Discrimination and the healthy immigrant effect: A focus on marriage migrant women in Korea

Abstract

Why does immigrants’ health deteriorate over time? Numerous scholars across multiple disciplines have probed the question, and the term “healthy immigrant effect” was coined precisely to describe this paradoxical phenomenon. This study aims to examine, first, the existence of the healthy immigrant effect among marriage migrant women in Korea, and second, to evaluate the discrimination-health relationship as a potential explanation for the healthy immigrant effect. The 2012 National Survey of Multicultural Families was used for the analyses, using the self-reported health status of women as a measure of health. The results indicate that the health status of marriage migrant women in Korea is lower among those who have stayed longer, and that experiences of discrimination partially mediate the relationship between the acculturation process and the health status of marriage migrant women.

Keywords

immigrants’ health acculturation discrimination immigrants in Korea

Introduction

For immigrants, adjusting to a new life in the host country requires not only acquiring a new language and customs, but also facing possible changes in lifestyles and relationships. They have to adopt new social norms, build new support networks and adjust to different daily patterns of life. This process of adjustment, referred to as acculturation, is known to be accompanied by high levels of acculturative stress, which often triggers physical, psychological and social distress among immigrants. Studies commonly report a negative relationship between acculturative stress and immigrants’ physical and mental health (Gorman et al., 2010; Salgado et al., 2012).

Acculturative stress tends to be high in the early years of immigration, when changes related to uprooting occur. It is often assumed that immigrants’ health is likely to suffer most during this period. Over time, it is expected that the health status of migrants should improve, as they become acculturated to the destination country. With longer residence, immigrants adjust to the new culture and customs, and their health should improve as stress associated with acculturation attenuates. However, researchers investigating the physical and mental health of immigrants have reported a finding counter to this expectation: Acculturated immigrants—those who have stayed in the host country for longer periods of time—actually tend to be less healthy than both recent immigrants and the native-born population (Ali, 2002; Goel et al., 2004; Kennedy et al., 2006; McDonald and Kennedy, 2004; Puyat, 2013; Wu and Schimmele, 2004; Stafford et al., 2011). Researchers have labeled this phenomenon the “healthy immigrant effect” (HIE) or the immigrant health paradox. It is a topic that has attracted research attention in many countries with a long history of immigration.

Why does the health of immigrants decline as they become acculturated and adjusted to the host society? If acculturation theories are correct, their health status should improve as they become acculturated to the host society and as the associated stress declines. To understand the HIE, scholars have explored a number of hypotheses; some suggest that the HIE is a function of selective immigration policies that allow only healthy immigrants to enter (Gushulak and Williams, 2004), and others argued that selectivity plays a role such that the healthier individuals choose to migrate and the less healthy tend to stay (Kennedy et al., 2015). Others attribute the poorer health of long-term immigrants to the adoption of unhealthy behaviors in an environment in which they have better access to alcohol, cigarettes and unhealthy diet (Domnich et al., 2012). As there is no univocal theory of the HIE, alternative theories have also gained some traction. According to Domnich et al. (2012), psychological discomfort borne out of one’s immigrant status may be linked to declines in health over time. Immigrants encounter unique experiences as a result of their foreign identities, which can include discrimination at both the personal and structural levels, and this can lead to psychological discomfort.

Discrimination is one of the most challenging yet common obstacles immigrants face in host countries, and the effects of discrimination on immigrants’ health are well documented in the literature. Since discrimination, by definition, includes exclusion from resources and opportunities in the host society (Kaplan and Marks, 1990) as well as prejudicial mistreatment on grounds of individual characteristics, such as race, age or gender (Krieger, 1999), it is plausible that only those who are somewhat acculturated and knowledgeable about the host country’s norms know when discrimination occurs. In other words, those who have stayed in the host country for a longer period of time are more likely to report being discriminated against than recent immigrants because the former tends to be better aware of their position, status and experiences than the less acculturated and somewhat more oblivious newcomers (Kulis et al., 2009).

In view of these perspectives, this paper asks how marriage migrant women are faring in Korea, a society which has been receiving a continuous influx of foreigners. More specifically, are acculturated immigrants in Korea healthier than recent immigrants, or is the HIE also observed among its immigrant population? While some efforts have been made to understand the health status of immigrants in Korea, the findings remain limited. Furthermore, the HIE has not been adequately considered in the immigrant literature in Korea, which limits a broader understanding of the relationship among immigrants’ health, acculturation and experiences with discrimination. This study thus represents an attempt to investigate the HIE phenomenon in Korea by first examining whether recent immigrants are healthier than the acculturated, and second, evaluating the role of discrimination in the acculturation-health relationships of immigrants in Korea. To address these research questions, this study focuses on marriage migrant women in Korea, a population group that has grown considerably over the past decade.

Marriage migrant women in Korea

Once a labor exporting country, Korea is now a destination country for immigrants from across the globe, looking for new opportunities for employment, marriage, education and a new life. Over a 20-year period from 1998 to 2018, the number of foreign-born residents in Korea increased nearly tenfold, from 308,339 to 2,298,949 (Korea Immigration Services, 2018). Among the immigrant population, one group that has received particular attention from academics and policy-makers is the marriage migrant women who enter the country to form families with Korean men. The number of marriage migrant women has increased steadily from 87,964 in 2007 to 257,404 in 2016, with many coming from China, the Philippines and Vietnam (Statistics Korea, 2017). To meet the increasing needs of these women and their families, the Korean government enacted the Support for Multicultural Families Act in 2008 and established over 200 community-based support centers to assist their adjustment in Korea. As of 2018, a total of 218 Support Centers for Multicultural Families are in operation, providing an array of services from language training to employment assistance and family counseling.

Literature review

The HIE

The health of the immigrant population has been a key subject of interest for scholars and policy-makers in countries with a longer history of immigration for several reasons. First, immigrants’ health is directly linked to health care costs and expenditures for the host society. Second, immigrants’ health directly affects their ability to effectively adjust and contribute to the host society through their participation in the labor market and tax contributions. Lastly, understanding the factors that contribute to immigrants’ health may provide valuable information that could potentially guide immigration and immigrant policies (Kennedy et al., 2006; McDonald and Kennedy, 2004).

As McDonald and Kennedy (2004: 1613) explain, the main question regarding immigrants’ health is “what happens to immigrants’ health as they spend more time in the new country?” Does their health improve as they become acculturated? Or does it diminish as acculturation progresses? The recent immigrant literature has demonstrated that new immigrants tend to show better health profiles than their long-term counterparts as well as the native-born population (Ali, 2002; Perez, 2002). The presence and magnitude of this HIE have been accepted as a phenomenon across different health outcomes—from mental health, such as depression and anxiety (Ali, 2002; Alegria et al., 2008; Stafford et al., 2011), to physical health, including self-rated health (SRH; Newbold, 2005; Omariba and Ng, 2011), obesity (Antecol and Bedard, 2006), and health behaviors (Perez, 2002) in numerous countries with heavy immigrant populations, including Canada, Australia and the US. For example, Antecol and Bedard (2006), in their study of body mass index (BMI) in the US, show that both female and male immigrants indeed arrive with lower BMI and better self-reported health status, and that their BMIs converge to that of the US-born population after extended residency in the US (approximately 10 years for female immigrants). In assessing the SRH of immigrants, McDonald and Kennedy (2004), found that recent female immigrants’ health was better than that of Canadian-born women. Perez’s (2002) study examining diabetes, high blood pressure and cancer among immigrants and the Canadian-born also found supporting evidence for the HIE; the immigrants were consistently in better health than the native-born. More recently, Omariba and Ng (2011) compared the self-reported health status of recent immigrants, long-term immigrants and non-immigrants in Canada; they found that immigrants were healthier than non-immigrants, and recent immigrants were healthier than long-term ones.

Scholars have also uncovered patterns of the HIE in mental health research (Ali, 2002; Algeria et al., 2008; Stafford et al., 2011). Using the Canadian Community Health Survey data to compare rates of depression and alcohol dependence among immigrants and the Canadian-born, Ali (2002) reported that recent immigrants faced the lowest levels of mental health challenges. Specifically, immigrants had lower rates of depression and alcohol dependence than the Canadian-born overall, and recent immigrants were also in better health than immigrants with longer periods of residence in Canada. Stafford et al.’s (2011) study also supports the HIE; they uncovered lower depression rates among immigrants than the Canadian-born. Evidence supporting the HIE is also found in studies conducted with smaller samples. For example, Huang and Yang’s (2016) study, which focused on immigrant women in Taiwan, indicated that these women were less depressed than native-born women. Comparing low birth weights between immigrant and non-immigrant populations in the Czech Republic, Stipkova’s (2016) findings also support the HIE.

The findings of these HIE studies can be summarized as follows: first, immigrants are indeed healthier than the native-populations, and recent immigrants have health advantages over long-term immigrants. As Ali (2002) puts it, residence or years since migration (YSM) plays a vital role in predicting the health of immigrants. The longer the YSM, the more likely the immigrants’ health status will converge to that of the native-born population. In other words, long-term immigrants are less healthy than more recent immigrants, and immigrants’ health status deteriorates to the level of the native-born population as YSM increases.

Several models help to explain the health gap between recent and long-term immigrants, as well as between recent immigrants and the native-born population: health screening, self-selection and adoption of unhealthy behaviors (Domnich et al., 2012; Kennedy et al., 2006). Health screening refers to the immigration policy requiring the submission of health records of potential immigrants, through which host country authorities select only those who are deemed healthy. Canada and the USA require such documents, but recent studies report that health screening is not a significant determinant of the health advantage of recent immigrants (Laroche, 2000).

The second model suggests that new immigrants tend to be healthier than the native-born population because only those who are healthy and capable of adjusting to changes self-select to become immigrants (Jasso et al., 2003). Jasso et al. (2003) examined the immigrant self-selection effect in the context of immigrants’ health and labor market success in the US and found empirical evidence supporting the selection effect. However, as the authors noted, their findings only explain the health gap between new immigrants and the native-born population; they do not explain the subsequent deterioration in health status over time for immigrants.

The third model argues that unhealthy lifestyles and habits in the host country are often adopted by immigrants, which may contribute to their deteriorating health status over time. For example, McDonald and Kennedy (2004) conducted a study in Canada observing obesity among immigrant women and found that while recent immigrants’ BMI was significantly lower than that of the native-born population, the gap gradually decreased with additional years in Canada, converging to the mean or often exceeding that of the native-born after 20–30 years of residence. Scholars suggest that in many cases, immigrants moving from developing countries to developed countries are likely to acquire unhealthy diets, smoking and drinking habits that contribute to a deterioration of overall health, which may, in turn, explain the health gap between recent and long-term immigrants (Antecol and Bedard, 2006). However, the model fails to explain the health gap between immigrants from countries of similar socio-economic or development status.

While these models have provided some insights into the HIE and potential explanations behind the phenomenon, they may be difficult to test in the context of Korea.¹ This paper thus adopts the proposed explanation of Kulis et al. (2009) as an alternative approach to understanding the HIE. These authors argue that discrimination may play a vital role in the health of immigrants: as they acquire additional years of residence in the host country, they are better positioned to recognize the discrimination taking place around them and hence, more likely to suffer adverse, stress-related health consequences.

Discrimination and health

Discrimination encompasses all forms of unfair treatment and exclusion targeting social minorities as defined and categorized by a given society. While the targets of discrimination include a wide range of groups, such as the aged, children and those with disabilities, a large body of discrimination literature is dedicated to examining race/ethnic discrimination and its effect on racial/ethnic minorities in a society. Among these racial/ethnic minorities, immigrants are often considered easy targets due to their lack of language skills, unfamiliarity with customs and practices or distinguishable physical traits. In fact, a study conducted by the Ministry of Gender Equality and Family (2013) in Korea reported that 41.3 percent of marriage migrant women experienced some type of discrimination directly related to their foreign-background. Given such alarming levels of discrimination, immigrants’ well-being in general is likely to be adversely affected, which can manifest in chronic stress (Prelow et al., 2006).

The ill effects of discrimination on the health status of those who experience or perceive discrimination is well-documented in the immigrant literature across the globe (Karlson and Nazroo, 2002; Pavalko et al., 2003; Pascoe and Richman, 2009; Prelow et al., 2006). For example, Pascoe and Richman (2009) conducted a meta-analysis of 134 studies to investigate the effects of perceived discrimination on health and mental health and found that perceived discrimination had a significant negative effect on both mental and physical health. Karlson and Nazroo’s (2002) study in the UK provides additional empirical evidence supporting the negative consequences of discrimination on health. The few studies conducted in Korea also provide supporting evidence for the discrimination-health relationship. For example, Kim et al.’s (2011) study of bi-ethnic children revealed a significant negative relationship between experiences of discrimination and psychological distress. Similarly, studies of marriage migrant women (Kim, 2016; Ryu, 2016; Na and Kim, 2017) reported that experiences of discrimination had a negative effect on their health status.

Discrimination affects health via various routes. According to Ahmed et al. (2007), discrimination undermines good health by creating significant differences in the residential environment, including job opportunities, housing conditions, the safety of neighborhoods, socio-economic status and access to services. Importantly, discrimination often denies or limits access to proper medical care, and discriminatory behavior by health care providers often prevents minorities from seeking care even when they are in need. Furthermore, as Kim (2016) suggests, experience with discrimination often ignites patterns of risky health behaviors, such as smoking, which may result in health problems. In sum, it is clear that discrimination, whether structural or interpersonal in form, adversely affects the health of the targeted population, and the mechanisms through which discrimination affects health are often complex and operate at multiple levels.

Interestingly, reports of discrimination are far more frequent from the acculturated, long-term immigrants as opposed to recent immigrants. Kulis et al. (2009) explain that compared to long-term immigrants, recent immigrants may be less likely to perceive or recognize discrimination because of their limited language proficiency and lack of contact with or knowledge of the host society’s racial/ethnic hierarchy. By contrast, highly acculturated immigrants tend to be familiar with the culture, are more interactive with members of other social and ethnic groups, and may be aware of the negative images and stereotypes associated with their minority group. Such familiarity, coupled with their own expectations to be treated as equal members of the host society, render acculturated immigrants more cognizant of when discrimination takes place (Vega and Gil, 1998). Finch et al.’s (2000) study on Mexican-origin adults supports this argument.

Thus, it is plausible that acculturation is associated with poor health because acculturated immigrants are likely to be more aware of discrimination, and thus, suffer from associated health problems. The role of discrimination has been somewhat overlooked in understanding immigrants’ health and the HIE, hence, this study focuses on probing the role of discrimination in determining immigrants’ health in the context of Korea. More specifically, the study examines whether HIE is observed among marriage migrant women in Korea, and whether HIE can be explained by their experiences of discrimination. To the best of the author’s knowledge, these questions have not been examined for marriage migrant women in Korea. While there had been many studies about marriage migrants, most such studies have focused on the acculturation process, satisfaction with and problems in their relationships, or life satisfaction; a few studies have investigated depression among marriage migrant women (Ahn et al., 2010). This study on marriage migrant women’s health status may thus provide important insights into the relationship between acculturation and health that will enable researchers, practitioners and policy-makers to better understand the challenges they face and to develop necessary interventions and systems to improve the health status of these women and Korean society more broadly.

Methods

Sample

To address the research questions, the 2012 National Survey of Multicultural Families was used for analyses. The National Survey is conducted every three years as a conjoint project between the Ministry of Gender Equality and Families and the Korea Women's Development Institute. The face-to-face interviews are conducted by trained interviewers with all members of sampled multicultural families. The resulting dataset is the only large-scale, nationally representative dataset open for public use, and it contains detailed information on foreign-born individuals married to Korean citizens (both naturalized and Korea-born) as well as their children. The wide range of data covers information regarding their immigrant status, such as the country of origin, the length of residence in Korea, their naturalization status, utilization of services and their life satisfaction. For the purposes of this study, the analyses focused on the marriage migrant women. The initial sample of marriage migrant women was 15,001; the sample was then limited to women between the ages of 18 and 60. Female spouses who arrived in Korea before the age of 12, who had resided in Korea for less than one month at the time of the survey, whose year of birth was incorrectly reported, or who could not provide information on key variables, such as SRH and length of residence, were excluded from the sample. In the final sample, only married female spouses were included; male spouses and non-married (divorced, separated, etc.) individuals made up less than five percent of the total sample. The total number of eligible marriage migrant women was 11,273.

This study used the SRH as a measure of the health status of immigrants based on the question, “In general, how do you rate your health?” Respondents had five response options: “very good,” “good,” “fair,” “poor” or “very poor.” While this may not be a direct measure of individuals’ current health, it is widely utilized to examine health disparities and various health-related matters in population studies (Zajacova and Dowd, 2011). In addition, a number of studies demonstrate the utility of this measure as a good proxy for overall health and a powerful predictor of mortality (Kaplan and Comacho, 1993; Newbold, 2005). For the analyses, the SRH was transformed into a dichotomous variable by combining responses of “very good,” “good” or “fair” as “good health” (coded 1), and “poor” or “very poor” was categorized as “poor health” (coded 0) (Idler and Benyamini, 1997; Lee and Kim, 2014).

Acculturation was measured by two variables. The primary independent variable is YSM, measured by subtracting the individual immigrant’s year of entry to Korea from the year when the survey was conducted. Another proxy for acculturation is the marriage migrants’ Korean language ability. Unlike many previous studies that probed whether the primary language used by immigrants is the language of the destination country or their native language (e.g., English versus immigrants’ native language) (Wu and Schimmele, 2004; Newbold, 2005), this study used Korean language ability instead since the dataset does not include information on the primary language used by marriage migrant women. The 2012 Survey measured language ability by asking respondents to assess their Korean language ability in the domains of speaking, reading, writing and listening. Respondents rated their fluency on a five-point scale ranging from 1 (very poor) to 5 (very good). For each of the domains, responses were recoded to range from 0 to 4. The summated score ranged from 0 to 16, with a higher score indicative of a higher level of Korean language ability.

The 2012 Survey included a screening question that asked whether respondents have experienced discrimination because of their foreign nationality, race or ethnicity. Those who answered “yes” to the question were instructed to answer five subsequent questions under the category of “Have you ever experienced discrimination at the following places?” The places include workplace, neighborhood, schools, retail stores, and public offices (e.g., district offices, the police and real estate agencies). For each one, respondents rated their discrimination experience on a five-point Likert scale ranging from 1 (did not experience discrimination) to 5 (experienced severe or blatant forms of discrimination). For analyses, a separate variable was created to first categorize those who responded “no” to the screening question, and then to capture the experience as a whole by summating the scores of each response. The score ranged from 0 to 25, with a higher score indicative of more severe or blatant forms of discrimination experienced by the marriage migrant women.

There were other covariates included in the analyses. Citizenship status, ethnic background and age at arrival in Korea comprised the immigrant variables. Citizenship status was measured by asking respondents if they are naturalized citizens of Korea; the responses were coded into a binary variable with 0 indicating non-citizens and 1 indicating citizens. Ethnic background was measured by a list of the marriage migrants’ country of origin. A total of five ethnic groups were identified: Korean–Chinese, Chinese, Vietnamese, Filipino, and others.² Age at arrival in Korea was included in the study as previous literature has demonstrated the association between immigrants’ age of immigration and various constructs of health (Lee and Kim, 2014; Ng and Omariba, 2010).³ Age at arrival was calculated by subtracting the YSM from their current age, and the responses were divided into four groups: those who immigrated before 20 years of age, in their 20s, in their 30s, and in their 40s or above.

Respondents’ socio-demographic variables included age, education, employment status, household monthly income and their place of residence. Current age was grouped into the following categories: 18–29, 30–39, 40–49, and 50 years and older. Educational background was measured in terms of the highest education completed; it ranged from 0 (no formal education) to 5 (graduate school and beyond). This was recoded into a binary variable to distinguish between those who had completed high school education or less (code 0) and those with college or above (code 1). Employment status was measured by asking whether they are currently in the workforce. Monthly household income was measured by respondents’ income level, which ranged from 0 (zero to KRW 1,000,000 equivalent to approximately USD 1,000) to 7 (above seven million KRW). This was transformed into a binary variable with those with incomes equal to and higher than the median income coded as 1, and those with lower than the median income coded as 0. Lastly, their place of residence was measured by asking the marriage migrants whether they reside in an urban area (code 1) or a rural area (code 0).

Lastly, social support, marital satisfaction and medical treatment experiences were included. Social support was measured by asking the women whether they have someone to talk to about their problems or difficulties related to family life or themselves, or with whom they can discuss matters related to work, childrearing and/or share hobbies or spend time together for leisure activities. The “yes” response was given the score 1 and “no” a 0, and the summated score was used as a total support score. The score ranges from 0 to 12, with a higher score indicating more support. As previous studies demonstrate the importance of marital relationship in determining marriage migrant women’s well-being (Kim, 2016; Lee and Kim, 2014), satisfaction with their marital relationship was also included. Respondents were asked how satisfied they were with their spousal relationship, with responses coded from 0 (not satisfied) to 4 (very satisfied). Lastly, their medical treatment experience was included as a control variable. Marriage migrants’ experiences of being treated for their illness at a medical clinic or hospital were coded into a binary variable, with “1” indicating treatment experience and “0” indicating no experience.

Statistical analyses

The analyses proceeded in three steps. First, a descriptive analysis was conducted with respect to SRH, acculturation variables and other attributes. Second, factors associated with the SRH of marriage migrant women were evaluated with a particular focus on the association among YSM, language ability and SRH. Third, a mediation test was conducted to test the discrimination hypothesis, which asserts that acculturation leads to better perceptions of discrimination, and ultimately poorer health outcomes. To do so, multivariate logistic and linear regression analyses were conducted, and the Sobel-Goodman test was used to quantify the proportion of the total effect explained by the mediator and to test for statistical significance (MacKinnon et al., 2002). STATA 13.0 was used for the analyses.

Results

Descriptive analysis

As shown in Table 1, the mean age of the marriage migrant women was 34.51 (SD = 9.22), with the largest number falling in the 18–29 age group, followed by the 30–39 age group; marriage migrant women in Korea thus tend to represent a relatively young group. By ethnic group, women from “other” countries made up the largest group (35.7 percent), followed by Vietnamese (18.0 percent), Chinese (17.1 percent), Korean–Chinese (16.3 percent) and Filipinos (13 percent).

Table 1.

Self-rated health of marriage migrant women by various factors.

Variable			Self-rated health		t/χ²
Variable		Total	Good	Poor	t/χ²
Acculturation variables
Language ability (mean, SD)	9.60 (0.041)		9.54 (4.37)	10.36 (4.52)	t = 4.84***
Years since migration (mean, SD)	7.30 (0.049)		7.17 (5.20)	9.11 (5.34)	t = 9.75***
Perceived experiences of discrimination (mean, SD)	3.06 (0.039)		2.99 (4.09)	4.08 (4.47)	t = 6.54***
Immigrant factors	N	%	N (%)
Citizenship status
Citizen (naturalized)	3,998	35.47	3640 (34.6)	358 (46.9)	χ²= 46.92***
Non-citizen	7,275	64.53	6870 (65.4)	405 (53.1)
Ethnicity
Chinese	1,926	17.09	1764 (16.8)	162 (21.2)
Korean–Chinese	1,837	16.30	1,638 (15.6)	199 (26.1)
Vietnamese	2,032	18.03	1,954 (18.6)	78 (10.2)
Filipino	1,457	12.92	1,380 (13.1)	77 (10.1)
Others	4,021	35.67	3,774 (35.9)	247 (32.4)	χ²= 91.55***
Age at arrival
Before 20 years old	1,959	17.38	1,896 (18.0)	63 (8.3)
In their 20 s	6,269	55.61	5,940 (56.5)	329 (43.1)
In their 30 s	2,280	20.23	2,037 (19.4)	243 (31.9)
In their 40 s	765	6.79	637 (6.1)	128 (16.7)	χ²= 237.15***
Socio-demographic factors
Age (mean, SD)	34.51 (9.22)		34.07 (9.03)	40.51 (9.68)	t = 17.82***
18–29	4,005	35.53	3,879 (36.9)	126 (16.5)
30–39	3,905	34.64	3,694 (35.2)	211 (27.7)
40–49	2,558	22.69	2,281 (21.7)	277 (36.3)
50 and older	805	7.14	656 (6.2)	149 (19.5)	χ²= 337.50***
Educational background
High school or less	9,306	83.71	8,644 (8.4)	662 (88.4)
College or more	11,811	16.29	1,724 (16.6)	87 (11.6)	χ²= 12.88***
Household income per month (KRW)
Mean (SD)	2.01 (1.36)		2.04 (1.37)	1.60 (1.25)	t = −8.722***
Less than median income	4,335	38.45	3,920 (37.3)	415 (54.4)
Equal to or greater than median income	6,938	61.55	6,590 (62.7)	348 (45.6)	χ²= 87.81***
Employment status
Currently not working	5,818	51.61	5,391 (51.29)	427 (56.0)
Currently working	5,455	48.39	5,119 (48.71)	336 (44.0)	χ²= 6.21*
Place of residence
Urban	7,058	62.61	6,567 (62.5)	491 (64.4)
Rural	4,251	37.39	3,943 (37.5)	272 (35.6)	χ²= 1.06 (ns)
Had medical treatment?
Yes	10,410	92.34	9,662 (91.9)	748 (98.0)
No	863	7.66	848 (8.1)	15 (2.0)	χ²= 37.47***
Marital satisfaction (mean, SD)	3.39	1.05	4.14 (0.94)	3.72 (1.09)	t = −10.35***
Social support (mean, SD)	5.93	3.98	2.93 (1.64)	2.60 (1.80)	t = −5.01***

SD: standard deviation; KRW: South Korean Won.

p < 0.05; **p < 0.01; ***p < 0.001.

Most of the women had less than a high school level of education (83.7 percent), and about half reported that they were working at the time of the survey (48.4 percent). The majority of the women resided in urban areas (62.6 percent). Their mean monthly household income was 2.01 (SD = 1.36) with a median score of 2.00, indicating that about half of the women reported having a monthly household income of about two million KRW. Only 35 percent of the women were naturalized. Many reported having entered Korea in their 20s. The mean YSM was 7.30 (SD = 0.049), and the mean score for language ability was 9.60 (SD = 0.041), indicating that as a group, the women assessed their Korean language ability as slightly above “average.” The majority of women (59.9 percent) reported never having experienced discrimination. This was supported by the data on mean score of discrimination experience, which stood at 3.06 (SD = 0.039). In other words, as a group, few of the women had experienced being discriminated against in Korea. The mean score for marital satisfaction was 3.39 (SD = 1.05), and the mean score for social support was 5.93 (SD = 3.98).

As for their SRH, the great majority, 93.2 percent, reported their health to be fair or better; 6.8 percent reported that they were in poor health. To examine whether immigrants’ health status is “better” than that of the native-born population, a separate analysis was conducted (Table not shown) using the 2013 Korean Welfare Panel Study.⁴ In that study, approximately 7.8 percent of native-born married Korean women between the ages of 18 and 60 years reported their health to be poor, which is slightly higher than the rate reported by the marriage migrant women.

As for the relationship between acculturation variables and SRH, the t-test results show that the women who assess their language abilities to be better and who have resided in Korea for longer periods reported their health status to be poorer, and the differences were statistically significant. Furthermore, those who scored higher on the discrimination scale also self-reported to be in poorer health.

Logistic analyses

Determinants of women’s SRH: Prior to conducting the analyses, a correlation analysis was performed to ascertain potential multicollinearity problems among the independent and mediating variables. The Pearson’s correlation results (not shown in table) indicate that no values above 0.6 were identified (the value ranged from 0.011 to 0.554), thus allowing for further analysis. In order to identify the determinants of women’s SRH, a multivariate logistic analysis was conducted. As shown in the full Model 3 in Table 2, logistic analyses were conducted to examine the direct effect of YSM and language ability on women’s SRH. While YSM, the primary independent variable was found to be significantly associated with the women’s SRH, another proxy for acculturation, the respondent’s language ability, was not a significant predictor. The results suggest that HIE indeed is observed among marriage migrant women, as those with longer YSM are less likely to report better health.

Table 2.

Logistic regression analyses.

Variable	Model 1 Self-rated health as DV		Model 2 Discrimination as DV	Model 3 Self-rated health as DV with mediator present
	OR	95% CI	β (SE)	OR	95% CI
Language ability	1.01	0.98–1.03	−0.084*** (0.10)	1.01	0.98–1.02
Years since migration	0.96**	0.94–0.99	0.073*** (0.01)	0.97**	0.95–0.99
Citizenship status	0.79*	0.66–0.95	0.04** (0.09)	0.80*	0.66–0.96
Ethnicity
Chinese	Reference
Korean–Chinese	0.91	0.72–0.78	0.010 (0.13)	0.92	0.73–1.17
Vietnamese	1.09	0.78–1.52	−0.067*** (0.15)	1.04	0.74–1.44
Filipino	1.24	0.91–1.69	−0.007 (0.15)	1.23	0.90–1.67
Others	1.11	0.87–1.41	−0.034* (0.12)	1.08	0.85–1.38
Age at arrival
Before 20 yrs old	Reference
In their 20 s	0.80	0.58–1.10	0.008 (0.13)	0.80	0.58–1.11
In their 30 s	0.55**	0.29–0.68	0.001 (0.19)	0.54**	0.35–0.84
In their 40 s	0.42**	0.23–0.76	0.017 (0.31)	0.42**	0.23–0.77
Age
18–29	Reference
30–39	0.70*	0.51–0.94	0.007 (0.13)	0.70*	0.51–0.95
40–49	0.44***	0.29–0.67	−0.033 (0.20)	0.44***	0.28–0.66
50 and older	0.35***	0.20–0.62	−0.057 (0.31)	0.34***	0.19–0.60
Educational background	1.41**	1.10–1.81	−0.005 (0.11)	1.41**	1.10–1.81
Household income per month (KRW)	1.71***	1.46–2.00	−0.008 (0.08)	1.70***	1.45–1.99
Employment status	1.80***	1.53–2.13	0.084*** (0.08)	1.84***	1.56–2.18
Place of residence	0.93	0.79–1.10	0.061*** (0.08)	0.96	0.81–1.13
Had medical treatment?	0.23***	0.14–0.39	0.042*** (0.15)	0.24***	0.14–0.40
Marital satisfaction	1.40***	1.30–1.51	−0.111*** (0.024)	1.37***	1.27–1.48
Social support (mean, SD)	1.12***	1.07–1.18	0.060*** (0.024)	1.13***	1.08–1.19
Experienced discrimination?				0.95***	0.94–0.97
Model fit	4,873.03		F = 27.80***	4,843.46

Note: Model fit for logistic analyses: based on −2 Log likelihood.

DV: dependent variable; OR: odds ratio; CI: confidence interval; SE: standard error; KRW: South Korean Won; SD: standard deviation.

p < 0.05; **p < 0.01; ***p < 0.001.

The immigrant factors significantly associated with the SRH of marriage migrant women are citizenship status and age at arrival. Naturalized immigrant women were also less likely to report good health than were their non-naturalized counterparts, and the women who arrived in Korea in their 30s and 40s were less likely to report good health than were those who arrived before the age of 20. As for socio-demographic factors, the women’s age, educational background, household income and employment status were significantly related to their SRH. Younger women in the group of 18–29 years of age were more likely to report better health than were women in the older age groups (30s, 40s and 50s and older), and the more educated women (college or above) were also more likely to report better health than the less educated women. A similar pattern appears for income and employment status, as employed women and those who reported their monthly household income to be above the median level were more likely to report good health than the unemployed and those with below the median level of income. Other factors, such as experiences of medical treatment, marital satisfaction and social support, were all significant in predicting women’s health status. Women who were highly satisfied with their marital relationships as well as those who had a broad network for social support were all more likely to report better health than their counterparts with opposite characteristics. Those who had received some form of medical treatment in the past were significantly less likely to report their health to be in “good” status compared to those without such an experience.

Experiences of discrimination were also identified as a significant predictor of women’s SRH. As predicted, women who reported experiencing discrimination because of their foreign identity were less likely to report good health than the women who did not experience discrimination as severely or as often.

Discrimination as a mediator: In order to examine the mechanism through which acculturation variables affect the SRH of marriage migrant women in Korea, mediation analyses were conducted as suggested by Kenny (2008). In the first step, as shown in Model 1 in Table 2, logistic analyses were conducted to examine the direct effect of YSM and language ability on SRH—a model without the mediator variable. YSM and SRH were significantly associated, as the women with longer YSM were less likely to report good health compared to the women with shorter YSM. Having satisfied the first criterion of mediation analysis, in the second step, the SRH is regressed on the primary variables and covariates. As shown in Model 2 in Table 2, the association between YSM and discrimination experiences still held strong after controlling for all other covariates. In the third step, all variables including discrimination experiences were entered to predict the SRH, the outcome variable. The Z-score was reduced from−2.94 in Model 1 to −2.74 with the odds ratio being reduced slightly, though the Z-score remained significant at the 99 percent confidence level. A Sobel-Goodman test was performed to test the significance of the mediator, with results indicating that experience with discrimination partially mediated the YSM–SRH relationship with a Z-score of −3.507, significant at p < 0.001. Discrimination experiences explained 8.7 percent of the total effect of YSM on SRH.

Discussion

It has been well-established that the acculturation process for immigrants is accompanied by a high level of stress, particularly in the initial years after the immigration and which declines in time as immigrants acquire various ways to cope with their changed circumstances (Berry, 1988). However, studies investigating the association between acculturation and immigrants’ health, both physical and mental, have demonstrated findings to the contrary (Ali, 2002; Goel et al., 2004; Kennedy et al., 2006; McDonald and Kennedy, 2004; Wu and Schimmele, 2004; Stafford et al., 2011). That is, new immigrants tend to fare better than immigrants with longer residence (Wu and Schimmele, 2004; Perez, 2002; Kennedy et al., 2006). Often labeled as the immigrant paradox or HIE in health research, numerous studies have investigated the HIE phenomenon in an attempt to provide plausible explanations.

This study attempted to investigate the HIE phenomenon among marriage migrant women in Korea. In particular, it interrogated the relationship between acculturation and immigrants’ health with a focus on discrimination experiences, as suggested by Kulis et al. (2009). Using language ability and YSM as proxy variables for acculturation, and the SRH as the health outcome variable, the study examined first whether HIE is observed among the marriage migrant women, and second, whether the acculturation-health relationship can be explained by their discrimination experiences.

The findings of the study indeed support the HIE phenomenon: the length of time that marriage migrant women had resided in Korea (YSM) was significantly related to their health status. More specifically, the marriage migrant women who have resided in Korea for longer periods were more likely to report poor health compared to those with a shorter length of residence in Korea. The relationship remained significant after controlling for the effect of other immigrant and socio-demographic factors. However, their language ability, another proxy variable for acculturation, was not significantly associated with the women’s SRH, and interestingly, language skills were negatively associated with their experiences with discrimination. In other words, those who assessed their language skills to be better reported having experienced less or less severe discrimination because of their foreign identity. To examine whether discrimination experience mediates the acculturation and health of the women, a mediation analysis was conducted. The result confirmed that experiences with discrimination partially mediated the relationship between YSM and SRH, indicating that the women who have resided in Korea for longer periods were more likely to experience discrimination. This, in turn, adversely affected their SRH.

In short, the findings show that marriage migrant women in Korea are indeed healthier at arrival, and their health, or more precisely their self-assessments of health, tend to deteriorate as their time in Korea lengthens. The findings also point out that marriage migrant women tend to experience more discriminatory events as they become adjusted to Korean society, and such experience, in turn, affects their health status. Supporting the argument of Kulis et al. (2009), these findings paint a rather dreary and uninviting picture of life for immigrants in Korea. Contrary to traditional acculturation theory (Berry, 1988), their state of well-being does not necessarily stabilize or become enhanced as they become more acculturated.

The finding is even more alarming given that marriage migrant women are currently the only group of immigrants who are eligible to receive a wide range of social services, including healthcare on equal terms with the citizens. If the group of immigrants with relatively better access to social and health care services exhibits a downward pattern in their health as they spend more years in Korea, the long-run outcome of the well-being of immigrants more generally is rather bleak, as it had been reported in other countries. Furthermore, such an unfortunate outcome may also be observed in the second generation of those immigrants, in this case, the children of multicultural families who are already at risk of developing social, psychological and physical problems (Choi, 2012). The findings raise concerns for Korean society as a whole and they suggest that measures are needed to prevent the extension of the HIE into the second and subsequent generations of multicultural families.

The finding that women with longer YSM tend to experience more discrimination also highlights the need to address discrimination-related issues in greater depth. One view of migration is that it is a decision made after careful consideration of potential trade-offs (Todaro, 1969). In other words, individuals base their decisions to migrate on potential improvement in their lives (Massey et al., 1993). Women who do so also take on the challenges associated with moving, and becoming part of a Korean family. It is important to note that these women endure hardships during and after the migration process, in an effort to achieve what for many constitutes the Korean dream. Many of these women also make a choice to be naturalized through marriage. When one makes a conscious choice to migrate and to become naturalized, it is likely that they expect to be treated as a citizen and a legitimate member of society. However, the reality remains counter to those expectations; despite their naturalization status, the women are still perceived as foreigners. As many of the women experience first-hand discrimination due to their ethnic background or country of origin, it is likely that their experiences with discrimination are perceived as a threat with negative consequences on their well-being. The finding that naturalized women are far less likely to report good health than are women without citizenship supports the argument. It also illuminates the need for Korean society to acknowledge and discuss the extent to which such discrimination exists at both structural and interpersonal levels. As institutional and interpersonal discrimination is often identified as a main cause of health disparities among different ethnic groups in society (Williams and Collins, 1995), much more assertive efforts are required to shift society's perception of foreign-born individuals who have become vital members of Korean society. Furthermore, the findings point to a need for Korean society to expand its policies and services to address the women’s health considering the impact of acculturation and the aging process.

The findings of the study are not all bleak. The women’s SRH depended importantly on how they assessed their relationship with their husbands and their social support. Thus, amid the challenges that long-term immigrants may face in Korea, their health may be improved through healthy relationships with their spouses and close networks of support in their communities.

In sum, as the first known study to explore the existence of the HIE in the Korean context, specifically among marriage migrant women, the findings of this study provide an important insight into the health and well-being of immigrants in Korea. The findings indeed support the HIE, adding new empirical evidence and extending the understanding of the HIE in an Asian country. The finding that discrimination partially mediates the acculturation-health relationship also has important implications for both theory and practice, as the role of discrimination in explaining the deteriorating health of immigrants has rarely been examined.

On the other hand, the study also carries limitations. First, the research objectives are limited by the variables available from the 2012 National Survey on Multicultural Families. In order to understand the HIE and investigate the underlying mechanisms, models proposed by previous studies must also be taken into consideration. Health-related behaviors, such as, drinking, smoking and dietary habits as well as information concerning immigrants’ health, lifestyle, socio-economic status and health-related behavior prior to migration to Korea must be examined in order to gain a fuller understanding of the HIE phenomenon. Educational attainment and economic status were also identified as important predictors of better SRH among the marriage migrant women, which raises questions about the possibility of self-selection. The absence of such information presents a significant limitation to current studies that explore the HIE.

As mentioned previously, the HIE includes two dimensions: The health of immigrants is reported to be better than that of the native-born, and the health of newly arrived immigrants is also superior to that of immigrants with longer YSM. In order to properly probe the HIE phenomenon in Korea, it is important to have a dataset containing information on both the native-born and immigrants (in similar or equal portion). Though this study provided a descriptive comparison between the SRH of the marriage migrant women and the native-born women using two separate datasets, the finding cannot be taken as a direct comparison with statistical significance.

Furthermore, other health and mental health indices aside from the SRH should be examined in relation to immigrants’ generational status. Though the SRH is deemed to be a good proxy of overall health, the response and reporting of overall health may depend on cultural perceptions of health, that is, there could be fundamental differences in perceptions of health and illness (Ali, 2002). More objective measurements of health should be incorporated to accurately assess the HIE among immigrants in Korea. In addition, experiences with discrimination should be examined using more systematic scales with cultural validity. The current measurement of discrimination is quite limited in its utility and lacks sensitivity as a valid measurement tool. Future studies should consider incorporating a more detailed, comprehensive and multi-dimensional measurement to assess immigrants’ experiences of discrimination, both subtle and overt.

Lastly, the study did not distinguish between the health status of women by immigration class (which can be gauged from the reason(s) for migration, that is, whether marriage migrants differ from those who enter Korea under other types of visa). The present discussion is limited to within-group differences. Since factors influencing women’s health vary across countries of origin and routes of immigration (Kim, 2016), future studies should consider the cohort effect and the within-group differences to further examine the HIE. It should also be noted that the findings are limited to the health of marriage migrant women in Korea. As this particular group of immigrants may exhibit unique characteristics and face different challenges and acculturation patterns compared to other immigrants, such as migrant workers and refugees, the findings may not be generalizable to the entire immigrant population in Korea.

In sum, in order to capture how immigrant women’s health changes over time, longitudinal analyses are required to observe the changes and patterns in their health as residence in the country of destination lengthens. The current study’s cross-sectional design, based on available data, limits the interpretation of the causal relationship between acculturation and health variables.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this paper.

Funding

This research received funding support from the Incheon National University (2016-2040).

1

Korea selectively requires foreigners to submit health documents for entry. For example, for student visa issuance, applicants from 16 countries are required to submit health records verifying they do not carry tuberculosis while those entering Korea with other visa statuses, such as E-5 (which is given out to professionals employed in Korea), are not required to submit any health documents. For individuals entering the country as marriage migrants, in which case the F-6 visa is issued, only those from selected countries (China, Vietnam, Cambodia, Mongolia, Uzbekistan and Thailand) are required to submit health documents; it is waived for those from other countries. In sum, since the health screening procedure varies by visa status and issuance process, the health screening hypothesis is not applicable to the current study (for more details, see ). Furthermore, data and information prior to immigration to Korea are limited and often not provided, hence, the self-selection effect cannot be tested using the current dataset. In addition, there are currently no datasets that include information on immigrants’ dietary habits and health-related behaviors in Korea.

2

Marriage migrants from countries such as the US, Canada, Mongolia, Cambodia and others were grouped into the “others” category.

3

Age of immigration is considered an important factor in understanding the outcome of immigration: those who immigrated at a young age have more opportunities to acquire skills and knowledge needed to navigate the host society through education or socialization. The socio-economic as well as health outcomes of immigrants who migrated at a young age tend to resemble those of the native-born population (Ng and Omariba, 2010).

4

Though the data may not be comparable with the data from the 2012 National Survey of Multicultural Families used in this study, the analysis was conducted to provide a basic description of how the native-born population rates their health and whether there is a difference between the native-born and the immigrant populations. Both datasets include the same SRH question, and the responses were coded in the same way. The 2013 Korean Welfare Panel Study data were also screened to include only married women between the ages of 18 and 60 years, though other socio-demographic characteristics were not matched. It should be noted that the results of the analysis are provided only to delineate a descriptive picture of the health status of those residing in Korea.

References

Ahmed

Mohammed

Williams

(2007) Racial discrimination and health: Pathways and evidence. Indian Journal of Medical Research 126(4): 318–327.

Ahn

Jeon

Hwang

, et al. (2010) An analysis of articles for international marriage immigrant women related to health. Journal of Agricultural Medicine and Community Health 35(2): 134–150.

Alegria

Canino

Shrout

, et al. (2008) Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. American Journal of Psychiatry 165(3): 359–369.

Ali

(2002) Mental health of Canada’s immigrants. Health Reports 13(Suppl.): 101–113.

Antecol

Bedard

(2006) Unhealthy assimilation: Why do immigrants converge to American health status levels? Demography 43(2): 337–360.

Berry

(1988) Cognitive and social factors in psychological adaptation to acculturation among the James Bay Cree. In: Bagley

Verma

(eds) Cross-Cultural Studies of Personality, Attitudes and Cognition, London: Palgrave Macmillan, pp. 60–95.

Choi

(2012) Personal characteristics, ethnic identity, experiences of discrimination, self-esteem, and problem behavior of Korean-Japanese multicultural adolescents. Korean Journal of Family Welfare 17(2): 49–71.

Domnich

Panatto

Gasparini

, et al. (2012) The health immigrant effect: Does it exist in Europe today? Italian Journal of Public Health 9(3): 7532–1–7532-7.

Finch

Kolody

Vega

(2000) Perceived discrimination and depression among Mexican-origin adults in California. Journal of Health and Social Behavior 41(3): 295–313.

10.

Goel

McCarthy

Philips

, et al. (2004) Obesity among US immigrants’ subgroups by duration of residence. Journal of the American Medical Association 292(23): 2860–2867.

11.

Gorman

Read

Krueger

(2010) Gender, acculturation, and health among Mexican Americans. Journal of Health and Social Behavior 51(4): 440–457.

12.

Gushulak

Williams

(2004) National Immigration Health Policy. Canadian Journal of Public Health 95(3): 1–27.

13.

Huang

Yang

(2016) Is there a healthy immigrant effect among women through transnational marriage? Result from immigrant women from Southeast Asian countries in Taiwan. Journal of Immigrant and Minority Health 20(1): 178–187.

14.

Idler

Benyamini

(1997) Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior 38(1): 21–37.

15.

Jasso

Massey

Rosenzweig

, et al. (2003) Immigrant health-selectivity and acculturation, Santa Monica: RAND.

16.

Kaplan

Comacho

(1993) Self-evaluated health and mortality: A nine-year follow up of the human population laboratory component. American Journal of Epidemiology 117: 292–305.

17.

Kaplan

Marks

(1990) Adverse effects of acculturation: Psychological distress among Mexican American young adults. Social Science and Medicine 31(12): 1313–1319.

18.

Karlson

Nazroo

(2002) Agency and structure: The impact of ethnic identity and racism on the health of ethnic minority people. Sociology of Health and Illness 24(1): 1–20.

19.

Kennedy

Kidd

McDonald

, et al. (2015) The healthy immigrant effect: Patterns and evidence from four countries. Journal of International Migration and Integration 16(2): 317–332.

20.

Kennedy S, McDonald JT and Biddle N (2006) The health immigrant effect and immigration selection: Evidence from four countries. SEDAP Research Paper no. 164. Ontario: Social and Economic Dimensions of an Ageing Population, McMaster University.

21.

Kenny DA (2008) Mediation with dichotomous outcomes. Available at: http://davidakenny.net/doc/dichmed.pdf.

22.

Kim

(2016) Exploring the health of female spouses from multicultural families: Examining the differences by their country of origin. Journal of the Korean Academia-Industrial Cooperation Society 17(3): 252–261.

23.

Kim

Won

Choi

(2011) Experiences of discrimination and psychological adjustment among children of multicultural families. Korean Social Welfare Research 42(1): 117–149.

24.

Korea Immigration Services (2018) Statistics related to foreign-born residents in Korea. Available at: http://www.immigration.go.kr/HP/COM/bbs_003/ListShowData.do?strNbodCd=noti0097&strWrtNo=258&strAnsNo=A&strOrgGbnCd=104000&strRtnURL=IMM_6070&strAllOrgYn=N&strThisPage=1&strFilePath=imm/.

25.

Krieger

(1999) Embodying inequality: A review of concepts, measures, and methods for study. International Journal of Health Services 29(2): 295–352.

26.

Kulis

Marsiglia

Nieri

(2009) Perceived ethnic discrimination versus acculturation stress: Influences on substance use among Latino youth in the Southwest. Journal of Health and Social Behavior 50(4): 443–459.

27.

Laroche

(2000) Health status and health service utilization of Canada’s immigrant and non-immigrant populations. Canadian Public Policy 26(1): 51–73.

28.

Lee

Kim

(2014) Acculturation and self-rated health among foreign women in Korea. Health and Social Welfare Review 34(2): 453–483.

29.

Massey

Arango

Hugo

, et al. (1993) Theories of international migration: A review and appraisal. Population and Development Review 19(3): 431–446.

30.

McDonald

Kennedy

(2004) Insights into the “healthy immigrant effect”: Health status and health service use of immigrants in Canada. Social Science & Medicine 59(8): 1613–1627.

31.

MacKinnon

Lockwood

Hoffman

, et al. (2002) A comparison of methods to test mediation and other intervening variable effects. Psychological Methods 7(1): 83–104.

32.

Ministry of Gender Equality and Families (2013) 2012 National Survey of Multicultural Families, Seoul: Ministry of Gender Equality and Families.

33.

Kim

(2017) The effect of discrimination on self-rated health among foreign spouses: The moderating effect of social support and subjective health status. Journal of Digital Convergence 15(11): 485–496.

34.

Newbold

(2005) Self-rated health within the Canadian immigrant population: Risk and the healthy immigrant effect. Social Science & Medicine 60(6): 1359–1370.

35.

Omariba

DWR

(2010) Health literacy and immigrants in Canada: Determinants and effects on health outcomes. Canadian Issues. Available at: https://pdfs.semanticscholar.org/7f7d/78e6f2f0e183a02adee41ce1989a3fc2c714.pdf.

36.

Omariba

DWR

(2011) Immigration, generation and self-rated health in Canada: On the role of health literacy. Canadian Journal of Public Health 102(4): 281–285.

37.

Pascoe

Richman

(2009) Perceived discrimination and health: A meta-analytic review. Psychological Bulletin 135(4): 531–554.

38.

Pavalko

Mossakowski

Hamilton

(2003) Does perceived discrimination affect health? Longitudinal relationships between work discrimination and women’s physical and emotional health. Journal of Health and Social Behavior 44(1): 18–33.

39.

Perez

(2002) Health status and health behavior among immigrants. Health Reports 13(Suppl.): 89–100.

40.

Prelow

Mosher

Bowman

(2006) Perceived racial discrimination, social support, and psychological adjustment among African American college students. Journal of Black Psychology 32(4): 442–454.

41.

Puyat

(2013) Is the influence of social support on mental health the same for immigrants and non-immigrants? Journal of Immigrant and Minority Health 15(3): 598–605.

42.

Ryu

(2016) Effects of the marriage migrant women’s discriminatory experiences on the physical and mental health. Journal of Korean Contents 16(8): 345–356.

43.

Salgado

Castaneda

Talavera

, et al. (2012) The role of social support and acculturative stress in health-related quality of life among day laborers in Northern San Diego. Journal of Immigrant and Minority Health 14(3): 379–385.

44.

Stafford

Newbold

Ross

(2011) Psychological distress among immigrants and visible minorities in Canada: A contextual analysis. International Journal of Social Psychiatry 57(4): 428–441.

45.

Statistics Korea (2017) Multicultural Families Status Report. Available at: http://kostat.go.kr/portal/korea/kor_nw/2/1/index.board?bmode=read&bSeq=&aSeq=364679&pageNo=1&rowNum=10&navCount=10&currPg=&sTarget=title&sTxt.

46.

Stipkova

(2016) Immigrant disadvantage or the healthy immigrant effect? Evidence about low birth weight differences in the Czech Republic. European Journal of Public Health 26(4): 662–666.

47.

Todaro

(1969) A model of labor migration and urban unemployment in less developed countries. American Economic Review 59(1): 138–148.

48.

Vega

Gil

(1998) Drug Use and Ethnicity in Early Adolescence, New York: Plenum Press.

49.

Williams

Collins

(1995) U.S. socioeconomic and racial differences in health: Patterns and explanations. Annual Review of Sociology 21: 349–386.

50.

Schimmele

(2004) The healthy migrant effect on depression: Variation over time? Canadian Studies in Population 32(2): 271–295.

51.

Zajacova

Dowd

(2011) Reliability of self-rated health in U.S. adults. American Journal of Epidemiology 174(8): 977–983.