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The relationship between acculturation strategies
and depressive and anxiety disorders in Turkish
migrants in the Netherlands
Burçin Ünlü Ince
1,2*
, Thijs Fassaert
3
, Matty AS de Wit
3
, Pim Cuijpers
1,2,4
, Jan Smit
2,5
, Jeroen Ruwaard
1
and Heleen Riper
1,2,4
Abstract
Background: Turkish migrants in the Netherlands have a high prevalence of depressive and/or anxiety disorders.
Acculturation has been shown to be related to higher levels of psychological distress, although it is not clear
whether this also holds for depressive and anxiety disorders in Turkish migrants. This study aims to clarify the
relationship between acculturation strategies (integration, assimilation, separation and marginalization) and the
prevalence of depressive and anxiety disorders as well as utilisation of GP care among Turkish migrants.
Methods: Existing data from an epidemiological study conducted among Dutch, Turkish and Moroccan
inhabitants of Amsterdam were re-examined. Four scales of acculturation strategies were created in combination
with the bi-dimensional approach of acculturation by factor analysis. The Lowlands Acculturation Scale and the
Composite International Diagnostic Interview were used to assess acculturation and mood and anxiety disorders.
Socio-demographic variables, depressive, anxiety and co-morbidity of both disorders and the use of health care
services were associated with the four acculturation strategies by means of Chi-Squared and Likelihood tests.
Three two-step logistic regression analyses were performed to control for possible, confounding variables.
Results: The sample consisted of 210 Turkish migrants. Significant associations were found between the
acculturation strategies and age (p< .01), education (p< .01), daily occupation (p< .01) and having a long-term
relationship (p= .03). A significant association was found between acculturation strategies and depressive disorders
(p= .049): integration was associated with a lower risk of depression, separation with a higher risk. Using the axis
separately, participation in Dutch society showed a significant relationship with a decreased risk of depressive,
anxiety and co-morbidity of both disorders (OR = .15; 95% CI: .024 - .98). Non-participation showed no significant
association. No association was found between the acculturation strategies and uptake of GP care.
Conclusions: Turkish migrants who integrate may have a lower risk of developing a depressive disorder.
Participation in Dutch culture is associated with a decreased risk of depressive, anxiety and co-morbidity of both
disorders. Further research should focus on the assessment of acculturation in the detection of depression.
Keywords: Acculturation, Integration, Assimilation, Separation, Marginalization, Depression, Anxiety, Migrants
* Correspondence: b.unlu@vu.nl
1
Department of Clinical Psychology, VU University Amsterdam, Van der
Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
2
EMGO Institute for Health and Care Research (EMGO+), VU University
Medical Center, Amsterdam, The Netherlands
Full list of author information is available at the end of the article
© 2014 Ünlü Ince et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Ünlü Ince et al. BMC Psychiatry 2014, 14:252
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Background
Research shows that the prevalence of depressive symp-
toms is significantly higher among adult ethnic minor-
ities than among native populations in Europe [1]. In the
Netherlands, it was found that Turkish migrants, one of
the largest ethnic minorities in the Netherlands, have a
significantly higher 1-month prevalence of depressive
and/or anxiety disorders (18.7%) in comparison with
Dutch (6.6%) as well as other ethnic minorities such as
Moroccans (9.8%) [2]. Moreover, Turkish women espe-
cially, have a higher risk of prevalence of these affective
disorders. However, in an international comparison study,
it was shown that the 1-month prevalence of depressive
and anxiety disorders for Turkish nationals living in
Turkey was 3.1% [3]. It seems thus that the higher preva-
lence of depression among Turkish migrants may be re-
lated to migration.
While the Turkish population is at an increased higher
risk for developing depression in comparison to other
ethnic groups (Moroccan and Dutch), this is comparable
with research concerning ethnic minorities in general.
For example, in a European study in 23 countries, it was
found that depressive symptoms were more prevalent
among immigrants and ethnic minorities than among
native populations [1]. A possible explanation for this
higher risk may be lower socio-economic status and dis-
crimination perceived by ethnic minorities in their host
countries [1]. This increased risk for developing dep-
ression, therefore, is probably generalizable to many
ethnic minority groups, including Turkish migrants in
the Netherlands.
One of the first definitions of acculturation was given
by Redfield and colleagues [4] in 1936 as “the changes
that occur in the ethnic cultural patterns when groups
or individuals with different cultures come into continu-
ous contact with each other”(page 149)”. Later in 1980,
Berry [5] applied this definition as a basis for his bi-
dimensional model in which he defines acculturation as
a) the degree of participation in the host culture by mi-
grants and b) the degree of maintenance of their own
ethnic culture. These two dimensions can vary inde-
pendently of each other and can lead to four accultur-
ation strategies according to Berry [6]. The first strategy
can be described as integration, the combination of
maintenance of the ethnic culture and participation in
the host culture. Assimilation is the second strategy,
which consists of participation in the host culture, but
rejection of the original ethnic culture. Third, separation
(or segregation) implies maintenance of the ethnic cul-
ture, but no participation in the host culture; and finally
marginalization, when both the host and ethnic cultures
are rejected.
In the past decades, alternative definitions have been
given to acculturation, such as a second-culture acquisition
[7] (p. 106) or enculturation [8] (p. 125). Both of these con-
ceptualizations are viewing acculturation uni-dimensional,
as one particular culture [9]. When viewing acculturation
in a one-dimensional manner, the migrant chooses either
to adapt the host culture or to maintain the ethnic culture.
However, this one-dimensional approach neglects the dy-
namic of acculturation. According to the very first defini-
tions of acculturation by Redfield, acculturation includes
the interplay or transmission of one or more cultures,
which is a criterion for acculturation nowadays [9]. The bi-
dimensional model posits the independency of the two
cultural orientations, which is shown to be a more valid
approach of acculturation [10]. Therefore, its assessment
by defining it in acculturation strategies has become an es-
sential feautre of acculturation (e.g. [9,11,12]).
The integration strategy has often been associated with
better psychological outcomes in comparison with the
other three acculturation strategies. For example, mi-
grants who are better integrated in the host culture show
higher self-esteem, more prosocial behaviours and less
depressive symptoms (e.g. [13,14]). In a recent meta-
analysis by Gupta and colleagues [15] based on 38 studies
on Asian Americans, it was found that participation in the
American culture was related to lower depression scores
among Asian Americans. Furthermore, they found that
maintenance of the Asian culture had a negative but non-
significant relationship with depression scores. Although
acculturation was measured according to a bi-dimensional
model (participation in the host country or maintenance
of the ethnic culture), the combination of both strategies
was not analysed by Gupta and colleagues [15].
Most research on ethnic minorities and mental health
shows a negative association between acculturation and
mental health. For example, in a study among Korean
immigrants in the USA, self-reported language profiency
of English (which is part of the adaptation dimension)
was shown to be related with depression [16]. Further-
more, integration has been shown to be associated with
lower mental health problems in Black male adolescents
in the UK [17]. In Chinese American students, it was
found that maintenance of the ethnic (Chinese) culture
was related to fewer depressive symptoms [18].
However, there are also examples of studies in which this
association hasn’t been found. For example, Beirens and
Fontaine (2010) [19] evaluated differences in well-being in
Turkish immigrants in Belgium, Turkish majority mem-
bers (in Turkey) and Belgian majority members. Results
showed no relationships were found between adaptation
and maintenance (which were the only two acculturation
dimensions) and sadness, anxiety nor with anger.
In the Netherlands, it was found that having fewer
skills to enable participation in the host culture is gener-
ally related to more psychological distress [20-22]. This
association was also confirmed for Turkish migrants, for
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example, by Fassaert and colleagues (2011) [23]. However,
previous Dutch studies have not analysed acculturation ac-
cording to the aforementioned four acculturation strategies
(e.g. [20-25]). It is not yet clear whether the acculturation
strategies are associated with affective disorders in Turkish
migrants in the Netherlands. Since the literature shows
that an integration strategy is related to lower levels of psy-
chological distress in migrants, it is important to evaluate
this explicitly in order to improve our understanding of the
relationship between acculturation strategies and the
prevalence of affective disorders among migrants.
In addition, ethnic minorities seem generally to receive
less help from mental health care services than native citi-
zens of Western countries [e.g. [26-29]). One of the rea-
sons for this lower uptake is that ethnic minorities seek
mental health care often at a later and at a more advanced
stages of their mental health problems [16,17]. Moreover,
ethnic minorities have a higher chance of dropping out
from psychological treatment prematurely [18]. Although
Dutch national data is lacking, there are signals that the
dropout rate is twice as high in ethnic minorities in men-
tal health care compared to native Dutch people in the
Netherlands [30]. Research also shows that the perceived
need for mental health care is higher for Turkish migrants
than in Moroccan and Dutch people [24]. This may be re-
lated to their higher levels of mental distress and their less
often met need perceived by Turkish migrants [24].
Several studies suggest that greater participation in the
host culture is associated with higher general health ser-
vice use (e.g. [31,32]). Earlier Dutch research found a sig-
nificantly positive association between communication in
Dutch and the use of care from General Practitioners
(GPs) among Turkish men in the Netherlands [25]. How-
ever, an association between the four acculturation strat-
egies and GP-care uptake by migrants was also not studied
in the study of Fassaert and colleagues (2009) [25].
We therefore decided to examine the relationship be-
tween the four acculturation strategies (integration, as-
similation, separation and marginalization) and mental
health in terms of prevalence of depression and anxiety
disorders in Turkish migrants living in Amsterdam as
well as the association between these strategies and GP-
care uptake. For this purpose we re-examined existing
data from the General Health Monitor of Amsterdam of
2005 (e.g. [33]). Using the bi-dimensional framework of
acculturation, we hypothesized that 1) higher integration
is associated with lower prevalences of depression and
anxiety disorders and 2) higher integration is associated
with higher GP-care uptake.
Methods
The Amsterdam health monitor
The Amsterdam Health Monitor (AHM) consists of
cross-sectional health surveys conducted by the public
health service of Amsterdam (GGD). These surveys are
performed periodically (every four years) in order to
monitor the general health of the population living in
Amsterdam and are representative for the population.
Data for the current study were derived from the survey
conducted in 2005, which was a (follow-up) study of the
AHM of 2004 (GGD Amsterdam), stratified by age and
ethnicity, and specifically aimed at studying mental health.
The follow-up consisted of structured (diagnostic) inter-
views conducted by trained bilingual lay interviewers.
The first phase of the survey included 1449 respon-
dents from the four largest ethnic minority groups (479
Dutch, 374 Moroccan, 454 Turkish and 142 Surinamese
or Antillean). All of these respondents were asked for a
second approach, without mentioning the topic of the
study, one year after the first phase. This second phase
(follow-up, one year after the first phase) consisted of a
structured interview conducted by bilingual interviewers.
A total of 1210 respondents gave permission to be
approached for the follow-up study by invitation letter
for a home visit by the interviewer. Appointments for a
home visit could be changed by telephone, up to 8 at-
tempts. The interviews took place between February
and June 2005, while summer vacation, Christmas and
Ramadan were avoided. The interviews could be held in
Dutch, Turkish, Moroccan or Berber, depending on the
preference of the respondent. The interviewers were in-
tensively trained and coached before and during data-
collection. The interviews were also recorded in order
to check and coach the researchers. After completing
the interviews, these were checked for consistency and
completeness.
The second phase resulted in 812 respondents, of whom
321 were Dutch, 191 Moroccan, 213 Turkish and 87
Surinamese or Antillean. All the study procedures were
approved by the ethics commission of the Amsterdam
Academic Medical Center. For more detailed informa-
tion about the recruitment, procedures and details, we
refer to previous AHM publications (e.g. [2,23,24]). For
the current study, we selected the data of the Turkish
group, comprising 210 respondents with complete in-
formation (Table 1).
Measures
The structured diagnostic interview consisted of several
translated instruments, of which we selected only the
following sections: demographic information, the Low-
lands Acculturation Scale and the Composite International
Diagnostic Interview and the use of health care services.
The questionnaire was translated into Turkish by official
translators. A back translation to Dutch was performed by
another translator and checked by the researchers. Any in-
consistencies with the original were discussed with both
translators and adjusted. The interviewers also reported
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back when they had difficulties with the translation, and
then together a standard was chosen. Of the acculturation
scale (LAS) and the measurement of anxiety and depres-
sion (CIDI) official Turkish translations were available and
used in this study.
Socio-demographic variables
Socio-demographic information included gender, age (18–
35 years, 36–49 and 50 years and older), level of education
(none, to at most 6 years of primary schooling; up to
10 years of schooling including middle education; up to
18 years of schooling including higher education), daily
occupation (employed for more than 12 hours a week; a
student; or no job) and partnership status (having a long-
term relationship or partner). Turkish ethnicity was de-
fined as when the respondent or at least one of his/her
parents was born in Turkey. First and second generation
migrants were taken together as one group. These items
were translated from Dutch to Turkish and back to Dutch
by professional translators.
Acculturation
The level of acculturation was measured with the Low-
lands Acculturation Scale (LAS), which was used in the
AHM of 2005 [34]. The validated Turkish translation
was used [34]. It consists of 25 items that are rated on
6-point Likert-type scales, ranging from ‘totally disagree’
to ‘totally agree’. The LAS can be divided into 5 sub-
scales: Skills, Traditions, Social Integration, Values and
Norms; and Feelings of Loss.
However, for the purpose of the research question ad-
dressed in this paper, we did not use the original scales
of the LAS. We developed four new acculturation strategy
scales based on the items of the LAS questionnaire (inte-
gration, assimilation, separation and marginalization) in
two steps:
First, following the two-dimensionality theory of Berry
[5,6], two new scales were developed for the question-
naire. These scales were: participation and contact in the
host culture (Participation) and maintenance of the eth-
nic culture (Maintenance). The two-dimensionality of
the items on the LAS questionnaire was created by ex-
plorative factor analysis (principal component analysis)
with a two-factor solution, based on the respondents of
the AHM 2005. However, eight items concerning eman-
cipation were excluded from further analyses because it
was not possible to determine how this scale was associ-
ated with acculturation, due to the lack of information
about emancipation in the ethnic Dutch and Turkish
cultures. The two factors, participation and mainten-
ance, were yielded with the rotation solution, as shown
in Table 2. The participation factor accounted for 16.9%
of the item variance, and the maintenance factor
accounted for 21.6% of the item variance. With a cut-off
point of .40 for the loadings [35], only 3 items were ex-
cluded from both factors. In order to fit the LAS items
to the scales, some items (items 10, 11, 13, 16 and 17)
were recoded by adjusting the range of the response op-
tions, so that higher scores indicated lower levels of
maintenance or participation. Internal consistency for
the Participation and Maintenance scales of the LAS
were good, with Cronbach’s alpha indicating strong reli-
ability for both of the scales - each .86.
Table 1 Characteristics of the Turkish group from the
AHM of 2005
Turkish migrants
N = 210
n%
Gender
Male 126 60.0
Female 84 40.0
Age (M,SD) 47.4 14.2
18 - 35 44 21.0
36 - 49 74 35.2
≥50 92 43.8
Education level
a
None or primary school 103 49.0
Middle education. 35 16.7
Higher education 48 22.9
Daily occupation
Yes, job/student 60 28.6
No, unemployed. 150 81.4
Partnership
b
Yes, partner 169 80.5
No, single 38 18.1
Acculturation
c
Integration 41 19.5
Assimilation 44 21.0
Separation 87 41.4
Marginalization 24 11.4
Depression and dysthymia (1-month) 36 17.1
Anxiety disorders (1-month) 21 10.0
Comorbidity 14 6.7
Amount of the contacts with GP
d
No contact (0) 58 27.6
Low (0–3) 90 42.9
High (>3) 61 29.0
Note. Results are based on the completers only sample due to varying attrition
rates on measurements. Numbers do not add up to 210, because not all
participants answered all the questions. Missing values are noted in
superscript: a: n= 24; b: n=3;c:n= 14 and d: n= 59.
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Second, in order to combine participation (low or
high) and maintenance (low or high) to create the 4 ac-
culturation strategies, the medians of the two scales were
used as the cut-off scores indicating high (higher or
equal to the median) and low (lower than the median)
levels of participation or maintenance. Choosing a me-
dian split instead of a continuous measure was based on
the fact that the distribution of the dimensions was not
normal distributed, and therefore the dimensions could
not be validly included as continuous measures and
were therefore dichotomized. This also made it feasible
to compare the four strategies instead of two separate
dimensions. The median for participation was 20.0
(range: 5–30) and for maintenance it was 50.0 (range:
25–66).
This resulted in four scales of acculturation strategies:
the scale integration was composed of the combination
of high participation and high maintenance. The scale
assimilation was composed of the combination of high
participation and low maintenance. The scale separation
consisted of low participation and high maintenance. Fi-
nally, the scale marginalization was the combination of
lower levels of both participation and maintenance.
Anxiety and depressive disorders
The Composite International Diagnostic Interview (CIDI
2.1) was used to establish the presence of depressive and
anxiety disorders [36]. Depressive disorders included
major depressive disorder and dysthymia; anxiety disor-
ders included social phobia, agoraphobia, panic disorders
and generalised anxiety disorders. All disorders were
coded according to the DSM-IV criteria [37]. The WHO
Turkish version of the CIDI was used and was con-
ducted by trained lay interviewers.
Use of health care services
The outcome measure for health services utilisation was
evaluated in terms of contacts with a General Practitioner
(GP) by a self-report measure. Contacts were defined as con-
sulting hours, telephone contacts, number of consultations
with the GP for general health in the 6 months preceding
the interview. A distinction was made between low and high
number of contacts (0 to 3 versus more than 3 contacts).
Analyses
Socio-demographic variables, depressive disorder, anx-
iety disorders, co-morbidity and the use of health care
Table 2 Factor loadings of the items on the LAS
Factors
Items Participation Maintenance
Participation items
11. I find Dutch difficult, so I’m not motivated to learn .67 .30
15. I am misunderstood when I speak Dutch .70 .26
16. I have difficulties understanding the Dutch language .80 .36
17. I have to depend on other people to show me how things are done here .77 .22
20. I must learn how certain tasks are done, such as renting an apartment .51 .25
Maintenance items
2. I prefer to listen to Turkish music .15 .53
4. I prefer to eat Turkish food .17 .59
6. I consider it important to pass our traditions on to the next (future) generation .04 .61
8. It is important to me to celebrate the Turkish traditional feast in the Netherlands .11 .56
10. I belong here less than I belong to my homeland .24 .50
12. When I go out, I usually go to places where I can meet people from my home country .33 .52
13. Even though I am living here, it does not feel like my country .32 .44
14. Most of my friends have the same cultural background as I do .32 .60
22. My country of origin is always on my mind and in my memories .11 .64
24. I miss the people I left behind in my original country .21 .67
25. I feel homesick .26 .65
No Factor items
5. I have frequent contact with Dutch people .26 -.19
7. In my experience encounters with the Dutch are fine -.17 .07
18. I am familiar with the Dutch politics -.29 -.11
Note. Factor loadings above.40 are presented in bold.
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services were analysed in terms of associations with ac-
culturation strategies. To assess the significance of an as-
sociation between these variables and the acculturation
strategies, Pearson’s Chi-Squared test was used. For cross
tabulations with low cell frequencies (<5) the Likelihood
ratio test was performed Acculturation was also analysed
in terms of a division in two general dimension (participa-
tion in the Dutch society and non-participation in the
Dutch society) in order to explore one specific cultural
attitude. To control for possible confounding variables,
we conducted three two-step logistic regression ana-
lyses, with the binary (yes/no) psychopathology vari-
ables (depression/dysthymia, anxiety and comorbidity)
as dependent variables. In step 1 of the analysis, we en-
tered the five socio-demographic variables listed as an
independent variable (Model 1). In step 2, we added the
four acculturation variables (Model 2). Next, a Chi-
Squared test of the log likelihood of model 1 versus model
2 was used to test the relationship between acculturation
and psychopathology, taking into account the effects of
socio-demographic variables. Associations were consid-
ered statistically significant if p< .05. All analyses were
conducted in SPSS 20.0.
Results
Socio demographic characteristics of participants
The sample consisted of 210 Turkish migrants, as shown
in Table 1. More than half of the migrants were male
(60%) and most were over 36 years of age (79%). Almost
half of the participants had only primary education and
80% were unemployed. Likewise, 80% were in a long-
term partnership.
The 1-month prevalence of depression and dysthymic
disorders was 17.1%, while the 1-month prevalence of
anxiety disorders was 10%. The prevalence of co-morbidity
of both disorders was high, namely 6.7%. Almost half of the
of the participants (42.9%) reported 0 to 3 contacts with
their GP for their general health in the last 6 months, of
whom 64.4% (n = 58) had no contact at all. Finally, 29% had
contact with their GP on more than 3 occasions.
Acculturation and demographic characteristics
Several associations were found between acculturation
strategies and demographic characteristics, as shown in
Table 3. Results show that age (Likelihood ratio = 40.79,
p< .001), education (Likelihood ratio = 59.51, p< .001),
daily occupation (χ
2
(4) = 32.22, p< .001) and partnership
status (χ
2
(3) = 9.12, p= .03) were significantly associated
with acculturation. Gender did not show an association
with acculturation (χ
2
(3) = 6.20, p= .10).
Table 3 also illustrates the proportions of demographic
characteristics of migrants in the four acculturation strat-
egies. The acculturation scale separation had the highest
percentage of migrants (41,4%, n = 87) and marginalization
had the lowest percentage of migrants (11.4%, n = 24).
The integration scale consisted mainly of migrants who
were aged between 18 and 35 (34.1%, n=14)and 50years
or older (34.1%, n= 14) and unemployed (65.9%, n=27).
The assimilation scale included migrants with slightly dif-
ferent characteristics than for the integration scale, namely
those aged between 18 and 35 (45.5%, n=20), were
employed or were students (59.1%, n=26).
The separation scale comprised migrants with a differ-
ent profile than the previous scales, i.e. 54.0% (n= 47)
were older migrants, 55.2% (n= 48) were female, 70.1%
(n= 61) had a lower educational level and 87.4% (n= 76)
were unemployed. The marginalization scale had a simi-
lar profile of migrants to those in the separation scale,
with the exception of the relationship status. In the sep-
aration scale 33.3% of the migrants (n= 8) had no
relationship.
Acculturation and depressive/anxiety disorders
Table 3 also presents the results of the association be-
tween acculturation and depressive and anxiety disorders.
Acculturation was significantly associated with depressive
disorders (Likelihood ratio = 7.85, p= .049), but not with
anxiety disorders (Likelihood ratio = 6.85, p= .08) nor
with co-morbidity of these disorders (Likelihood ratio =
6.08, p= .11).
Migrants who had a depression diagnosis (n= 36) were
mainly represented in the separation scale (n= 20), while
the integration scale had the lowest number of migrants
with depression (n= 2).
Acculturation and anxiety/depressive disorders controlled
for socio-demography
Tables 4 and 5 present the results of the three regression
analyses we conducted in order to control for possible
cofounders. Results were similar to the results of the ori-
ginal analyses presented in Table 6. Accounting for the
effects of socio-demographic variables, acculturation
strategies were related to depression, but not to anxiety
although the relationship with anxiety approached signifi-
cance (p= .055). Risk of depression was significantly lower
among those adopting an integration strategy (OR = .15;
95% CI: .024- .98).
Combining acculturation strategies
Additional analyses were performed on the basis of a
division into two combined acculturation strategies: (1)
participation in the host culture consisting of integration
and assimilation and (2) non-participation in the Dutch
society consisting of separation and marginalization, shown
in Table 6. The two combined strategy categories showed
no significant association with depressive disorders, however
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there was a trend towards statistical significance (χ
2
(1) =
3.80, p= .051).
For anxiety disorders there was a significant associ-
ation between the two acculturation categories (Likeli-
hood ratio = 4.61, p= .03). Finally, co-morbidity likewise
showed a significant association between the two general
acculturation strategies (Likelihood ratio = 4.00, p= .02).
For all three measures of psychopathology results showed
a higher prevalence among those with a non-participatory
strategy.
Next, we focused on the same regression analysis
method to examine the relationship between accultur-
ation strategies (divided into two general categories)
and psychopathology (comparing participation to non-
Table 3 Associations between acculturation strategies and demographic characteristics, mood/anxiety disorders and
contact with GP (n,%)
Acculturation strategies Statistics
Integration Assimilation Separation Marginalization Chi-Squared df
n = 41 n = 44 n = 87 n = 24
Demographic characteristics
Age 40.79ª *** 6
18-35 14 (34.1%) 20 (45.5%) 8 (9.2%) 0 (0%)
36-49 13 (31.7%) 15 (34.1%) 32 (36.8%) 10 (41.7%)
≥50 14 (34.1%) 9 (20.5%) 47 (54.0%) 14 (58.3%)
Gender 6.20 3
Female 26 (63.4%) 31 (70.5%) 48 (55.2%) 10 (41.7%)
Male 15 (36.6%) 13 (29.5%) 39 (44.8%) 14 (58.3%)
Education
b
59.51ª *** 6
low 15 (36.6%) 8 (18.2%) 61 (70.1%) 13 (54.2%)
middle 7 (17.1%) 15 (34.1%) 8 (9.2%) 2 (8.3%)
high 16 (39.0%) 19 (43.2%) 4 (4.6%) 7 (29.2%)
Daily pursuits
c
32.22*** 3
Job/student 14 (34.1%) 26 (59.1%) 11 (12.6%) 5 (20.8%)
Unemployed 27 (65.9%) 18 (40.9%) 76 (87.4%) 19 (79.2%)
Partnership
d
9.12* 3
Yes, partner 34 (82.9%) 32 (72.7%) 75 (86.2%) 16 (66.7%)
No, single 7 (17.1%) 12 (27.3%) 9 (10.3%) 8 (33.3%)
Mood/anxiety disorders
Depression/Dysthymia
Yes 2 (4.9%) 8 (18.2%) 20 (23.0%) 5 (20.8%) 7.85* 3
No 39 (95.1%) 36 (81.8%) 67 (77.0%) 19 (79.2%)
Anxiety disorders
Yes 2 (4.9%) 2 (4.5%) 12 (13.8%) 5 (20.8%) 6.85 3
No 39 (95.1%) 42 (95.5%) 75 (86.2%) 19 (79.2%)
Co-morbidity
Yes 1 (2.4%) 1 (2.3%) 10 (11.5%) 2 (8.3%) 6.08 3
No 40 (97.6%) 43 (97.7%) 77 (88.5%) 22 (91.7%)
Contact with GP
Frequency of contacts
e
3.73 3
Low (0–3 ) 16 (39.0%) 23 (52.3%) 35 (40.2%) 11 (45.8%)
High (>3) 9 (22.0%) 9 (20.5%) 32 (36.8%) 8 (33.3%)
Note. a =The Likelihood Ratio Value is provided due to low cell frequency (<5). Results are shown based on the completers only sample due to varying attrition
rates on measurements. Numbers do not add up to 210, because not all participants answered all the questions. Missing values are noted in superscript: b: n= 35;
c: n= 14; d: n= 17 and e: n= 67.
*=p< .05; ** = p< .01; *** = p< .000.
Ünlü Ince et al. BMC Psychiatry 2014, 14:252 Page 7 of 11
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participation). As shown in Table 5, the acculturation-
strategy category of participation did relate to each of
the three measures of psychopathology. Participation
was associated with decreased risk of depression (OR = .30,
95% CI: .10 - .89), anxiety (OR= .13, 95% CI: .03- .66) and
co-morbidity (OR = .12, 95% CI: .02 - .90).
Acculturation and the use of health care services
As presented in Table 3, acculturation did not show an
association with the frequency of contacting the General
Practitioner (χ
2
(3) = 3.73, p= .29).
Discussion
In this paper, the relationship between four accultur-
ation strategies (integration, assimilation, separation
and marginalization) and depressive/anxiety disorders
among Turkish migrants living in Amsterdam was ex-
amined. For this purpose we used existing data from the
General Health Monitor of Amsterdam, dating from
2005 [e.g. [2,23-25,33].
Results showed that age, education, daily occupation
and partnership status were significantly associated with
acculturation. We also found a significant association be-
tween the acculturation strategies and depressive disor-
ders. Migrants who adopted the integration strategy had a
significantly lower risk of depression compared to those
with one of the other three strategies. There was no asso-
ciation between any of the four acculturation strategies
and the frequency of contacting the General Practitioner.
When the four acculturation strategies were com-
bined into two categories (defined as either participa-
tion in the Dutch culture (integration and assimilation)
or non-participation in the Dutch society (separation
and marginalization), our results suggest that participa-
tion in the host country seems to be associated with
lower risk of depressive and anxiety disorders and co-
morbidity of both these disorders.
It is noteworthy to mention that the migrants included
in the study have a high level of unemployment (over
80%) across all acculturation strategies. The unemploy-
ment rate in our sample was much higher than found
in the general Turkish population in the Netherlands,
which was 14.8% in 2005 [38]. This means that our results
are mainly indicative for unemployed Turkish migrants.
Furthermore, migrants who applied a participatory strategy
(integration and assimilation) were often young, female
and higher educated, while those in the non-participating
strategy (separation and marginalization) comprised mainly
migrants aged 50 or older, who were lower educated. Sev-
eral studies have shown that a low socio-economic status
(SES) is a risk factor for developing mental health disorders
in general and also for developing depression (e.g. [39-41].
Although, after correction for the socio-economic variables
the association were still significant, we could not examine
whether the association might be different within different
levels of socio-economic status (SES).
Comparison with prior work
Our results are in line with the general finding that an
integration strategy among migrants is associated with
better psychological outcomes as found in the studies by
Chen and colleagues [13] and Schwartz et al. [14]. These
authors found that migrants who hold an integration
strategy experience higher self-esteem and less depres-
sive symptoms [13,14]. Moreover, the two combined ac-
culturation strategies (participation in the host country
and non-participation in the host country) seem to be
independent mechanisms, as participation is associated
with depression while non-participation is not, corre-
sponding to the independent bi-dimensional theory of
Berry [5,6].
There are number of possible explanations for the
lower risk of depression among migrants with participa-
tory acculturation strategies. Earlier research showed
that migrants who have integrated into the host society,
have cultural knowledge about the host society, are better
able to control the degree of contact and have positive cul-
tural group attitudes. All these factors may contribute to
minimising cultural distance between migrants and their
host society [42,43]. In turn, integration may enable mi-
grants to manage their daily life in the host society better
and therefore lower their risk of depression. Since integra-
tion involves a positive multicultural attitude [44] that
Table 4 The association between Acculturation and 1-
month prevalence of mood/anxiety disorders, controlling
for socio-demographic variables
−2 Log Likelihood Chi-Square
Model 1 Model 2 Statistic df P-Value
Depression/Dysthymia 153.05 145.18 7.87 3 .049
Anxiety disorders 109.67 102.08 7.59 3 .055
Co-morbidity 82.86 76.81 6.05 3 .11
Note. Results are based on the completers-only sample. Model 1: includes
the five socio-demographic variables as an independent variable. Model 2:
acculturation was added as a variable.
Table 5 The association between integration/assimilation
and 1-month prevalence of mood/anxiety disorders,
controlling for socio-demographic variables
−2 Log Likelihood Chi-Square
Model 1 Model 2 Statistic df P-Value
Depression/Dysthymia 153.05 147.95 5.10 1 .02
Anxiety disorders 109.67 102.09 7.58 1 .01
Co-morbidity 82.86 77.33 5.52 1 .02
Note. Results are based on the completers-only sample. Model 1: includes
the five socio-demographic variables as an independent variable. Model 2:
acculturation was added as a variable.
Ünlü Ince et al. BMC Psychiatry 2014, 14:252 Page 8 of 11
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enables migrants to manage daily life in a new context, it
is likely that these behaviours play a role in a decreased
prevalence of depression in Turkish migrants who adopt
such a strategy.
Finally, our results showed no association with the ac-
culturation strategies and uptake of GP care and thereby
confirmed the generic analysis of acculturation and GP
care uptake by Fassaert and colleagues [25]. However, our
results are not in line with earlier research (e.g. [31,32])
which showed that participatory strategies were associated
with higher use of general health care services. For ex-
ample, having higher levels of skills to participate in Dutch
society was related to greater use of health care by mi-
grants in the Netherlands [32]. It thus seems that Turkish
migrants make use of GP services to the same degree, re-
gardless of their acculturation strategy.
Limitations
This study has several limitations. First, the definitions
of immigrants/migrants will undoubtedly have affected
the results. First and second generation immigrants were
taken as equal groups in the analysis, because the num-
ber of second generation migrants in the study was too
small (n= 16) to study this group separately. Therefore,
these results mainly represent first generation migrants.
Yet, it is likely that each of these groups will experience
the process of acculturation through different (path)
ways, which were not monitored. Second, the cross-
cultural validity of the four created acculturation strategy
scales was not tested, although the new scales showed
good reliability (e.g. Cronbach’s alpha was .86 for both
scales). The small size of the groups distinguished by ac-
culturation strategy resulted in low power to detect pos-
sible associations and differences. We found several
associations, however, not all were significant. Further-
more, the absence of the cross-cultural validity of the
CIDI is also an important limitation. Third, the theoret-
ical conceptualisation of acculturation is complex. We
adopted the bi-dimensional model of Berry [5,6], how-
ever, acculturation does not take place in a ‘vacuum’.Ac-
culturation is a dynamic process that encompasses not
only certain life domains, but also contextual, political,
economic and social factors that require further explor-
ation [45]. It was beyond the scope of our study to in-
clude all these factors in our analyses. Furthermore, the
response rate over the first and second phases was 26%.
It is not clear why the response was that low. However,
despite efforts put into reaching and recruiting ethnic
minorities, it seems that this low response rate is the
highest possible response to be attained in ethnic minor-
ities [2,46]. There may have been a selective response,
which is a limitation. However, the response rate of the
Turkish group was similar to the other ethnic minorities
in the data (Moroccan, Antillean and Surinamese), sug-
gesting that in case of selective response this was similar
in all the ethnic minority groups. Finally, the cross-
sectional design of the study restricts the causality of the
associations.
Implications and future research
The finding that integration may play an important role
in a lower risk of developing depression is also of im-
portance for public health policy makers, clinicians as
well as for researchers. Supporting immigrants in the
process of adjustment to the host society, while encour-
aging ethno-cultural maintenance at the same time, is an
important task for the Dutch society as well as for ethnic
minorities themselves. This process can be aided through
several pathways, including educational and public health
policies, such as implementing acculturation in prevention
programs. Although integration has been found to be re-
lated to a lower risk of depression, its causality and
Table 6 Acculturation strategies in two categories and 1-month prevalence of mood/anxiety disorders (n,%)
Acculturation strategies Statistics
Participation Non-participation Chi-Squared df
n = 85 n = 111
Depression/Dysthymia 3.80 1
Yes 10 (11.8%) 25 (22.5%)
No 75 (88.2%) 86 (77.5%)
Anxiety disorders 4.61ª * 1
Yes 4 (4.7%) 17 (15.3%)
No 81 (95.3%) 94 (84.7%)
Co-morbidity 4.00ª * 1
Yes 2 (2.4%) 12 (14.1%)
No 83 (97.6%) 99 (89.2%)
Note. Results are based on the completers-only sample. a = The Likelihood Ratio Value is provided due to low cell frequency (<5); * = p< .05; ** = p < .01
and *** = p< .000.
Ünlü Ince et al. BMC Psychiatry 2014, 14:252 Page 9 of 11
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implications for prevention and clinical practice should be
examined in more detail for example the potentials of in-
cluding it as component in screening or treatment strat-
egies. Awareness by practitioners and professionals of the
acculturation strategies of ethnic minorities should be
promoted in order to optimize health services for mental
health problems. The assessment of the acculturation
strategies migrants adopt may be useful in identifying high
risk profiles of migrants who are at increased risk for de-
pression. From a public health perspective it may thus be
advised to include types of acculturation strategies in
screening procedures for depression. It is also of import-
ance to examine what factors are affecting the relationship
between integration and depressive disorders and whether
these also hold for the employed Turkish migrant popu-
lation. Moreover, future research should also explore
the influence of socio-economic status on the relation-
ship between acculturation and depression.
Conclusion
Turkish migrants who participate in Dutch society, while
at the same time maintaining their ethnic culture, may
have a lower risk of developing a depressive disorder
compared to those who adopt other acculturation strat-
egies. Participation in Dutch culture is associated with a
decreased risk of depression/dysthymia, anxiety and co-
morbidity of both disorders. No association was found
between the acculturation strategies and GP care. Future
research should focus on the assessment of acculturation
in the detection of depression.
Abbreviations
GP: General practitioner; AHM: Amsterdam Health Monitor; GGD: Public
Health Service; LAS: Lowlands acculturation scale; CIDI: Composite
international diagnostic interview.
Competing interests
The authors declare that they have no competing interests.
Authors’contribution
The AHM data was provided by the GGD Amsterdam. BÜI drafted the
manuscript and all authors contributed to further writing of the manuscript.
All authors read and approved the final manuscript.
Acknowledgements
The data-collection of this study was funded by the Municipality of
Amsterdam, the mental health care institutions Arkin (formerly Jellinek
Mentrum and AMC de Meren), GGZinGeest (formerly Stichting Buitenamstel
Geestgronden). There was no extra funding for the academic collaboration.
The authors would like to thank Arnoud Verhoeff, Henriëtte Dijkshoorn,
Joanne Ujcic, Daan Uitenbroek for the AHM data and Jeroen Knipscheer for
the LAS questionnaire.
Author details
1
Department of Clinical Psychology, VU University Amsterdam, Van der
Boechorststraat 1, 1081 BT Amsterdam, The Netherlands.
2
EMGO Institute for
Health and Care Research (EMGO+), VU University Medical Center,
Amsterdam, The Netherlands.
3
Public Health Service Amsterdam,
Epidemiology and Health Promotion, Amsterdam, The Netherlands.
4
Division
of Online Health Training, Innovation Incubator, Leuphana University,
Lueneburg, Germany.
5
GGZ inGeest, Regional Mental Health Service Centre,
VU University Medical Centre, Amsterdam, The Netherlands.
Received: 28 February 2014 Accepted: 27 August 2014
Published: 5 September 2014
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doi:10.1186/s12888-014-0252-5
Cite this article as: Ünlü Ince et al.:The relationship between acculturation
strategies and depressive and anxiety disorders in Turkish migrants in the
Netherlands. BMC Psychiatry 2014 14:252.
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