# Social Determinants of Immigrant Women’s Mental Health

Authors: Mahin Delara
Journal: Advances in Public Health
 (2016)

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## Abstract

Migration is a population movement with enormous challenges for immigrant women that influence their mental health. Mental health is a social issue and its determinants need to be recognized for health policy making. This paper reviews and consolidates findings from the existing literature on social determinants of immigrant women’s mental health within a socioecological framework. Findings of this review revealed that mental health of immigrant women is an outcome of several interacting determinants at social, cultural, and health care system levels and hence calls for many different ways to promote it. Recommendations for mental health promotion of immigrant women with respect to research, education, practice, and policy are explored.


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## Body

## 1. Introduction

Migration is a process of population movement either across an international border or within a country [1]. Globally, five to ten million people cross an international border yearly to take up residence in a different country with a higher percentage of women than men [2, 3]. People migrate for different reasons but women usually have their own motives including family reunification, economic incentives, and educational opportunities, as well as escaping from gender-based discrimination and/or political violence and gaining more social independence [4]. While there are many benefits of immigration, living in a new society presents enormous challenges for immigrant and refugee women and migration may not necessarily make these women’s status better within or outside home. They have to navigate social systems, government bureaucracy, new cultures, and languages [5]. Besides having to establish themselves, they also have to meet the basic necessities of life such as employment, housing, food, and shelter. Even after the initial resettlement period, they continue to encounter various challenges in their adopted country. Moreover, the process of immigration might be dehumanizing [6]. All these circumstances of immigration can influence women’s health in general and their mental health in particular [5].Upon arrival, most immigrants are generally in better health than their native-born counterparts [2, 7]. This healthy immigrant effect has been associated with factors related to immigration selection criteria such as rigorous health screening and the immigration process itself which indicates that healthier people tend to move more than those with a poor health status [3]. However, this healthy immigrant effect appears to diminish over a period of time and the longer the immigrants live in the host country, the worse their health status becomes [8–10].The pattern of immigrants’ mental well-being seems to differ from a healthy immigrant effect. According to disillusionment model, immigrants’ psychological adaptation has predictable phases [11, 12]. During the first phase, called euphoria of arrival, the mental health of immigrants is equal or even better than that of host population. In the second phase, which is disillusionment and nostalgia for the past, immigrants’ mental health deteriorates and finally adaptation takes place and immigrants’ mental health approximates to that of native born. However, there is a decline in both mental health and physical health of immigrants overtime. This decline has been attributed to many factors including socioeconomic status, financial and employment constrains, resettlement and acculturation challenges, multiple responsibilities, discriminatory treatment, and difficulty obtaining services in a timely manner due to language differences [2, 9, 13–15]. As a result, immigrant women’s mental health can be influenced by a range of factors both within and outside their control. Accordingly, this review is aimed at examining the research evidence to identify the most pertinent factors that contribute to mental health status of international immigrant women who migrate to another country with different cultures from their country of origin irrespective of their reason and legal state for migration or preimmigration experiences. These factors refer to social determinants of mental health that is defined by Canadian Mental Health Association [16] as life experiences, workplace, or other environments and the social and economic conditions that shape people’s lives and influence their mental health. Meanwhile this review has based its theoretical foundation on a socioecological perspective. Socioecological approach focuses on the interaction between individuals and their environment and its core concept is that behavior has multiple layers and levels of influence [17, 18]. Embedded in socioecological perspective, diverse health determinants models have been proposed by scholars like Evans and Stoddart [19]; Dahlgren and Whitehead [20]; Hertzman et al. [21]; Najman [22]; Brunner and Marmot [23] and commission on social determinants of health [24] that all can be applicable for this review but none is specifically designed for female immigrants’ mental health. For the purpose of this review, we discuss social determinants of mental health within a socioecological approach that acknowledges the interaction between and among various levels of determinants. We further emphasize that mental health outcomes in immigrant women may be attributed to factors from more than one level of the model.


## 2. Social Determinants

Three significant determinants of mental health have been identified in the literature as social connectedness, freedom from discrimination and violence, and economic participation [25]. In the case of immigrant women, these determinants may be more complex as their premigration experiences can intersect with the postmigration determinants to affect their mental health status [26]. However, irrespective of home-country circumstances, there are common factors that immigrants face following migration that influence their mental well-being. These postimmigration factors can be examined at different levels of cultural, social, and health care system influences. These levels can also intersect and interact with each other as depicted in Figure 1.Figure 1
Female immigrants’ social determinants of mental health.Notably, migration itself is a social determinant of mental health that can influence and be influenced by other determinants. In fact, being a migrant makes women more vulnerable to positive or negative mental effects of migration [2]. These effects depend on variables such as the mode of travel, legal status of the migrant, and the stage of the migration cycle [2]. In particular, the migration process can affect access to health care services especially for those with illegal status that have experienced unsuccessful journeys multiple times.Migration also influences women’s mental well-being through exposing them to sexual exploitation. Women, who migrate through clandestine means or fall into the hands of traffickers, may end up in sexual abuse and exploitative situations which can have a negative impact on their mental health [2]. Research also shows that some aspects of the immigration process may be dehumanizing and particularly stressful [27]. For instance, asking repetitive questions about immigrants’ victimization may precipitate mental disorders such as depression, anxiety, and PTSD because of reminding traumatizing experiences [3]. Examples also include completing documents to settle as a landed immigrant in Canada which requires additional expenses that are not covered by welfare [28]. When immigrant women intend to save enough money to cover these expenses, they raise suspicion and become accused of fraud which is a significant source of stress, anxiety, and despair [29].Another aspect of migration process which may influence mental health is related to the age of immigrants at the time of migration but this impact from a life stage perspective has not been well studied. However, in one study immigrant children’s health status irrespective of their gender was reported to be almost the same as their native-born counterparts [7]. In another study on female refugee youth, Khanlou and Guruge [30] found that this age group face specific resettlement challenges due to traumatic premigration contexts and postmigration identity crisis that make them vulnerable for negative mental health outcomes. Racism is also a bigger challenge for female youth immigrants since they have to deal with peer group pressure for adjusting into new culture and at the same time respond to their family cultural expectations [31]. There is also some evidence that old immigrant women experience specific problems with isolation, abuse, language, culture, and mobility [7, 32, 33]. More research is warranted in this area.


### 2.1. Cultural Levels

Grob [34] defines culture as a common heritage or set of beliefs, norms, and values shared by one group. He further argues that cultural groups can be described in a variety of ways by ethnicity, religion, geographic region, age group, sexual orientation, or profession. Accordingly, individuals can have multiple cultural identities. In the case of immigrant women, the literature suggests various pathways that cultural identities can shape these women’s responses to mental health and illness. First, culture can influence immigrant women’s access to the health care system by influencing their perceptions and interpretations of symptoms, help-seeking behavior, decision-making, expectations of the sick role, and coping style and communication with health providers [35]. Second, culture determines how much stigma immigrant women attach to mental illness [36]. Third, culture can prescribe acceptable norms for behaviors associated with gender role. As discussed by Adler et al. [35], the engagement of women in employment outside the home, the circumstances under which care giving is undertaken, and the reaction to domestic violence are some manifestations of the influential role of cultural norms. Finally culture can influence the acculturation process of immigrant women [17].Acculturation occurs when groups of individuals with different cultures come into continuous first hand contact with subsequent changes in the original culture patterns of either or both groups [37, 38]. Acculturation is premised on the existence of ethnic, cultural, and national identities [9] and entails both cultural and psychological changes in individuals following intercultural contact [39]. Acculturation strategies include integration, assimilation, separation, marginalization, and enculturation [40, 41]. Studies have linked the lack of acculturation with poor health among immigrants but this association is much stronger in integration and assimilation strategies compared to other acculturation strategies [42, 43].   Alegria et al. [44] argue that this association is moderated by contextual factors such as immigration experience and structural factors such as historic racism. In their studies on Chinese immigrants’ integration into the communities in England, Green et al. [45] found that these individuals were more affected by lack of social support than their native-born counterparts and frequently reported worries about harassment. In a similar vein, Oppedal et al. [46] stated that immigrant youth when adjusting with new life in Norway were particularly vulnerable to self-perceived discrimination and an ethnic identity crisis, especially when they lacked social support. Accordingly Berry [47] argues that ability to balance a sense of ethnic identity with adaptation into the new society can lead to positive mental health. Following the findings of aforementioned studies, it seems that cultural influence on immigrant women’s mental health through acculturation process is interwoven with factors such as immigration experience, racism, social support, discrimination, and ethnic identity.


### 2.2. Social Levels

#### 2.2.1. Social Connections

There is a large body of evidence that social networks and connections have powerful effects on mental health of immigrant women [7, 35, 48–50]. According to Berman et al. [31], social networks are defined by their structures (number of ties and proximity of ties) and functions (frequency of contact and reciprocity) and their impact on mental health can be explained through three primary mechanisms of social support; social influence; and social integration.


#### 2.2.2. Social Support

Social network ties affect mental health most clearly via the provision of various kinds of support including emotional, instrumental, appraisal, and informational [51]. Social support refers to the cognitive appraisal of being connected to others and knowing that support is there if needed [52]. According to Lynam [53], immigrant women tend to rely on three types of social support including family, peer, and outsiders. First and foremost, they rely on their extended family members to meet their settlement related needs and consider this support as the most crucial, powerful, and protective factor for their mental health status [7, 17]. The second source of social support is peer or insiders who are immigrant women’s close, ethnically similar community members whom women expect to understand their needs because of sharing a common culture. Third in the social support line is outsiders which is a social network outside their family and ethnic community [53].Whatever the social support immigrant women receive, they uniformly can influence mental well-being via some psychological pathways. For instance, self-efficacy which is defined as individuals’ belief and confidence in their ability to perform specific behaviors [54] has been linked to social support and a variety of health outcomes like depression [50]. Some evidence also suggests that social support enhances coping styles in the sense that the tendency to seek social support per se is a coping style [55–57]. In addition, some studies have revealed that social support operates through its influence on emotion, mood, self-esteem, and perceived well-being and also contributes to this perception that the individuals can control their own destiny [50, 58].


#### 2.2.3. Social Influence

Social networks may affect immigrant women’s mental health via another pathway which is based on social influence. When two persons in a social network contact each other, an interpersonal influence occurs between them [50]. This influence does not originate necessary from a face-to-face contact and does not require deliberate or conscious attempts to modify behavior [59]. This interaction provides individuals with normative guidance by comparing their attitudes with those of a reference group similar to others [60]. As a result, shared attitudes can be confirmed, reinforced, or altered when there is discrepancy [59]. These shared norms and behavioral patterns such as mental health care utilization or treatment adherence can be considered as powerful resources to influence the mental health behaviors of immigrant women as members of their social network.


#### 2.2.4. Social Integration

The third path that social networks may influence mental health status of immigrant women is by promoting social integration which refers to the “involvement with ties spanning the range from intimate to extend” [50]. Through this involvement, social networks provide a basis for intimacy and attachment which has meaning both for intimate and for more extended ties. Thus, when social relationships are strong, individuals feel powerful bonds and attachments to places such as neighborhood and voluntary or religious organizations [50]. Social integration can also engage immigrant women in a variety of meaningful social roles including parental, familial, occupational, and community roles. Through opportunities for engagement, social networks can enhance these social roles which in turn supply a coherent and consistent sense of identity, value, belonging, and attachment [50]. There is some evidence that possessing multiple social roles promotes self-esteem and self-worth which in turn reinforces adaptation to stressful life events and prevents depression [61–63]. In addition, social integration provides opportunities for companionship and sociability [50]. In this sense, social ties give meaning to immigrant women’s life by providing them with full participation and attachment to their community and an obligation to be even a supporter for others. In line with this assumption, the term “social inclusion” can be used interchangeably which is described by Omidvar and Richmond [64] as the notion that immigrant women can participate fully and equally in all social economic and political aspects of life in new country. Evidence suggests that some factors such as discrimination can hinder immigrant women to be integrated and included in the new society and consequently make them socially excluded [3]. Finally, lack of social network that manifests itself as lack of social support, social influence, or social exclusion is a significant determinant of immigrant women’s mental health.


#### 2.2.5. Social Position

Women’s social position is shaped by various factors including age, gender role, race, ethnic identity, and marital and socioeconomic status (SES) [35, 65]. Accordingly, disadvantaged social positions or discrimination is defined as actions taken to exclude or treat immigrant women differently because of their race, ethnicity, gender, and socioeconomic position [16]. Discrimination as a determinant of mental health and a source of stress has been linked to many psychological symptoms and subsequent service utilization among immigrant women [7, 25, 66, 67]. The literature suggests material and psychosocial pathways for the impact of discrimination on mental health. Material factors are related to SES in terms of barriers to employment education and housing [68]. Psychological factors that have been proposed in some studies include disempowerment, low self-esteem, perceived control, and the weathering effect which has resulted from years of cumulative stress due to discrimination and socioeconomic marginalization [26, 66, 69–72]. Beiser and Hou [73] suggest another psychological factor that experiences of discrimination serve as reminders of marginalized status for ethnic minorities. However, the association between discrimination and mental health is generally segregated based on the type of discrimination that is discussed here.


#### 2.2.6. Gender Discrimination

In most societies, women are assigned subordinate positions to men and experience systematic discrimination in access to power, prestige, and resources [24]. In case of immigrant women, in particular, they experience more gender discrimination as they work in informal and different sectors than men and occupy lower professional ranks and lower wage jobs [5]. As a result they experience differential employment conditions and work related mental health risks. In addition, some legislation in host societies is gender based. For instance, the Canadian immigration citizenship, through family class classification, places the newly sponsored immigrant woman in a dependent position in relation to the labor force, government benefits, and services [74]. Meanwhile, individuals in different social contexts have different perceptions and experiences of gender role as illustrated by Anderson [75] that the majority of immigrant women perceive household duties as a woman’s responsibility. While Alvi et al. [48] argue that patriarchal attitudes can be seen in both immigrant and nonimmigrant cultures, Yoshioka et al. [76] stated that these ideas are more common among immigrant women with mental health problems. Research also shows that gender hierarchy and male domination affect women’s timely access to mental health services by situating them in a socially vulnerable and dependent situation [17]. Therefore, gender can configure both the position of women in the social hierarchy and their perceptions and experiences that shape their lives. Accordingly, WHO [67] conceptualize gender as a powerful structural determinant of mental health that interacts with other determinants including age, family structure, education, occupation, income, and social support. With respect to gender differences in mental health outcomes such as depression and anxiety, gender has explanatory power and must be viewed as a determinant of mental health.


#### 2.2.7. Racism

Race is used as a social marker to assign people into groups [77]. Accordingly Collins and Guruge [78] define racism as “actions of individuals and/or groups that exclude people from resources and privileges on the basis of race” (p. 25). Substantial literature shows that race and gender discrimination are major inhibitors of radicalized immigrant women to attain economic and social inclusion [5]. For instance, high rates of underemployment, unemployment, and poverty have been reported in Canadian immigrants. Radicalized minority immigrants also experience wage discrimination in labor market and many adverse living conditions that threaten their health as well as the overall health of the host society [5]. Nevertheless, immigrant women may experience three forms of racism that have influential effect on their mental health. First one is institutionalized racism which is related to the structures of society and may be systematized in institutions of practice, law, and governmental inaction when necessary such as unequal access to mental health care resources [74]. Another form of racism is personally mediated which refers to prejudice and discrimination and can be recognized as lack of respect, suspicion, devaluation, and dehumanization [79]. Examples include negative attitudes or behaviors shown by the health professionals due to cultural diversity and misunderstandings in communication [80]. The third form is internalized racism which occurs when immigrant women accept and internalize stigmatized messages about their abilities and lack of worth. However, studies have revealed that experiencing any form of racism can lead to resignation, helplessness, and lack of hope which in turn deteriorate immigrant women’s mental well-being [74, 79, 81].


#### 2.2.8. Socioeconomic Status

Socioeconomic status (SES) may pose social limitation for immigrant women. SES, which is measured by a person’s income, education, and occupation, determines a person’s behavior and life conditions which in turn can induce higher or lower prevalence of mental health problems such as depression, anxiety, low self-esteem, and anger [35, 82, 83]. The impact of SES on immigrant women’s mental well-being can be explained through material, psychosocial, and behavioral pathways.Material factors are related to economic hardship and health-damaging conditions in the physical environment such as housing, neighborhood, and physical working conditions. Research indicates that low socioeconomic status provides poor housing conditions in a sense that households of the lower income groups suffer much more frequently from dampness, mold, and crowding than households with higher incomes [2, 24]. In addition, crowding, where less than one room is available per person, influences mental well-being through its association with noise disturbance, low indoor air quality, a higher frequency of accidents, and lack of privacy [84]. There is also some evidence that socioeconomic status manifested itself as lack of finances and influenced immigrant women’s help-seeking behavior, access to health resources, quality of care, and health literacy [35, 48, 83].SES can also affect immigrant women’s mental health through behavioral pathway. Poor women choose unhealthy behaviors such as overeating, alcohol consumption, and smoking to cope with their daily difficult lives instead of expressing anxiety and frustration with limited financial resources [35]. These unhealthy behaviors make them more vulnerable to mental ill health [83].The psychological mechanism underlying the association between mental health and women’s economic status becomes clearer when adopting a broad definition of poverty and wealth, which encompasses the need for empowerment, freedom, and autonomy over the circumstances determining immigrant women’s life and health [85]. Research indicates that migrants often do not possess the autonomy over conditions that lead their life based on their social and cultural norms [2]. Besides financial constraints, poor immigrant women also have to struggle with shame, stress, depression, hopelessness, alienation, and despair as consequences of both being stigmatized and stereotyped and living in material deprivation [28].Other relevant psychosocial factors are linked to stressful living circumstances and lack of social support. Studies have shown that at work and at home those, who have less education, lower income, and jobs with less prestige and power, have more stressors and fewer resources for coping [86, 87].Socioeconomic disadvantage is also related to un/underemployment [66, 82, 88–90]. Because of foreign status or lack of training, immigrant women often work in part time, temporary, or contract jobs such as domestic servants or low-wage workers in informal sectors that are considered as nonstandard employments with low financial security and sometimes without any health insurance [83]. All these working conditions are considered as low status and demeaning with little opportunity for advancement which in turn sets the stage for mentally ill health. Women with illegal documents are more likely to be exploited and are often forced to accept bad working conditions since they are afraid of being deported if they ask for better [2]. Furthermore, immigrant women who are paid by the hour or by piece of work are unwilling to seek health care during working hours as they find that missing work will reduce their income [2].


#### 2.2.9. Victimization

Immigrant women may experience discrimination due to their vulnerability for victimization for a variety of reasons including cultural and religious world views emphasizing female obedience, male privilege, an ethos of nondisclosure for fear of bringing shame on the family, lack of understanding of laws in the host country, lack of financial and other resources, low levels of community and individual support, and the absence of appropriate services [48, 91–95]. Additionally many immigrant women particularly domestic workers and trafficked persons are at increased risk of sexual abuse, violence, and exploitation due to the invisible nature of their work [2]. Victimization in turn is related to wide-ranging mental outcomes including anxiety, depression, suicidal ideation, and alcohol or drug abuse [35, 48]. The impact of victimization on mental health may be more profound in the case of abused immigrant women who encounter major reproductive health problems such as sexually transmitted diseases, unwanted pregnancies, and unsafe abortions [96, 97].


### 2.3. Community and Health Systems Levels

Access to community and health care services as a determinant of mental health has been overlooked in immigrant women [3]. Evidence indicates that immigrant women face many barriers to seek government services, social assistance, shelters, and police and support services [28]. They also have less access to mental health services, and if they receive care, it is more likely to be poor in quality [17, 34]. This access is strongly determined by immigrant’s legal status, as undocumented migrants have the least access to social and health care services. In fact, many social and health services may be available to assist immigrant women but these women may experience barriers in accessing such services. In addition to accessibility, services may not be acceptable by immigrant women [2]. This availability, accessibility, acceptability, and quality of services depend on several barriers as follows.


#### 2.3.1. Communication Barriers

When seeking social and medical help, immigrant women usually face many communication barriers such as language differences [17, 48]. Lack of language skills limits social interaction and the ability to develop relationships within social and health care system [35]. It is also a major obstacle to both expressing their social and mental health needs and understanding bureaucratic procedures and the functioning of services [2]. In addition, professional interpreter services are not available in some settings and if available, their presence may not be acceptable particularly by female refugees. Ortiz et al. [28] illustrate that refugee women may experience fear and shame about disclosing their personal histories especially sexual abuse when the interpreter is male and/or a member of their community. They fear that their traumatic story become fodder for gossip within the community. They also fear that the interpreter (whether male or female) as a member of their community may contact authorities or groups back in their home country and jeopardize their immigration status [28].


#### 2.3.2. Psychological Barriers

Evidence suggests some psychological factors which delay social and mental help seeking in immigrant women. These barriers include insufficient mental health information; unfamiliarity with and mistrust of biomedical treatments; and fear of stigmatization and its consequences such as deportation and social isolation [17, 34]. These cognitive and perceptual barriers to some extent are embedded in lack of cultural acceptance and cultural differences between immigrant women and the social and health care system [17, 36]. In addition, immigrants may not perceive themselves as being in need of psychological and social assistance [2]. For instance, Green et al. [45] in a study on Chinese migrant women found that the idea of “mental illness” sometimes equated with “psychosis” which in turn inhibited these individuals to seek help for mental health problems. Immigrant women particularly refugees may have another perceptional barrier which is related to the fear that seeking social and health services could have a negative impact on their immigration application [28]. They believe that expressing any mental symptoms or reliance on social and health care services would be a mark against their application. This is especially problematic for women who are in abusive relationship. Research also has shown that immigrant women’s personality and the level of self-acceptance of the illness determine their willingness to take care of themselves and reach out for help [17].


#### 2.3.3. Social Barriers

Literature suggests that migrants are vulnerable to stigmatization and xenophobia [2]. Negative attitudes (prejudice) and negative behavior (discrimination) towards individuals with mental health problems may prevent immigrant women from seeking help or taking psychotropic medication [28]. In addition, immigrant women may express their physical symptoms such as headaches and fatigue instead of depression because they may find physical problems as more socially acceptable [28]. These factors can interact with social inequalities and can both influence and be influenced by social exclusion which has also been recognized as a social determinant of health [98].


#### 2.3.4. Spirituality and Religious Barriers

Immigrant women may underuse social and health services due to spiritual and religious barriers. Research in ethnically diverse populations has shown that spirituality is a frame of reference for immigrant women and can affect their decision to seek or avoid professional help [7, 34]. In another study by Donnelly et al. [17], religious beliefs discouraged and deterred immigrant women from using biomedical treatments and forced them to seek help from ethnic group leaders and informal support systems.


#### 2.3.5. Structural Barriers

Social and health system structure may also disable immigrant women from accessing or benefitting from available social and mental health counseling services. For instance, immigrant women may have to navigate bureaucratic hurdles, complete many application forms, or reach various agencies that may not be in close geographical proximity [99, 100]. Other structural barriers may include unequal power relationships between client and service provider, lack of confidentiality, fragmentation of services, and lack of professional translation and interpretation services in social and the health care system [34, 35, 101]. Lack of appropriate and culturally competent and sensitive services that suit immigrant women’s needs are other structural barriers which influence immigrant women’s well-being [17].


#### 2.3.6. Economic Barriers

Poverty and financial difficulties have been identified as barriers to access the social and mental health care services [49]. Costs of care can lead to a lower use of services in immigrant women particularly in those who are uninsured or underinsured or are in a lower income bracket [34, 35]. As a result, these women would be reluctant to visit doctors and receive proper treatment for their mental health issues [35].


#### 2.3.7. Cultural Barriers

Studies show that culture is a particular barrier for women migrants who adhere to traditional norms and have limited contacts outside their communities. As discussed earlier, culture has a powerful influence on these women’s access to health care system through different pathways. Cultural norms may also hinder women to accept care from male practitioners [49]. Lack of cultural acceptance and cultural differences between immigrant women and service providers are additional barriers specific to immigrant women [17, 36, 48].


## 2.1. Cultural Levels

Grob [34] defines culture as a common heritage or set of beliefs, norms, and values shared by one group. He further argues that cultural groups can be described in a variety of ways by ethnicity, religion, geographic region, age group, sexual orientation, or profession. Accordingly, individuals can have multiple cultural identities. In the case of immigrant women, the literature suggests various pathways that cultural identities can shape these women’s responses to mental health and illness. First, culture can influence immigrant women’s access to the health care system by influencing their perceptions and interpretations of symptoms, help-seeking behavior, decision-making, expectations of the sick role, and coping style and communication with health providers [35]. Second, culture determines how much stigma immigrant women attach to mental illness [36]. Third, culture can prescribe acceptable norms for behaviors associated with gender role. As discussed by Adler et al. [35], the engagement of women in employment outside the home, the circumstances under which care giving is undertaken, and the reaction to domestic violence are some manifestations of the influential role of cultural norms. Finally culture can influence the acculturation process of immigrant women [17].Acculturation occurs when groups of individuals with different cultures come into continuous first hand contact with subsequent changes in the original culture patterns of either or both groups [37, 38]. Acculturation is premised on the existence of ethnic, cultural, and national identities [9] and entails both cultural and psychological changes in individuals following intercultural contact [39]. Acculturation strategies include integration, assimilation, separation, marginalization, and enculturation [40, 41]. Studies have linked the lack of acculturation with poor health among immigrants but this association is much stronger in integration and assimilation strategies compared to other acculturation strategies [42, 43].   Alegria et al. [44] argue that this association is moderated by contextual factors such as immigration experience and structural factors such as historic racism. In their studies on Chinese immigrants’ integration into the communities in England, Green et al. [45] found that these individuals were more affected by lack of social support than their native-born counterparts and frequently reported worries about harassment. In a similar vein, Oppedal et al. [46] stated that immigrant youth when adjusting with new life in Norway were particularly vulnerable to self-perceived discrimination and an ethnic identity crisis, especially when they lacked social support. Accordingly Berry [47] argues that ability to balance a sense of ethnic identity with adaptation into the new society can lead to positive mental health. Following the findings of aforementioned studies, it seems that cultural influence on immigrant women’s mental health through acculturation process is interwoven with factors such as immigration experience, racism, social support, discrimination, and ethnic identity.


## 2.2. Social Levels

### 2.2.1. Social Connections

There is a large body of evidence that social networks and connections have powerful effects on mental health of immigrant women [7, 35, 48–50]. According to Berman et al. [31], social networks are defined by their structures (number of ties and proximity of ties) and functions (frequency of contact and reciprocity) and their impact on mental health can be explained through three primary mechanisms of social support; social influence; and social integration.


### 2.2.2. Social Support

Social network ties affect mental health most clearly via the provision of various kinds of support including emotional, instrumental, appraisal, and informational [51]. Social support refers to the cognitive appraisal of being connected to others and knowing that support is there if needed [52]. According to Lynam [53], immigrant women tend to rely on three types of social support including family, peer, and outsiders. First and foremost, they rely on their extended family members to meet their settlement related needs and consider this support as the most crucial, powerful, and protective factor for their mental health status [7, 17]. The second source of social support is peer or insiders who are immigrant women’s close, ethnically similar community members whom women expect to understand their needs because of sharing a common culture. Third in the social support line is outsiders which is a social network outside their family and ethnic community [53].Whatever the social support immigrant women receive, they uniformly can influence mental well-being via some psychological pathways. For instance, self-efficacy which is defined as individuals’ belief and confidence in their ability to perform specific behaviors [54] has been linked to social support and a variety of health outcomes like depression [50]. Some evidence also suggests that social support enhances coping styles in the sense that the tendency to seek social support per se is a coping style [55–57]. In addition, some studies have revealed that social support operates through its influence on emotion, mood, self-esteem, and perceived well-being and also contributes to this perception that the individuals can control their own destiny [50, 58].


### 2.2.3. Social Influence

Social networks may affect immigrant women’s mental health via another pathway which is based on social influence. When two persons in a social network contact each other, an interpersonal influence occurs between them [50]. This influence does not originate necessary from a face-to-face contact and does not require deliberate or conscious attempts to modify behavior [59]. This interaction provides individuals with normative guidance by comparing their attitudes with those of a reference group similar to others [60]. As a result, shared attitudes can be confirmed, reinforced, or altered when there is discrepancy [59]. These shared norms and behavioral patterns such as mental health care utilization or treatment adherence can be considered as powerful resources to influence the mental health behaviors of immigrant women as members of their social network.


### 2.2.4. Social Integration

The third path that social networks may influence mental health status of immigrant women is by promoting social integration which refers to the “involvement with ties spanning the range from intimate to extend” [50]. Through this involvement, social networks provide a basis for intimacy and attachment which has meaning both for intimate and for more extended ties. Thus, when social relationships are strong, individuals feel powerful bonds and attachments to places such as neighborhood and voluntary or religious organizations [50]. Social integration can also engage immigrant women in a variety of meaningful social roles including parental, familial, occupational, and community roles. Through opportunities for engagement, social networks can enhance these social roles which in turn supply a coherent and consistent sense of identity, value, belonging, and attachment [50]. There is some evidence that possessing multiple social roles promotes self-esteem and self-worth which in turn reinforces adaptation to stressful life events and prevents depression [61–63]. In addition, social integration provides opportunities for companionship and sociability [50]. In this sense, social ties give meaning to immigrant women’s life by providing them with full participation and attachment to their community and an obligation to be even a supporter for others. In line with this assumption, the term “social inclusion” can be used interchangeably which is described by Omidvar and Richmond [64] as the notion that immigrant women can participate fully and equally in all social economic and political aspects of life in new country. Evidence suggests that some factors such as discrimination can hinder immigrant women to be integrated and included in the new society and consequently make them socially excluded [3]. Finally, lack of social network that manifests itself as lack of social support, social influence, or social exclusion is a significant determinant of immigrant women’s mental health.


### 2.2.5. Social Position

Women’s social position is shaped by various factors including age, gender role, race, ethnic identity, and marital and socioeconomic status (SES) [35, 65]. Accordingly, disadvantaged social positions or discrimination is defined as actions taken to exclude or treat immigrant women differently because of their race, ethnicity, gender, and socioeconomic position [16]. Discrimination as a determinant of mental health and a source of stress has been linked to many psychological symptoms and subsequent service utilization among immigrant women [7, 25, 66, 67]. The literature suggests material and psychosocial pathways for the impact of discrimination on mental health. Material factors are related to SES in terms of barriers to employment education and housing [68]. Psychological factors that have been proposed in some studies include disempowerment, low self-esteem, perceived control, and the weathering effect which has resulted from years of cumulative stress due to discrimination and socioeconomic marginalization [26, 66, 69–72]. Beiser and Hou [73] suggest another psychological factor that experiences of discrimination serve as reminders of marginalized status for ethnic minorities. However, the association between discrimination and mental health is generally segregated based on the type of discrimination that is discussed here.


### 2.2.6. Gender Discrimination

In most societies, women are assigned subordinate positions to men and experience systematic discrimination in access to power, prestige, and resources [24]. In case of immigrant women, in particular, they experience more gender discrimination as they work in informal and different sectors than men and occupy lower professional ranks and lower wage jobs [5]. As a result they experience differential employment conditions and work related mental health risks. In addition, some legislation in host societies is gender based. For instance, the Canadian immigration citizenship, through family class classification, places the newly sponsored immigrant woman in a dependent position in relation to the labor force, government benefits, and services [74]. Meanwhile, individuals in different social contexts have different perceptions and experiences of gender role as illustrated by Anderson [75] that the majority of immigrant women perceive household duties as a woman’s responsibility. While Alvi et al. [48] argue that patriarchal attitudes can be seen in both immigrant and nonimmigrant cultures, Yoshioka et al. [76] stated that these ideas are more common among immigrant women with mental health problems. Research also shows that gender hierarchy and male domination affect women’s timely access to mental health services by situating them in a socially vulnerable and dependent situation [17]. Therefore, gender can configure both the position of women in the social hierarchy and their perceptions and experiences that shape their lives. Accordingly, WHO [67] conceptualize gender as a powerful structural determinant of mental health that interacts with other determinants including age, family structure, education, occupation, income, and social support. With respect to gender differences in mental health outcomes such as depression and anxiety, gender has explanatory power and must be viewed as a determinant of mental health.


### 2.2.7. Racism

Race is used as a social marker to assign people into groups [77]. Accordingly Collins and Guruge [78] define racism as “actions of individuals and/or groups that exclude people from resources and privileges on the basis of race” (p. 25). Substantial literature shows that race and gender discrimination are major inhibitors of radicalized immigrant women to attain economic and social inclusion [5]. For instance, high rates of underemployment, unemployment, and poverty have been reported in Canadian immigrants. Radicalized minority immigrants also experience wage discrimination in labor market and many adverse living conditions that threaten their health as well as the overall health of the host society [5]. Nevertheless, immigrant women may experience three forms of racism that have influential effect on their mental health. First one is institutionalized racism which is related to the structures of society and may be systematized in institutions of practice, law, and governmental inaction when necessary such as unequal access to mental health care resources [74]. Another form of racism is personally mediated which refers to prejudice and discrimination and can be recognized as lack of respect, suspicion, devaluation, and dehumanization [79]. Examples include negative attitudes or behaviors shown by the health professionals due to cultural diversity and misunderstandings in communication [80]. The third form is internalized racism which occurs when immigrant women accept and internalize stigmatized messages about their abilities and lack of worth. However, studies have revealed that experiencing any form of racism can lead to resignation, helplessness, and lack of hope which in turn deteriorate immigrant women’s mental well-being [74, 79, 81].


### 2.2.8. Socioeconomic Status

Socioeconomic status (SES) may pose social limitation for immigrant women. SES, which is measured by a person’s income, education, and occupation, determines a person’s behavior and life conditions which in turn can induce higher or lower prevalence of mental health problems such as depression, anxiety, low self-esteem, and anger [35, 82, 83]. The impact of SES on immigrant women’s mental well-being can be explained through material, psychosocial, and behavioral pathways.Material factors are related to economic hardship and health-damaging conditions in the physical environment such as housing, neighborhood, and physical working conditions. Research indicates that low socioeconomic status provides poor housing conditions in a sense that households of the lower income groups suffer much more frequently from dampness, mold, and crowding than households with higher incomes [2, 24]. In addition, crowding, where less than one room is available per person, influences mental well-being through its association with noise disturbance, low indoor air quality, a higher frequency of accidents, and lack of privacy [84]. There is also some evidence that socioeconomic status manifested itself as lack of finances and influenced immigrant women’s help-seeking behavior, access to health resources, quality of care, and health literacy [35, 48, 83].SES can also affect immigrant women’s mental health through behavioral pathway. Poor women choose unhealthy behaviors such as overeating, alcohol consumption, and smoking to cope with their daily difficult lives instead of expressing anxiety and frustration with limited financial resources [35]. These unhealthy behaviors make them more vulnerable to mental ill health [83].The psychological mechanism underlying the association between mental health and women’s economic status becomes clearer when adopting a broad definition of poverty and wealth, which encompasses the need for empowerment, freedom, and autonomy over the circumstances determining immigrant women’s life and health [85]. Research indicates that migrants often do not possess the autonomy over conditions that lead their life based on their social and cultural norms [2]. Besides financial constraints, poor immigrant women also have to struggle with shame, stress, depression, hopelessness, alienation, and despair as consequences of both being stigmatized and stereotyped and living in material deprivation [28].Other relevant psychosocial factors are linked to stressful living circumstances and lack of social support. Studies have shown that at work and at home those, who have less education, lower income, and jobs with less prestige and power, have more stressors and fewer resources for coping [86, 87].Socioeconomic disadvantage is also related to un/underemployment [66, 82, 88–90]. Because of foreign status or lack of training, immigrant women often work in part time, temporary, or contract jobs such as domestic servants or low-wage workers in informal sectors that are considered as nonstandard employments with low financial security and sometimes without any health insurance [83]. All these working conditions are considered as low status and demeaning with little opportunity for advancement which in turn sets the stage for mentally ill health. Women with illegal documents are more likely to be exploited and are often forced to accept bad working conditions since they are afraid of being deported if they ask for better [2]. Furthermore, immigrant women who are paid by the hour or by piece of work are unwilling to seek health care during working hours as they find that missing work will reduce their income [2].


### 2.2.9. Victimization

Immigrant women may experience discrimination due to their vulnerability for victimization for a variety of reasons including cultural and religious world views emphasizing female obedience, male privilege, an ethos of nondisclosure for fear of bringing shame on the family, lack of understanding of laws in the host country, lack of financial and other resources, low levels of community and individual support, and the absence of appropriate services [48, 91–95]. Additionally many immigrant women particularly domestic workers and trafficked persons are at increased risk of sexual abuse, violence, and exploitation due to the invisible nature of their work [2]. Victimization in turn is related to wide-ranging mental outcomes including anxiety, depression, suicidal ideation, and alcohol or drug abuse [35, 48]. The impact of victimization on mental health may be more profound in the case of abused immigrant women who encounter major reproductive health problems such as sexually transmitted diseases, unwanted pregnancies, and unsafe abortions [96, 97].


## 2.2.1. Social Connections

There is a large body of evidence that social networks and connections have powerful effects on mental health of immigrant women [7, 35, 48–50]. According to Berman et al. [31], social networks are defined by their structures (number of ties and proximity of ties) and functions (frequency of contact and reciprocity) and their impact on mental health can be explained through three primary mechanisms of social support; social influence; and social integration.


## 2.2.2. Social Support

Social network ties affect mental health most clearly via the provision of various kinds of support including emotional, instrumental, appraisal, and informational [51]. Social support refers to the cognitive appraisal of being connected to others and knowing that support is there if needed [52]. According to Lynam [53], immigrant women tend to rely on three types of social support including family, peer, and outsiders. First and foremost, they rely on their extended family members to meet their settlement related needs and consider this support as the most crucial, powerful, and protective factor for their mental health status [7, 17]. The second source of social support is peer or insiders who are immigrant women’s close, ethnically similar community members whom women expect to understand their needs because of sharing a common culture. Third in the social support line is outsiders which is a social network outside their family and ethnic community [53].Whatever the social support immigrant women receive, they uniformly can influence mental well-being via some psychological pathways. For instance, self-efficacy which is defined as individuals’ belief and confidence in their ability to perform specific behaviors [54] has been linked to social support and a variety of health outcomes like depression [50]. Some evidence also suggests that social support enhances coping styles in the sense that the tendency to seek social support per se is a coping style [55–57]. In addition, some studies have revealed that social support operates through its influence on emotion, mood, self-esteem, and perceived well-being and also contributes to this perception that the individuals can control their own destiny [50, 58].


## 2.2.3. Social Influence

Social networks may affect immigrant women’s mental health via another pathway which is based on social influence. When two persons in a social network contact each other, an interpersonal influence occurs between them [50]. This influence does not originate necessary from a face-to-face contact and does not require deliberate or conscious attempts to modify behavior [59]. This interaction provides individuals with normative guidance by comparing their attitudes with those of a reference group similar to others [60]. As a result, shared attitudes can be confirmed, reinforced, or altered when there is discrepancy [59]. These shared norms and behavioral patterns such as mental health care utilization or treatment adherence can be considered as powerful resources to influence the mental health behaviors of immigrant women as members of their social network.


## 2.2.4. Social Integration

The third path that social networks may influence mental health status of immigrant women is by promoting social integration which refers to the “involvement with ties spanning the range from intimate to extend” [50]. Through this involvement, social networks provide a basis for intimacy and attachment which has meaning both for intimate and for more extended ties. Thus, when social relationships are strong, individuals feel powerful bonds and attachments to places such as neighborhood and voluntary or religious organizations [50]. Social integration can also engage immigrant women in a variety of meaningful social roles including parental, familial, occupational, and community roles. Through opportunities for engagement, social networks can enhance these social roles which in turn supply a coherent and consistent sense of identity, value, belonging, and attachment [50]. There is some evidence that possessing multiple social roles promotes self-esteem and self-worth which in turn reinforces adaptation to stressful life events and prevents depression [61–63]. In addition, social integration provides opportunities for companionship and sociability [50]. In this sense, social ties give meaning to immigrant women’s life by providing them with full participation and attachment to their community and an obligation to be even a supporter for others. In line with this assumption, the term “social inclusion” can be used interchangeably which is described by Omidvar and Richmond [64] as the notion that immigrant women can participate fully and equally in all social economic and political aspects of life in new country. Evidence suggests that some factors such as discrimination can hinder immigrant women to be integrated and included in the new society and consequently make them socially excluded [3]. Finally, lack of social network that manifests itself as lack of social support, social influence, or social exclusion is a significant determinant of immigrant women’s mental health.


## 2.2.5. Social Position

Women’s social position is shaped by various factors including age, gender role, race, ethnic identity, and marital and socioeconomic status (SES) [35, 65]. Accordingly, disadvantaged social positions or discrimination is defined as actions taken to exclude or treat immigrant women differently because of their race, ethnicity, gender, and socioeconomic position [16]. Discrimination as a determinant of mental health and a source of stress has been linked to many psychological symptoms and subsequent service utilization among immigrant women [7, 25, 66, 67]. The literature suggests material and psychosocial pathways for the impact of discrimination on mental health. Material factors are related to SES in terms of barriers to employment education and housing [68]. Psychological factors that have been proposed in some studies include disempowerment, low self-esteem, perceived control, and the weathering effect which has resulted from years of cumulative stress due to discrimination and socioeconomic marginalization [26, 66, 69–72]. Beiser and Hou [73] suggest another psychological factor that experiences of discrimination serve as reminders of marginalized status for ethnic minorities. However, the association between discrimination and mental health is generally segregated based on the type of discrimination that is discussed here.


## 2.2.6. Gender Discrimination

In most societies, women are assigned subordinate positions to men and experience systematic discrimination in access to power, prestige, and resources [24]. In case of immigrant women, in particular, they experience more gender discrimination as they work in informal and different sectors than men and occupy lower professional ranks and lower wage jobs [5]. As a result they experience differential employment conditions and work related mental health risks. In addition, some legislation in host societies is gender based. For instance, the Canadian immigration citizenship, through family class classification, places the newly sponsored immigrant woman in a dependent position in relation to the labor force, government benefits, and services [74]. Meanwhile, individuals in different social contexts have different perceptions and experiences of gender role as illustrated by Anderson [75] that the majority of immigrant women perceive household duties as a woman’s responsibility. While Alvi et al. [48] argue that patriarchal attitudes can be seen in both immigrant and nonimmigrant cultures, Yoshioka et al. [76] stated that these ideas are more common among immigrant women with mental health problems. Research also shows that gender hierarchy and male domination affect women’s timely access to mental health services by situating them in a socially vulnerable and dependent situation [17]. Therefore, gender can configure both the position of women in the social hierarchy and their perceptions and experiences that shape their lives. Accordingly, WHO [67] conceptualize gender as a powerful structural determinant of mental health that interacts with other determinants including age, family structure, education, occupation, income, and social support. With respect to gender differences in mental health outcomes such as depression and anxiety, gender has explanatory power and must be viewed as a determinant of mental health.


## 2.2.7. Racism

Race is used as a social marker to assign people into groups [77]. Accordingly Collins and Guruge [78] define racism as “actions of individuals and/or groups that exclude people from resources and privileges on the basis of race” (p. 25). Substantial literature shows that race and gender discrimination are major inhibitors of radicalized immigrant women to attain economic and social inclusion [5]. For instance, high rates of underemployment, unemployment, and poverty have been reported in Canadian immigrants. Radicalized minority immigrants also experience wage discrimination in labor market and many adverse living conditions that threaten their health as well as the overall health of the host society [5]. Nevertheless, immigrant women may experience three forms of racism that have influential effect on their mental health. First one is institutionalized racism which is related to the structures of society and may be systematized in institutions of practice, law, and governmental inaction when necessary such as unequal access to mental health care resources [74]. Another form of racism is personally mediated which refers to prejudice and discrimination and can be recognized as lack of respect, suspicion, devaluation, and dehumanization [79]. Examples include negative attitudes or behaviors shown by the health professionals due to cultural diversity and misunderstandings in communication [80]. The third form is internalized racism which occurs when immigrant women accept and internalize stigmatized messages about their abilities and lack of worth. However, studies have revealed that experiencing any form of racism can lead to resignation, helplessness, and lack of hope which in turn deteriorate immigrant women’s mental well-being [74, 79, 81].


## 2.2.8. Socioeconomic Status

Socioeconomic status (SES) may pose social limitation for immigrant women. SES, which is measured by a person’s income, education, and occupation, determines a person’s behavior and life conditions which in turn can induce higher or lower prevalence of mental health problems such as depression, anxiety, low self-esteem, and anger [35, 82, 83]. The impact of SES on immigrant women’s mental well-being can be explained through material, psychosocial, and behavioral pathways.Material factors are related to economic hardship and health-damaging conditions in the physical environment such as housing, neighborhood, and physical working conditions. Research indicates that low socioeconomic status provides poor housing conditions in a sense that households of the lower income groups suffer much more frequently from dampness, mold, and crowding than households with higher incomes [2, 24]. In addition, crowding, where less than one room is available per person, influences mental well-being through its association with noise disturbance, low indoor air quality, a higher frequency of accidents, and lack of privacy [84]. There is also some evidence that socioeconomic status manifested itself as lack of finances and influenced immigrant women’s help-seeking behavior, access to health resources, quality of care, and health literacy [35, 48, 83].SES can also affect immigrant women’s mental health through behavioral pathway. Poor women choose unhealthy behaviors such as overeating, alcohol consumption, and smoking to cope with their daily difficult lives instead of expressing anxiety and frustration with limited financial resources [35]. These unhealthy behaviors make them more vulnerable to mental ill health [83].The psychological mechanism underlying the association between mental health and women’s economic status becomes clearer when adopting a broad definition of poverty and wealth, which encompasses the need for empowerment, freedom, and autonomy over the circumstances determining immigrant women’s life and health [85]. Research indicates that migrants often do not possess the autonomy over conditions that lead their life based on their social and cultural norms [2]. Besides financial constraints, poor immigrant women also have to struggle with shame, stress, depression, hopelessness, alienation, and despair as consequences of both being stigmatized and stereotyped and living in material deprivation [28].Other relevant psychosocial factors are linked to stressful living circumstances and lack of social support. Studies have shown that at work and at home those, who have less education, lower income, and jobs with less prestige and power, have more stressors and fewer resources for coping [86, 87].Socioeconomic disadvantage is also related to un/underemployment [66, 82, 88–90]. Because of foreign status or lack of training, immigrant women often work in part time, temporary, or contract jobs such as domestic servants or low-wage workers in informal sectors that are considered as nonstandard employments with low financial security and sometimes without any health insurance [83]. All these working conditions are considered as low status and demeaning with little opportunity for advancement which in turn sets the stage for mentally ill health. Women with illegal documents are more likely to be exploited and are often forced to accept bad working conditions since they are afraid of being deported if they ask for better [2]. Furthermore, immigrant women who are paid by the hour or by piece of work are unwilling to seek health care during working hours as they find that missing work will reduce their income [2].


## 2.2.9. Victimization

Immigrant women may experience discrimination due to their vulnerability for victimization for a variety of reasons including cultural and religious world views emphasizing female obedience, male privilege, an ethos of nondisclosure for fear of bringing shame on the family, lack of understanding of laws in the host country, lack of financial and other resources, low levels of community and individual support, and the absence of appropriate services [48, 91–95]. Additionally many immigrant women particularly domestic workers and trafficked persons are at increased risk of sexual abuse, violence, and exploitation due to the invisible nature of their work [2]. Victimization in turn is related to wide-ranging mental outcomes including anxiety, depression, suicidal ideation, and alcohol or drug abuse [35, 48]. The impact of victimization on mental health may be more profound in the case of abused immigrant women who encounter major reproductive health problems such as sexually transmitted diseases, unwanted pregnancies, and unsafe abortions [96, 97].


## 2.3. Community and Health Systems Levels

Access to community and health care services as a determinant of mental health has been overlooked in immigrant women [3]. Evidence indicates that immigrant women face many barriers to seek government services, social assistance, shelters, and police and support services [28]. They also have less access to mental health services, and if they receive care, it is more likely to be poor in quality [17, 34]. This access is strongly determined by immigrant’s legal status, as undocumented migrants have the least access to social and health care services. In fact, many social and health services may be available to assist immigrant women but these women may experience barriers in accessing such services. In addition to accessibility, services may not be acceptable by immigrant women [2]. This availability, accessibility, acceptability, and quality of services depend on several barriers as follows.


### 2.3.1. Communication Barriers

When seeking social and medical help, immigrant women usually face many communication barriers such as language differences [17, 48]. Lack of language skills limits social interaction and the ability to develop relationships within social and health care system [35]. It is also a major obstacle to both expressing their social and mental health needs and understanding bureaucratic procedures and the functioning of services [2]. In addition, professional interpreter services are not available in some settings and if available, their presence may not be acceptable particularly by female refugees. Ortiz et al. [28] illustrate that refugee women may experience fear and shame about disclosing their personal histories especially sexual abuse when the interpreter is male and/or a member of their community. They fear that their traumatic story become fodder for gossip within the community. They also fear that the interpreter (whether male or female) as a member of their community may contact authorities or groups back in their home country and jeopardize their immigration status [28].


### 2.3.2. Psychological Barriers

Evidence suggests some psychological factors which delay social and mental help seeking in immigrant women. These barriers include insufficient mental health information; unfamiliarity with and mistrust of biomedical treatments; and fear of stigmatization and its consequences such as deportation and social isolation [17, 34]. These cognitive and perceptual barriers to some extent are embedded in lack of cultural acceptance and cultural differences between immigrant women and the social and health care system [17, 36]. In addition, immigrants may not perceive themselves as being in need of psychological and social assistance [2]. For instance, Green et al. [45] in a study on Chinese migrant women found that the idea of “mental illness” sometimes equated with “psychosis” which in turn inhibited these individuals to seek help for mental health problems. Immigrant women particularly refugees may have another perceptional barrier which is related to the fear that seeking social and health services could have a negative impact on their immigration application [28]. They believe that expressing any mental symptoms or reliance on social and health care services would be a mark against their application. This is especially problematic for women who are in abusive relationship. Research also has shown that immigrant women’s personality and the level of self-acceptance of the illness determine their willingness to take care of themselves and reach out for help [17].


### 2.3.3. Social Barriers

Literature suggests that migrants are vulnerable to stigmatization and xenophobia [2]. Negative attitudes (prejudice) and negative behavior (discrimination) towards individuals with mental health problems may prevent immigrant women from seeking help or taking psychotropic medication [28]. In addition, immigrant women may express their physical symptoms such as headaches and fatigue instead of depression because they may find physical problems as more socially acceptable [28]. These factors can interact with social inequalities and can both influence and be influenced by social exclusion which has also been recognized as a social determinant of health [98].


### 2.3.4. Spirituality and Religious Barriers

Immigrant women may underuse social and health services due to spiritual and religious barriers. Research in ethnically diverse populations has shown that spirituality is a frame of reference for immigrant women and can affect their decision to seek or avoid professional help [7, 34]. In another study by Donnelly et al. [17], religious beliefs discouraged and deterred immigrant women from using biomedical treatments and forced them to seek help from ethnic group leaders and informal support systems.


### 2.3.5. Structural Barriers

Social and health system structure may also disable immigrant women from accessing or benefitting from available social and mental health counseling services. For instance, immigrant women may have to navigate bureaucratic hurdles, complete many application forms, or reach various agencies that may not be in close geographical proximity [99, 100]. Other structural barriers may include unequal power relationships between client and service provider, lack of confidentiality, fragmentation of services, and lack of professional translation and interpretation services in social and the health care system [34, 35, 101]. Lack of appropriate and culturally competent and sensitive services that suit immigrant women’s needs are other structural barriers which influence immigrant women’s well-being [17].


### 2.3.6. Economic Barriers

Poverty and financial difficulties have been identified as barriers to access the social and mental health care services [49]. Costs of care can lead to a lower use of services in immigrant women particularly in those who are uninsured or underinsured or are in a lower income bracket [34, 35]. As a result, these women would be reluctant to visit doctors and receive proper treatment for their mental health issues [35].


### 2.3.7. Cultural Barriers

Studies show that culture is a particular barrier for women migrants who adhere to traditional norms and have limited contacts outside their communities. As discussed earlier, culture has a powerful influence on these women’s access to health care system through different pathways. Cultural norms may also hinder women to accept care from male practitioners [49]. Lack of cultural acceptance and cultural differences between immigrant women and service providers are additional barriers specific to immigrant women [17, 36, 48].


## 2.3.1. Communication Barriers

When seeking social and medical help, immigrant women usually face many communication barriers such as language differences [17, 48]. Lack of language skills limits social interaction and the ability to develop relationships within social and health care system [35]. It is also a major obstacle to both expressing their social and mental health needs and understanding bureaucratic procedures and the functioning of services [2]. In addition, professional interpreter services are not available in some settings and if available, their presence may not be acceptable particularly by female refugees. Ortiz et al. [28] illustrate that refugee women may experience fear and shame about disclosing their personal histories especially sexual abuse when the interpreter is male and/or a member of their community. They fear that their traumatic story become fodder for gossip within the community. They also fear that the interpreter (whether male or female) as a member of their community may contact authorities or groups back in their home country and jeopardize their immigration status [28].


## 2.3.2. Psychological Barriers

Evidence suggests some psychological factors which delay social and mental help seeking in immigrant women. These barriers include insufficient mental health information; unfamiliarity with and mistrust of biomedical treatments; and fear of stigmatization and its consequences such as deportation and social isolation [17, 34]. These cognitive and perceptual barriers to some extent are embedded in lack of cultural acceptance and cultural differences between immigrant women and the social and health care system [17, 36]. In addition, immigrants may not perceive themselves as being in need of psychological and social assistance [2]. For instance, Green et al. [45] in a study on Chinese migrant women found that the idea of “mental illness” sometimes equated with “psychosis” which in turn inhibited these individuals to seek help for mental health problems. Immigrant women particularly refugees may have another perceptional barrier which is related to the fear that seeking social and health services could have a negative impact on their immigration application [28]. They believe that expressing any mental symptoms or reliance on social and health care services would be a mark against their application. This is especially problematic for women who are in abusive relationship. Research also has shown that immigrant women’s personality and the level of self-acceptance of the illness determine their willingness to take care of themselves and reach out for help [17].


## 2.3.3. Social Barriers

Literature suggests that migrants are vulnerable to stigmatization and xenophobia [2]. Negative attitudes (prejudice) and negative behavior (discrimination) towards individuals with mental health problems may prevent immigrant women from seeking help or taking psychotropic medication [28]. In addition, immigrant women may express their physical symptoms such as headaches and fatigue instead of depression because they may find physical problems as more socially acceptable [28]. These factors can interact with social inequalities and can both influence and be influenced by social exclusion which has also been recognized as a social determinant of health [98].


## 2.3.4. Spirituality and Religious Barriers

Immigrant women may underuse social and health services due to spiritual and religious barriers. Research in ethnically diverse populations has shown that spirituality is a frame of reference for immigrant women and can affect their decision to seek or avoid professional help [7, 34]. In another study by Donnelly et al. [17], religious beliefs discouraged and deterred immigrant women from using biomedical treatments and forced them to seek help from ethnic group leaders and informal support systems.


## 2.3.5. Structural Barriers

Social and health system structure may also disable immigrant women from accessing or benefitting from available social and mental health counseling services. For instance, immigrant women may have to navigate bureaucratic hurdles, complete many application forms, or reach various agencies that may not be in close geographical proximity [99, 100]. Other structural barriers may include unequal power relationships between client and service provider, lack of confidentiality, fragmentation of services, and lack of professional translation and interpretation services in social and the health care system [34, 35, 101]. Lack of appropriate and culturally competent and sensitive services that suit immigrant women’s needs are other structural barriers which influence immigrant women’s well-being [17].


## 2.3.6. Economic Barriers

Poverty and financial difficulties have been identified as barriers to access the social and mental health care services [49]. Costs of care can lead to a lower use of services in immigrant women particularly in those who are uninsured or underinsured or are in a lower income bracket [34, 35]. As a result, these women would be reluctant to visit doctors and receive proper treatment for their mental health issues [35].


## 2.3.7. Cultural Barriers

Studies show that culture is a particular barrier for women migrants who adhere to traditional norms and have limited contacts outside their communities. As discussed earlier, culture has a powerful influence on these women’s access to health care system through different pathways. Cultural norms may also hinder women to accept care from male practitioners [49]. Lack of cultural acceptance and cultural differences between immigrant women and service providers are additional barriers specific to immigrant women [17, 36, 48].


## 3. Implications for Mental Health Promotion

Promoting mental health of immigrant women requires a holistic approach to addressing mental health determinants at all individual and social levels with respect to research, education, practice, and policy as follows.


### 3.1. Research

In spite of abundance research on immigrant women’s mental health, there is still a gap in areas such as mental health perception of immigrant women at different age groups, their mental health changes over time, the intersections of immigrant experiences and homelessness, addictions, violence, and trauma. In general, the mental health needs of immigrant women should be identified and priorities should be set as to which needs should be addressed at the beginning [49]. It is also essential to ensure that immigrant women have a voice and are primarily involved in formulating consensus on their own issues [102].


### 3.2. Practice

Mental health practitioners are responsible for identifying the negative impact of immigration on women’s mental health. Foremost, they must pay attention to both pre- and postimmigration experiences of immigrant women and the influence of these experiences on women’s mental health. They should also explore the coping styles of immigrant women in new environment and find the ways to improve their access to mental health services. For instance, they should convince clients that access to health care and social services have no effect on their refugee or citizenship application [28]. Meanwhile, mental health professionals must assess the value system of their own and the health care system in order to recognize those actions in practice that are facilitators or inhibitors for immigrant women [103].


### 3.3. Education

The sociodemographic features of host countries are changing due to the growing numbers of immigrant women from diverse ethnocultural groups who are also consumers of mental health services. Therefore, education of mental health professionals must be aimed at addressing these shifts in the needs of diverse groups. Administrators of educational systems must also assign resources for organizational changes in their educational curricula and faculty staffing that includes diversity, inclusiveness, and capacity building.


### 3.4. Policy

To achieve health equity and improve the mental health of immigrant women, national governments of host societies should provide appropriate funding and resources to support newcomers such as job training programs and migrant friendly services by strengthening mental health professionals’ capacity and multisector partnerships. In addition, immigration policies should be amended to address gender-specific issues that influence women’s mental health. Current legislation should also acknowledge immigrant women’s potential for economic contribution and provide them with employment opportunities [3]. Additionally immigrant women should be encouraged to participate in policy development for mental health promotional activities along with nonprofit organizations and advocacy groups such as stakeholders which would lead to capacity building in the area of mental health [49]. Furthermore, mental health promotion strategies can focus on strengthening the social ties in the lives of immigrant women in order to enhance their sense of care, support, and belonging. For instance, an important part of mental health promotion activities could be exposing the immigrant women to various social, cultural, or religious clubs or groups and, at the mean time encouraging, advocating and sensitizing these groups to deal with mental health issues. Another health promotion program can aim at developing and improving healthy habits and lifestyle. These programs can encourage leisure and recreational activities which will enable immigrant women to build social capital; to prevent and control emotional distress; and eventually to improve their sense of body image and self-esteem [49]. It is also recommended that these activities are gender specific for some cultural groups such as Muslim immigrant women. Enhancing mental health literacy is another strategy that can be adopted by policy makers. To achieve this goal, health promotion activities should not only target immigrant women but also focus on public awareness since social stigma towards mental illness is a general issue. Using television, radio, and printed media to increase mental health literacy can lead to empowerment of immigrant women [49]. In addition, immigrant and community services can provide multilingual educational materials about women’s rights and roles which in turn help eliminate racism, gender discrimination, and other social inequalities.


## 3.1. Research

In spite of abundance research on immigrant women’s mental health, there is still a gap in areas such as mental health perception of immigrant women at different age groups, their mental health changes over time, the intersections of immigrant experiences and homelessness, addictions, violence, and trauma. In general, the mental health needs of immigrant women should be identified and priorities should be set as to which needs should be addressed at the beginning [49]. It is also essential to ensure that immigrant women have a voice and are primarily involved in formulating consensus on their own issues [102].


## 3.2. Practice

Mental health practitioners are responsible for identifying the negative impact of immigration on women’s mental health. Foremost, they must pay attention to both pre- and postimmigration experiences of immigrant women and the influence of these experiences on women’s mental health. They should also explore the coping styles of immigrant women in new environment and find the ways to improve their access to mental health services. For instance, they should convince clients that access to health care and social services have no effect on their refugee or citizenship application [28]. Meanwhile, mental health professionals must assess the value system of their own and the health care system in order to recognize those actions in practice that are facilitators or inhibitors for immigrant women [103].


## 3.3. Education

The sociodemographic features of host countries are changing due to the growing numbers of immigrant women from diverse ethnocultural groups who are also consumers of mental health services. Therefore, education of mental health professionals must be aimed at addressing these shifts in the needs of diverse groups. Administrators of educational systems must also assign resources for organizational changes in their educational curricula and faculty staffing that includes diversity, inclusiveness, and capacity building.


## 3.4. Policy

To achieve health equity and improve the mental health of immigrant women, national governments of host societies should provide appropriate funding and resources to support newcomers such as job training programs and migrant friendly services by strengthening mental health professionals’ capacity and multisector partnerships. In addition, immigration policies should be amended to address gender-specific issues that influence women’s mental health. Current legislation should also acknowledge immigrant women’s potential for economic contribution and provide them with employment opportunities [3]. Additionally immigrant women should be encouraged to participate in policy development for mental health promotional activities along with nonprofit organizations and advocacy groups such as stakeholders which would lead to capacity building in the area of mental health [49]. Furthermore, mental health promotion strategies can focus on strengthening the social ties in the lives of immigrant women in order to enhance their sense of care, support, and belonging. For instance, an important part of mental health promotion activities could be exposing the immigrant women to various social, cultural, or religious clubs or groups and, at the mean time encouraging, advocating and sensitizing these groups to deal with mental health issues. Another health promotion program can aim at developing and improving healthy habits and lifestyle. These programs can encourage leisure and recreational activities which will enable immigrant women to build social capital; to prevent and control emotional distress; and eventually to improve their sense of body image and self-esteem [49]. It is also recommended that these activities are gender specific for some cultural groups such as Muslim immigrant women. Enhancing mental health literacy is another strategy that can be adopted by policy makers. To achieve this goal, health promotion activities should not only target immigrant women but also focus on public awareness since social stigma towards mental illness is a general issue. Using television, radio, and printed media to increase mental health literacy can lead to empowerment of immigrant women [49]. In addition, immigrant and community services can provide multilingual educational materials about women’s rights and roles which in turn help eliminate racism, gender discrimination, and other social inequalities.


## 4. Conclusion

Migration is a process of population movement. While there are many benefits of immigration, living in a new society presents enormous challenges for immigrant and refugee women that influence their mental health. Upon arrival, most immigrants are generally in better health than their native-born counterparts but this healthy immigrant effect appears to diminish over a period of time. The pattern of mental well-being of immigrants seems to differ from healthy immigrant effect. Within a socioecological framework, determinants of immigrant women’s mental health in postimmigration context can be examined at different level of cultural, social, and health care system. Migration as a social determinant of mental health can influence and be influenced by these determinants. In addition, immigrant women’s cultural identity can shape their responses to mental health and illness through influencing access to services, stigmatization, behavior norms associated with gender role, and acculturation process. Social factors include social connections and social position. Social networks can affect mental health through three primary mechanisms of social support; social influence; and social integration. Immigrant women may experience disadvantaged social positions due to gender role, racism, socioeconomic status, and victimization. Immigrant women may also face many difficulties in accessing the social and health care system due to communication, psychological, social, spirituality, and religious, structural, economic, and cultural barriers. Implications for mental health promotion with respect to research, education, practice, and policy have been discussed.



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