ABSTRACT
People from the Micronesian region represent one of the fastest growing migrant groups in the U.S., but little is known about their mental health. Research using respondent-driven sampling of 486 Micronesians living in Hawaiʻi was conducted to explore demographics, immigration-related variables, and connections to the Micronesian community and their association with anxiety and depression. Results show that connection to the Micronesian community was related to lower likelihood of experiencing probable anxiety, while depression was not as closely associated with demographic, immigration, or community connection variables. These findings suggest that interventions enhancing cultural pride and connection may be an effective tool to support Micronesians at risk for or experiencing anxiety.
KEYWORDS:
According to the 2010 Census, there are over 147,000 people in the US who identified as Micronesian in whole or part, and the fastest growing Native Hawaiian and Pacific Islander group in the U.S. are Chuukese people (Hixson et al., Citation2012). However, few social workers are familiar with the needs of these unique cultural and ethnic groups from the Pacific – with the “Micronesian” label encompassing people from over 2,000 islands and coral atolls, and hundreds of language and cultural variations among and between groups. The Micronesian region is still in the process of emerging from colonial status under various countries, and more recent US dominance (and nuclear testing) in the region. The region includes Guam, Palau/Belau, Northern Mariana Islands (including Saipan), the Federates States of Micronesia (which included Chuuk, Kosrae, Pohnpei, and Yap), the Marshall Islands (including Bikini, Enewatek, Kwajalein, Majuro, and Rongelap), Nauru, and Kiribati. While emerging research demonstrates some of this immigrant/migrant community’s health needs, and some possible mechanisms to explain physical health needs (Rehuher et al., Citation2021), and the ways that systemic barriers are posing threats to maintaining physical health in the United States (Molina et al., Citation2020), very little research has focused on the mental health experiences or needs of this community. Thus, this project explores demographic, immigration-related, and cultural connection variables that may be related to either anxiety or depression to better understand some of the mental health needs in this growing community of migrants in the US.
While the data about Pacific Islanders from the 2020 Census is still being processed, the U.S. has seen a significant increase in the number of migrants from the Micronesian region since the 1980s connected to the signing of the Compact of Free Association (COFA). COFA is a series of agreements between the U.S. and the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau that give exclusive military control of the region to the U.S. in exchange for protection, for support in infrastructure development, and the right for COFA nation citizens to be able to migrate to the U.S. and work without visas or green cards (United States Government Accountability Office, Citation2020). COFA ensures the U.S. has the ability to maintain their military interests in the Pacific, while also recognizing some responsibility for the destruction of these lands and ocean resources during World War II and later nuclear testing. These migrants face many of the same challenges that any new group faces – challenges with language, with finding jobs, understanding social institutions, etc. – while being legally allowed to work and access some limited social service resources due to their unique treaty status.
Information about the health and well-being of people from Micronesia in the United States is nascent. Recent research has found that among Micronesians who seek services at the hospital, they are frequently younger and more ill than counterparts in other racial/ethnic groups (Hagiwara et al., Citation2016). Micronesian migrants also face high rates of infectious disease, various cancers, and skin conditions (Pobutsky et al., Citation2009; Yamada & Pobutsky, Citation2009). Many of the health challenges faced by people from the region are due to exposure to nuclear testing (primarily in the Marshall Islands) or later fallout, including heightened risk of cancers (Palafox et al., Citation2004). The health vulnerability of these communities during the pandemic was particularly clear, from Micronesian migrant communities in Oregon (Drinkall et al., Citation2022), Arkansas (Stern & Laelan, Citation20222), and Hawaiʻi (Shek et al., Citation2021), where community members often face significant impacts related to social determinants of health, including working in “essential” jobs (that are often front line and low paying), larger household size, and lower levels of English language proficiency due to being recent immigrants. However, disease burden is difficult to disentangle from negative experiences in the healthcare industry itself (Inada et al., Citation2019) that may exacerbate disease. Studies across many areas, including research into health and cancer care (Cassel et al., Citation2020), prenatal and maternal/infant health (Ayers et al., Citation2019), and health, mental health, and social services (Stotzer, Citation2019) demonstrate that experiences of discrimination and racism (or fear of those experiences) are possible barriers to health.
Complimentary research on other Pacific Islanders have found that depression and/or depressive symptoms may be higher among Native Hawaiians and Other Pacific Islanders than other racial/ethnic groups in general (Kaholokula et al., Citation2020). Among studies with a focus on Micronesian populations, a survey from 2009 of over 2,000 people from the Micronesian region living in Hawaiʻi (Yamada & Pobutsky, Citation2009), roughly 1% reported experiencing “neurological/mental health” concerns. Pobutsky et al. (Citation2009) also found that mental health concerns displayed a similar pattern as other health conditions with Micronesians reporting greater severity of mental health concerns than other racial/ethnic groups in Hawaiʻi, but these differences did not reach statistical significance. However, compared to the general US population, Native Hawaiian and other Pacific Islanders have also been found to have higher levels of mental health stigma and a different understanding of the seriousness of mental health issues (Subica et al., Citation2019). While research has documented the limited access to mental health services in the Micronesian region (e.g., Leckie & Hughes, Citation2017; Twaddle et al., Citation2022) and thus many migrants’ lack of knowledge and experience regarding Western approaches to mental health, little is known about their experiences in the U.S.
Despite this small but growing body of research about overall physical health strengths and challenges, little is known about the mental health of people from the Micronesian region living in the U.S. Increased mental health concerns due to migration-related stress have been documented as a common issue for many immigrants (Bas-Sarmiento et al., Citation2016). In the wake of the COVID-19 pandemic, and evidence that Pacific Islanders were at particular risk of contracting and then dying from the virus, there has been increased attention on the health of Micronesian community members. Rehuher et al. (Citation2021) provided an overall narrative to better understand the three elements of the World Health Organization, Commission on Social Determinants of Health, Citation2008, including a) socioeconomic and political context, b) socioeconomic position, and c) intermediary determinants, and how they apply to Micronesian people in the U.S. Rehuher and colleagues highlighted how the socioeconomic and political context of Micronesians in the U.S. contributes to health vulnerabilities, since Micronesians often find employment in lower paying labor such as working in meat processing plants, in the tourism industry, in care facilities for older adults, and agricultural industry jobs. These tend to be low paying jobs that have a lot of physical demands. The changing nature of state laws and the COFA agreement itself due to repeated renegotiation (which is also currently underway) have also changed what social services Micronesian people are able to access, including health insurance, welfare, and housing supports, that have changed over time and under different political orientations over the last forty years. States have chosen different responses to their Micronesian community members as well, such as the network of informal supports in place to support Marshallese community members in Arkansas (Stern & Laelan, Citation2022), or Hawaiʻi choosing to extend state Medicaid dollars (with a variety of different programs over the last decades) to support the large number of uninsured migrants in the state (Hagiwara et al., Citation2015).
In regard to socioeconomic position, Rehuher et al. (Citation2021) highlight the various challenges that Micronesian community members face, including racism across a variety of domains (in health-care settings, housing, in schools, etc.), and low educational attainment rates and high poverty rates. In terms of intermediary determinants, the authors also highlight research that shows Micronesians experience food insecurity, quality of housing and housing insecurity overall, unemployment, and challenges in maintaining health-care access. While this model identifies social determinants that apply to physical health, one can see the parallels to help explain differences in mental health status as well.
The purpose of this study is to explore the demographic, migration, and cultural connection variables associated with increased depression or anxiety symptoms among 486 self-identified people from the Micronesian region who are living in Hawaiʻi. The study utilizes a secondary data analysis of a dataset that was originally funded by the National Institute of Justice (Stotzer, Citation2021) from 2017 to 2018 to explore the experiences of bias, discrimination, and harassment among Micronesian people in Hawaiʻi and the impacts of those experiences on mental health, community connection, acculturation, and feelings of safety. In addition to asking questions about experiences of bias, the study asked questions about how experiences of bias or discrimination may impact depressive symptoms, anxiety symptoms, fear of crime, feelings of connection to community, and other factors. While there is no existing model to base variable selection on for Micronesian migrants to the U.S., factors that fell into three areas – demographics, migration-related variables, and variables related to connection to Micronesian identity and community – were utilized to explore the relationship that these social determinants of health may have on depressive and/or anxiety symptoms. No specific hypothesis was proposed due to the lack of theoretical models for this community to inform a specific hypothesis. Instead, the analysis was exploratory in nature to begin to generate new models for understanding Micronesian migrant mental health.
Methods
The study was conducted through a collaboration between the University of Hawaiʻi, Mānoa Thompson School of Social Work & Public Health and We Are Oceania, the largest social service organization specifically serving the Micronesian community in Hawaiʻi. The study utilized a respondent-driven sampling methodology (Heckathorn, Citation1997), a type of chain referral that more closely approximates a random sample than typical snowball or other referral-based methods. Seeds, those who start the chain referrals, were selected from amongst the most prominent ethnic groups from the Micronesian region, both on O’ahu and on Hawaiʻi Island (with the help of Micronesians United – Big Island) and included both men and women. Of those seven initial seeds (five on O’ahu and two on big island), four productive chains were included in this study, yielding 517 total participants in the original study that is stored at the Inter-university Consortium for Political and Social Research. Participants were paid $20 for participating in the interview, and an additional $10 for each person they successfully recruited (up to three) who came in for an interview, for a maximum possible compensation of $50. Inclusion criteria were that participants had to be 18 years or older, to be ethnically from one of the ethnic/cultural groups in the Micronesian region, and to have lived in Hawaiʻi for at least one year. Surveys were read by an interviewer who entered responses into a tablet computer.
The study was reviewed by the University of Hawaiʻi Office of Research Compliance’s Institutional Review Board and was approved under protocol ID #2016-30977.
Survey materials
Surveys were conducted by one of three interviewers of Micronesian descent to the Micronesian community and who could offer potential language support specific to each participant. Interviewers represented four of the most common ethnic groups, and among those four, two spoke two variations of the same language. While there is some disagreement as to exactly how many languages vs. dialects there are in Micronesia (Lynch et al., Citation2002), these four languages represented the most common among migrants to Hawaiʻi, and whenever possible participants were matched with an interviewer who could provide language support should it be needed. However, the survey was written in English, was primarily delivered in English, but a handful of participants who spoke Marshallese asked for interpretation/language support that necessitated a live interpreter due to low English-language proficiency. Otherwise, interviewers provided language support for any item that caused confusion.
All scales and questions were vetted and approved by cultural consultants from the community who served to guide the project, for example, a social work practitioner who is Micronesian and runs a community organization, and a professor who is Micronesian, among others. The two main variables of interest were anxiety and depression. These were measured with two psychometrically validated scales that were found by the cultural consultants to contain questions that had a higher likelihood of being understood in a multicultural context (e.g., no scales that had questions like “I feel blue” that is very culturally specific). Depression was measured using the Center for Epidemiologic Studies Short Depression Scale (CES-D-10; originally by Radloff, Citation1977), a 10-item depression scale that measures the frequency of some behaviors or emotions related to depression the past week (χ2 = 0.80). Anxiety was measured using the Generalized Anxiety Disorder Scale (GAD-7; Spitzer et al., Citation2006), a seven-item anxiety scale that measures the frequency of how often they have been bothered by symptoms related to worry, anxiety, and irritability (χ2 = 0.95). As per the scale scoring recommendations, a score of 10 or more on each scale was considered the cutoff for symptom levels that may indicate probable anxiety of depression and would warrant further evaluation in a clinical setting. Thus, a binary variable was created from each scale that identified a person as having probable anxiety or depression.
In regard to demographic variables, sex, marital status, age, ethnic group, and questions about financial security (rather than income) were included in this analysis. In addition, based on their island of residence, participants’ location was coded as either on O’ahu or on one of the other more rural islands in Hawaiʻi. Financial security was utilized asking “how well would you say you are financially managing these days” with answers in a range from “findings it very difficult” to “doing all right” rather than specific income questions due to the fact that many Micronesian people live in multigenerational and multifamily homes with multiple income earners, making a specific dollar amount mean little without knowledge of how many people regularly live in the home. Participants were also asked which cultural group/ethnicity that they primarily identified with.
For migration-related factors, participants were asked where they were born, and it was collapsed into a binary variable reflection birth in the Micronesian region or born elsewhere. Participants were also asked about their overall English proficiency, and how readily they were identified as from the Micronesian region while out in public (leaving it to the respondents to determine based on their own phenotypes and/or style of dress). The Searle and Ward (Citation1990) sociocultural adaptation scale, which asked questions asking participants to rate themselves on their ability to use local transportation, to understand the local humor, and other various adaptation questions (χ2 = 0.97) was also included. In regard to experiences of prejudice, through a series of yes/no questions that asked about a variety of potential hate crime experiences, discrimination experiences in workplaces, housing, healthcare, and public accommodation, or threats/bullying and general incivility, a binary yes/no variable was created indicated those people who had experienced some type of prejudice motivated event based on their identity as Micronesian.
Last, two variables related to participants’ feelings of connection to their Micronesian culture and community were utilized. Two subscales from the Sense of Community Index 2 (SCI-2, Chavis et al., Citation2008) were utilized in this study. The first subscale addressed to what degree participants felt that they could get their needs met by the Micronesian community (e.g., “being a member of the Micronesian community makes me feel good” or “People in the Micronesian community have similar needs, priorities, and goals”) and the second focused on how connected they felt to the Micronesian community (e.g., “It is very important to me to be part of the Micronesian community” and “I feel hopeful about the future of the Micronesian community”). The two subscales were highly correlated and thus were treated as one overall scale of Micronesian Community Connection (χ2 = 0.911). In addition, participants took modified questions from the cultural shame and embarrassment subscale and internalized cultural/ethnic inferiority subscale of the Colonial Mentality Scale (David & Okazaki, Citation2006), a scale originally developed for Filipinos to assess their internalization of colonial ideas about the superiority of western cultures and inferiority other cultures (e.g., “There are situations where I feel that it is advantageous or necessary to deny my ethnic/cultural heritage”). The scale was modified so that the Filipino references were changed to Micronesian ones, such as “In general, I am embarrassed about Micronesian cultural traditions” (χ2 = 0.83).
Analysis
First, descriptive and frequency statistics for each variable were run. Then, a binary logistic regression was employed to test which factors were most closely related to probable depression and another for probable anxiety. Not all participants answered all questions and were automatically dropped from the model, leaving 340 in the model for anxiety and 316 people in the model for depression.
Results
The three largest ethnic groups represented in the sample were Pohnpeians (37.1%), Chuukese (34.1%), and Marshallese (23.8%), with only a handful of representatives from other Micronesian communities (n = 22). Other participants did not report their cultural group (n = 9). Thus, this study focused on those three main cultural groups and included them in the analysis, bringing the total sample size used in these analyses from 511 in the original sample to 486 included in this sample.
Of those 486 people, 41.7% identified as male and 58.3% as female, and 44% were married and 56% reported being single (with no one selecting other relationships options). The youngest participant was 19 years old and the oldest was 77, with a mean of 40.30 (SD = 14.93). 45.2% reported being employed full time and 54.8% employed part time, with no one indicating that they were not employed at all, suggesting a very high level of employment in this community. Despite this high level of employment, only 14.4% reported that they felt that were “doing all right” financially, while the rest reported “just getting by,” “finding it difficult,” or “finding it very difficult.” 87.6% lived on O’ahu and 12.4% on more rural islands. The RDS methodology clearly yielded a very diverse sample of the community, though it had a greater portion of Pohnpeians than are estimated to be in the population, possibly due to energetic Pohnpeians participating as interviewers and/or seeds in the project.
In regard to immigration-related variables, over 90% were born in the Micronesian region, 4% in Hawaiʻi and 2% born in another US place. The minimum number of years someone had lived in Hawaiʻi was one and the longest was 45, with a mean of 11.47 (SD = 8.43). The youngest participant was 19 years old, the old 77, with a mean of 40.31 (SD 14.93). The majority of respondents said that their English proficiency was fair (35.0%) or good (39.2%) while 11.2% said it was poor and 14.6% rated it as excellent. When asked how often they can be identified as a person from the Micronesian region by a stranger, 5.8% reported “all the time” or “most of the time” (10.7%) and 12.8% reported “never,” with the majority reporting “sometimes” (53.6%) followed by “about half the time” (17.0%). 26.5% reported experiencing some type of prejudicial experience due to being Micronesian.
In regard to the variables of interest, 34.2% of respondents reported symptoms reflecting probable anxiety, and 32.3% met threshold for probable depression.
When considering the results of the logistic binary regressions, the patterns of the variables tell an intriguing story. Demographic variables and those related to each participants’ connection to the Micronesian community were more related to reporting probable anxiety and depression rather than immigration-related factors. Sociocultural adaptation, where a person was born, how long they have lived in Hawaiʻi, and whether or not they had experienced prejudice were all unrelated to symptoms indicating probable anxiety or depression. Thus, focuses on only those factors that had p values less than .1 to discern the overall pattern of factors related to these expressions of mental health concern.
Table 1. Odds ratios and statistical significance for probable anxiety and depression.
Anxiety
Overall, based on the Nagelkerke R2, the variables in the model predicted 34% of the variability in probable anxiety and correctly classified 77% of cases. Fewer people who were married reported probable anxiety (24.6%) compared to those who reported that they were still single (41.8%), while sex of the participant was not related to reported levels of anxiety. Pohnpeians were most likely to report probable anxiety (52.8%) compared to Chuukese (31.9%) and Marshallese (10.8%) respondents. Participants who reported probable anxiety were also younger and more likely to report greater financial challenges. There were no immigration-related variables that were related to probable anxiety.
When examining the relationship between cultural connection variables and probable anxiety, those respondents who reported symptoms of probable anxiety reported higher levels of colonial mentality/internalized shame (M = 2.92, SD = 0.71) related to being Micronesian compared to those who did not meet criteria (M = 2.44, SD = 0.80). Those with probable anxiety also reported lower levels of connection to the Micronesian community (M = 3.22, SD = 0.61) than those who did not meet criteria (M = 2.98, SD = 0.70).
Depression
Based on the Nagelkerke R2, the variables in the model only predicted 16% of the variability in probable anxiety and correctly classified 73% of cases. While marriage seemed to be a protective factor for experiencing anxiety, marriage was not significantly related to probable depression, and neither was age, sex, nor financial status (). Pohnpeians were also slightly more likely to report probable depression (38.6%) compared to Chuukese (35.6%) who were both more likely to report probable depression than Marshallese (19.0%). Symptoms of probable depression were less likely to be reported among those who live on O’ahu (30.2%) compared to those who live on more rural islands (49.0%). The only immigration-related variable that was statistically significant was each participant’s English proficiency, with those who reported better English language skills being more likely to be in the group with probable depression, but not at a statistically significant level. Both sociocultural adaptation and experiences of prejudice were approaching statistical significance, but no variables related to sense of community emerged as related to probable depression.
Discussion
These results highlight the need for further research into the mental health of migrants from the Micronesian region to the U.S. One in three respondents reported concerning levels of anxiety and/or depression that may indicate a clinically significant condition. Overall, these two models suggest that demographic, immigration-related, and cultural connection variables are important for understanding both anxiety and depressive symptoms among Micronesian migrants, but that the same social determinants are not necessarily related to both anxiety and depression. The only factor that was associated with concerning levels of both depression and anxiety was a person’s self-identified ethnic/cultural group. A greater number of variables were unique to each mental health concern than were shared between them. These findings suggest that mental health concerns among Micronesian community members should not be lumped together but rather treated separately, with more research into their own predictors and health sequelae, as we come to learn more about the mental health of Micronesian migrants in the U.S.
Probable anxiety was better explained by the model variables overall than was probable depression, suggesting that there may be a different set of factors that put some Micronesian people at risk for depression than what was included in this study. One significant limitation may have been the scale selection in regard to an appropriate depression scale. Cultural consultants were utilized when selecting measures for the study, but were challenged to find a depression inventory that they predicted would work well with the Micronesian community. This failure to find explanatory variables related to worrying levels of depression may also be a reflection of scale selection and interpretation. Prior research has shown that lower levels of English language proficiency among Marshallese migrants was associated with lower general health (McElfish et al., Citation2021), but this study did not find that relationships with anxiety or depression. The marginally significant relationship with English language proficiency is also intriguing. This relationship may be related to immigration-related stress in adapting to a new environment, or could suggest that those whose English language proficiency was lower had a more challenging time understanding what was being asked in a depression screening tool. Further studies should explore translation and validation of depression measures for this community. More psychometric testing is needed to develop or adapt measures to better capture the experience of depression among Micronesian migrants. However, these ambiguities in either measurement or unknown factors not included in this study should give practitioners pause when considering how to evaluate their Micronesian clients for depression.
Beyond concerns with clarifying what measure of depression may be best for this community, there are other significant limitations to the study that must be considered. Given the lack of research into mental health issues with Micronesian community members, we chose an exploratory design rather than one based on a clear model with clear predictors and outcome variables with strong hypotheses. As the research base into the mental health of Micronesian migrants grows, future studies should utilize stronger designs. The study is also limited by its geographic location Hawaiʻi. While Hawaiʻi does have one of the larger concentrations of Micronesian migrants, their migration experiences may be different compared to those people who migrated to other areas with large concentrations, such as Guam, the Pacific northwest (such as Salem, Oregon), or Arkansas. Each state or territory has made different decisions in regard to extending supports and/or access to social programs that may make the migration experience different, and thus mental health outcomes could also potentially look different. Thus, at this point, a note of caution about overgeneralization of these results to other Micronesian communities in the US is warranted, although it provides a starting point for additional research. More research into the various communities of Micronesian migrants in the emerging diaspora need to be examined as well. Last, the use of interpreters was not well documented in the data or study design, making analyzing the data based on which participants took the study exclusively in English, which participants needed prompts or clarification in another language, and who needed almost complete interpretation. As the field moved closer to psychometrically validated mental health scales for Micronesian community members, more attention needs to be paid to the impact of language and English-proficiency in relating mental health needs or concerns.
While a first glimpse into understanding an underserved community, further research is certainly needed to generate more nuanced findings about the mental health of Micronesian migrants. For example, there is no clear reasoning in the literature why certain ethnic groups from Micronesia reported experiencing more/less symptoms. These differences could be due to their different cultural identities, but also differences in migration history/recency, or where in the US they came to reside, etc. More research is needed in this area. Additional research into the translation and validation of mental health inventories into the many languages of the Micronesian region is needed as well.
The results in regard to anxiety offer insights into a starting place for how to better support Micronesian migrants’ mental health. While demographic variables had a relationship with probable anxiety, variables related to connection to their culture of origin were also important for understanding anxiety symptoms. Those who reported a stronger connection to the Micronesian community and those who reported less internalized shame about being Micronesian were less likely to report symptoms of probable anxiety. These findings provide additional support to the emerging literature on culturally relevant practice in mental health social work. Since this research did not test a specific intervention, it only found a relationship between increased cultural connections/pride and lower levels of anxiety, making specific programmatic recommendations is premature. However, it is clear that while migration can cause many challenges, those who are well connected and feel pride in their culture of origin may be able to buffer the challenges of migration and the other social determinants of health that may lead to increased levels of anxiety. These results suggest that social service and health responses should include assistance in strengthening Micronesian migrants’ pride in, and feelings of connection with, the Micronesian community as possible intervention strategies to reduce or prevent anxiety symptoms in this growing U.S. community.
Data availability
Data are available from the Inter-university Consortium for Political and Social Research at the University of Michigan at https://www.icpsr.umich.edu/web/ICPSR/studies/37330
Acknowledgments
The author would like to acknowledge the various members of the Micronesian community in Hawaiʻi who helped this study to succeed. This project was supported by Award No. 2016-VF-GX-0002, awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
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