J.; Schulte-Körne, G. Depression in Pediatric Care: Is the WHO-Five Well-Being Index a Valid Screening Instrument for Children and Adolescents? Gen. Hosp. Psychiatry 2012, 34, 234–241. [Google Scholar] [CrossRef]
- Spitzer, R.L.; Kroenke, K.; Williams, J.B.W. Validation and Utility of a Self-Report Version of PRIME-MD: The PHQ Primary Care Study. J. Am. Med. Assoc. 1999, 282, 1737–1744. [Google Scholar] [CrossRef] [Green Version]
- Allgaier, A.K.; Pietsch, K.; Frühe, B.; Sigl-Glöckner, J.; Schulte-Körne, G. Screening for Depression in Adolescents: Validity of the Patient Health Questionnaire in Pediatric Care. Depress. Anxiety 2012, 29, 906–913. [Google Scholar] [CrossRef]
- Richardson, L.P.; McCauley, E.; Grossman, D.C.; McCarty, C.A.; Richards, J.; Russo, J.E.; Rockhill, C.; Katon, W. Evaluation of the Patient Health Questionnaire-9 Item for Detecting Major Depression among Adolescents. Pediatrics 2010, 126, 1117–1123. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Rossom, R.C.; Coleman, K.J.; Ahmedani, B.K.; Beck, A.; Johnson, E.; Oliver, M.; Simon, G.E. Suicidal Ideation Reported on the PHQ9 and Risk of Suicidal Behavior across Age Groups. J. Affect. Disord. 2017, 215, 77–84. [Google Scholar] [CrossRef]
- Löwe, B.; Decker, O.; Müller, S.; Brähler, E.; Schellberg, D.; Herzog, W.; Herzberg, P.Y. Validation and Standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the General Population. Med. Care 2008, 46, 266–274. [Google Scholar] [CrossRef] [PubMed]
- Mossman, S.A.; Luft, M.J.; Schroeder, H.K.; Varney, S.T.; Fleck, D.E.; Barzman, D.H.; Gilman, R.; DelBello, M.P.; Strawn, J.R. The Generalized Anxiety Disorder 7-Item Scale in Adolescents with Generalized Anxiety Disorder: Signal Detection and Validation. Ann. Clin. Psychiatry 2017, 29, 227–234. [Google Scholar] [PubMed]
- Gerber, M.; Lang, C.; Lemola, S.; Colledge, F.; Kalak, N.; Holsboer-Trachsler, E.; Pühse, U.; Brand, S. Validation of the German Version of the Insomnia Severity Index in Adolescents, Young Adults and Adult Workers: Results from Three Cross-Sectional Studies. BMC Psychiatry 2016, 16, 174. [Google Scholar] [CrossRef] [Green Version]
- Morin, C.M.; Belleville, G.; Bélanger, L.; Ivers, H. The Insomnia Severity Index: Psychometric Indicators to Detect Insomnia Cases and Evaluate Treatment Response. Sleep 2011, 34, 601–608. [Google Scholar] [CrossRef] [Green Version]
- Cohen, S.; Kamarck, T.; Mermelstein, R. A Global Measure of Perceived Stress. J. Health Soc. Behav. 1983, 24, 385–396. [Google Scholar] [CrossRef]
- Klein, E.M.; Brähler, E.; Dreier, M.; Reinecke, L.; Müller, K.W.; Schmutzer, G.; Wölfling, K.; Beutel, M.E. The German Version of the Perceived Stress Scale—Psychometric Characteristics in a Representative German Community Sample. BMC Psychiatry 2016, 16, 159. [Google Scholar] [CrossRef] [Green Version]
- Richter, F.; Strauss, B.; Braehler, E.; Altmann, U.; Berger, U. Psychometric Properties of a Short Version of the Eating Attitudes Test (EAT-8) in a German Representative Sample. Eat. Behav. 2016, 21, 198–204. [Google Scholar] [CrossRef]
- R Core Team. R: A Language and Environment for Statistical Computing; R Foundation for Statistical Computing: Vienna, Austria, 2020. [Google Scholar]
- Ho, D.E.; Imai, K.; King, G.; Stuart, E.A. MatchIt: Nonparametric Preprocessing for Parametric Causal Inference. J. Stat. Softw. 2011, 42. [Google Scholar] [CrossRef] [Green Version]
- IBM. IBM SPSS Statistics for Windows, Version 26.0; IBM: Armonk, NY, USA, 2020. [Google Scholar]
- Ravens-Sieberer, U.; Kaman, A.; Erhart, M.; Devine, J.; Schlack, R.; Otto, C. Impact of the COVID-19 Pandemic on Quality of Life and Mental Health in Children and Adolescents in Germany. Eur. Child Adolesc. Psychiatry 2021, 1–11. [Google Scholar] [CrossRef] [PubMed]
- Naumann, E.; von den Driesch, E.; Schumann, A.; Thönnissen, C. Increase of depressive symptoms among adolescents during the first COVID-19 lockdown in Germany: Results from the German family panel pairfam. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021, 64, 1533–1540. [Google Scholar] [CrossRef] [PubMed]
- Kaess, M.; Schnyder, N.; Michel, C.; Brunner, R.; Carli, V.; Sarchiapone, M.; Hoven, C.W.; Wasserman, C.; Apter, A.; Balazs, J.; et al. Twelve-Month Service Use, Suicidality and Mental Health Problems of European Adolescents after a School-Based Screening for Current Suicidality. Eur. Child Adolesc. Psychiatry 2020, 1–10. [Google Scholar] [CrossRef] [PubMed]
- Ammerman, B.A.; Burke, T.A.; Jacobucci, R.; McClure, K. Preliminary Investigation of the Association between COVID-19 and Suicidal Thoughts and Behaviors in the U.S. J. Psychiatr. Res. 2021, 134, 32–38. [Google Scholar] [CrossRef] [PubMed]
- Brettschneider, A.-K.; Hölling, H.; Schlack, R.; Ellert, U. Psychische Gesundheit von Jugendlichen in Deutschland: Ein Vergleich nach Migrationshintergrund und Herkunftsland. Bundesgesundheitsblatt—Gesundh.—Gesundh. 2015, 58, 474–489. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Orben, A.; Tomova, L.; Blakemore, S.J. The Effects of Social Deprivation on Adolescent Development and Mental Health. Lancet Child Adolesc. Health 2020, 4, 634–640. [Google Scholar] [CrossRef]
- Knoll, L.J.; Magis-Weinberg, L.; Speekenbrink, M.; Blakemore, S.J. Social Influence on Risk Perception During Adolescence. Psychol. Sci. 2015, 26, 583–592. [Google Scholar] [CrossRef] [Green Version]
- Pfeifer, J.H.; Berkman, E.T. The Development of Self and Identity in Adolescence: Neural Evidence and Implications for a Value-Based Choice Perspective on Motivated Behavior. Child Dev. Perspect. 2018, 12, 158–164. [Google Scholar] [CrossRef] [PubMed]
- Van Harmelen, A.L.; Kievit, R.A.; Ioannidis, K.; Neufeld, S.; Jones, P.B.; Bullmore, E.; Dolan, R.; Fonagy, P.; Goodyer, I. Adolescent Friendships Predict Later Resilient Functioning across Psychosocial Domains in a Healthy Community Cohort. Psychol. Med. 2017, 47, 2312–2322. [Google Scholar] [CrossRef]
- Household Income. Available online: http://www.statistik.at/web_en/statistics/PeopleSociety/social_statistics/household_income/index.html (accessed on 14 May 2021).
- Frasquilho, D.; Matos, M.G.; Salonna, F.; Guerreiro, D.; Storti, C.C.; Gaspar, T.; Caldas-de-Almeida, J.M. Mental Health Outcomes in Times of Economic Recession: A Systematic Literature Review. BMC Public Health 2015, 16, 115. [Google Scholar] [CrossRef] [Green Version]
- Seven, Ü.S.; Stoll, M.; Dubbert, D.; Kohls, C.; Werner, P.; Kalbe, E. Perception, Attitudes, and Experiences Regarding Mental Health Problems and Web Based Mental Health Information Amongst Young People with and without Migration Background in Germany. A Qualitative Study. Int. J. Environ. Res. Public. Health 2020, 18, 81. [Google Scholar] [CrossRef] [PubMed]
- Klein, E.M.; Müller, K.W.; Wölfling, K.; Dreier, M.; Ernst, M.; Beutel, M.E. The Relationship between Acculturation and Mental Health of 1st Generation Immigrant Youth in a Representative School Survey: Does Gender Matter? Child Adolesc. Psychiatry Ment. Health 2020, 14, 29. [Google Scholar] [CrossRef] [PubMed]
Variable | Migration Background (N) | No Migration Background (N) |
---|---|---|
Total | 479 | 479 |
Gender | ||
Female | 333 | 342 |
Male | 142 | 134 |
Diverse | 4 | 3 |
Migration | ||
Parents born abroad | 312 | - |
Both parents and self born abroad | 133 | - |
Only self born abroad | 34 | - |
Age | ||
14 | 42 | 41 |
15 | 92 | 96 |
16 | 110 | 108 |
17 | 119 | 118 |
18 | 85 | 87 |
19–20 | 31 | 29 |
Region | ||
North-East (Vienna, Lower Austria, Upper Austria) | 296 | 293 |
South-East (Carinthia, Styria, Burgenland) | 65 | 69 |
West (Tyrol, Salzburg, Vorarlberg) | 118 | 117 |
School | ||
Middle school | 5 | 3 |
Polytechnical School | 2 | 2 |
Part-Time Vocational School and Apprenticeship (Dual Training) | 17 | 14 |
School for Intermediate Vocational Education | 19 | 19 |
College for Higher Vocational Education | 194 | 193 |
Academic secondary school | 242 | 247 |
Other | - | 1 |
Migration Background | No Migration Background | Statistics | ||
---|---|---|---|---|
PHQ-9 score | <11 | 157 (35.5) | 192 (43.5) | z(882) = 2.44 |
N (%) | ≥11 | 285 (64.5) | 249 (56.5) | p = 0.01 |
GAD-7 score | <11 | 210 (46.5) | 247 (54.0) | z(908) = 2.28 |
N (%) | ≥11 | 242 (53.5) | 210 (46.0) | p = 0.02 |
ISI score | <15 | 318 (68.1) | 376 (79.0) | z(942) = 3.77 |
N (%) | ≥15 | 149 (31.9) | 100 (21.0) | p < 0.001 |
EAT-8 score | <2/<3 | 167 (36.8) | 187 (40.5) | z(915) = 1.15 |
N (%) | ≥2/≥3 | 287 (63.2) | 275 (59.5) | p = 0.25 |
PSS-10 score | <27 | 262 (57.0) | 293 (62.9) | z(925) = 1.84 |
N (%) | ≥27 | 198 (43.0) | 173 (37.1) | p = 0.07 |
Migration Background | No Migration Background | Statistics | ||
---|---|---|---|---|
WHO-5 | M | 33.85 | 37.82 | t(955) = −3.0; p < 0.01 |
SD | 20.74 | 20.32 | ||
N | 479 | 479 | ||
PHQ-9 | M | 13.37 | 11.94 | t(880) = 3.22; p = 0.001 |
SD | (6.59) | (6.60) | ||
N | 442 | 441 | ||
GAD-7 | M | 11.04 | 10.34 | t(906) = 1.98; p = 0.048 |
SD | (5.29) | (5.25) | ||
N | 452 | 457 | ||
PSS-10 | M | 24.35 | 23.74 | t(923) = 1.29; p = 0.20 |
SD | (6.79) | (7.50) | ||
N | 460 | 466 | ||
ISI | M | 11.84 | 10.14 | t(940) = 4.72; p < 0.001 |
SD | (5.55) | (5.49) | ||
N | 467 | 476 | ||
EAT-8 | M | 3.53 | 3.49 | t(919) = 0.17; p = 0.86 |
SD | (2.62) | (2.70) | ||
N | 457 | 465 |
Migration Background | No Migration Background | Statistics | ||
---|---|---|---|---|
PHQ-9 score | <11 | 157 (35.4) | 1081 (46.8) | χ2(1;2752) = 19.82 |
N (%) | ≥11 | 287 (64.6) | 1227 (53.2) | p < 0.001 |
GAD-7 score | <11 | 211 (46.5) | 1284 (54.2) | χ 2(1;2821) = 9.23 |
N (%) | ≥11 | 243 (53.5) | 1083 (45.8) | p = 0.002 |
ISI score | <15 | 332 (68.0) | 1976 (79.0) | χ 2(1;2988) = 28.14 |
N (%) | ≥15 | 156 (32.0) | 524 (21.0) | p < 0.001 |
EAT-8 score | <2/<3 | 169 (36.7) | 991 (41.3) | χ 2(1;2862) = 3.42 |
N (%) | ≥2/≥3 | 292 (63.3) | 1410 (58.7) | p = 0.065 |
PSS-10 score | <27 | 266 (57.2) | 1564 (64.7) | χ 2(1;2881) = 9.54 |
N (%) | ≥27 | 199 (42.8) | 852 (35.3) | p = 0.002 |
Migration Background | No Migration Background | Statistics | ||
---|---|---|---|---|
WHO-5 | M | 33.86 | 38.62 | t(3047) = −4.71; p < 0.001 |
SD | (20.71) | (20.80) | ||
N | 507 | 2542 | ||
PHQ-9 | M | 11.39 | 11.61 | t(2750) = 5.22; p <.001 |
SD | (6.60) | (6.57) | ||
N | 444 | 2308 | ||
GAD-7 | M | 11.06 | 10.18 | t(2819) = 3.23; p < 0.001 |
SD | (5.30) | (5.26) | ||
N | 454 | 2367 | ||
PSS-10 | M | 24.34 | 23.34 | t(705.2) = 2.87; p = 0.004 |
SD | (6.80) | (7.59) | ||
N | 465 | 2416 | ||
ISI | M | 11.87 | 10.01 | t(2986) = 6.71; p < 0.001 |
SD | (5.53) | (5.62) | ||
N | 488 | 2500 | ||
EAT-8 | M | 3.51 | 3.35 | t(2860) = 1.217; p = 0.224 |
SD | (2.62) | (2.66) | ||
N | 461 | 2401 |
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Pieh, C.; Dale, R.; Jesser, A.; Probst, T.; Plener, P.L.; Humer, E. The Impact of Migration Status on Adolescents’ Mental Health during COVID-19. Healthcare 2022, 10, 176. https://doi.org/10.3390/healthcare10010176
Pieh C, Dale R, Jesser A, Probst T, Plener PL, Humer E. The Impact of Migration Status on Adolescents’ Mental Health during COVID-19. Healthcare. 2022; 10(1):176. https://doi.org/10.3390/healthcare10010176
Chicago/Turabian StylePieh, Christoph, Rachel Dale, Andrea Jesser, Thomas Probst, Paul L. Plener, and Elke Humer. 2022. "The Impact of Migration Status on Adolescents’ Mental Health during COVID-19" Healthcare 10, no. 1: 176. https://doi.org/10.3390/healthcare10010176
APA StylePieh, C., Dale, R., Jesser, A., Probst, T., Plener, P. L., & Humer, E. (2022). The Impact of Migration Status on Adolescents’ Mental Health during COVID-19. Healthcare, 10(1), 176. https://doi.org/10.3390/healthcare10010176