Mental health of female foreign spouses in transnational marriages in southern Taiwan

As a result of globalization, the number of individuals who travel, work or study abroad is increasing, along with the number of transnational marriages. According to the United Nations [1], approximately half (49.6%) of the 200 million international migrants in 2005 were women. The UN has argued that globalization opens up a rather personal market of emotional relationships and marriages. Hence, the phenomenon of "mail-order brides" has become an important route for international migration, and the number of women from poor countries who have married men from more developed countries has increased. As a result, the number of marriage bureaus and matchmaking agencies has also risen. Recently, there has been a dramatic rise in the number of "mail-order brides" who have been provided through matchmaking agencies.

Today, cross-border marriages seem to be an alternative to poverty and starvation. Foreign brides usually come from countries such as Indonesia, the Philippines, Vietnam, and Thailand. Since the 1970s, such women have married men from the more affluent Western world, from countries that promise them a better life and a stable future, such as the United States, Canada, and Europe. In Asia, the recruitment of foreign brides has been increasing in Japan, Korea, Hong Kong, and Taiwan since the 1990s.

In 2006, one in every five marriages in Taiwan was transnational [2], and 89% of the foreign spouses involved were female. The majority of these female foreign spouses originated from countries in Southeastern Asia, including Vietnam and Indonesia. Such marriages were arranged predominantly through a commercial marriage agent [1]. The most common reason given for the decision to marry a foreign husband was economic stability (58%), because the marriage enables the woman to relocate and to obtain a higher social status and quality of life [3]. The other reasons included: to obtain a visa (16%), love (16%), curiosity about living in a foreign land (5%), an escape from family problems, and so on.

The impact of a transnational marriage on the relocated spouse includes changes in culture, language, role, and interpersonal interactions. According to Helman [4], culture is a set of guidelines that individuals inherit as members of a particular society. It tells them how to view the world, how to experience it emotionally, and how to behave in the world in relation to other people, to supernatural forces or gods, and to the natural environment. The context of culture comprises historical, economic, social, political, and geographical elements. Thus, the different cultural backgrounds of people from different countries might cause them to think, experience life, and behave differently. As a result, a move to another country is an important event for people, and it can alter their life dramatically.

Marriage, which is a big step in the life of an individual, also creates a new scenario in which the partners must adjust to their new roles. Female foreign spouses in Taiwan not only face the stress of immigration, but also have to cope with the cultural demands of their husband's family. In general, female foreign spouses go to more affluent countries, such as Japan, Hong Kong, Korea, and Taiwan, to gain a better life and a more stable future. These countries, including Taiwan, actively promote cross-border marriages and encourage the naturalization of foreign spouses in order to ensure a healthy productive line that will serve the needs and interests of neoliberal globalization [3].

Shu and colleagues interviewed 19 female foreign spouses and found them to have difficulties in adjustment to their new life in Taiwan [5]. The major themes raised regarding their living experience were: difficulty in finding a sense of belonging, children being the center of their life, and children being under pressure because of the insecurity and loneliness of their mother. Becoming a mother needs many more resources, and social networks are required to support the development of women emotionally, socially, psychologically, and culturally, while they develop their abilities as competent mothers. The need both to adjust to an alien culture and to serve as a mother causes foreign mothers to suffer from more pressures and conflicts than local mothers. Hence, the role of mental health services is very important in these populations, because mental health problems might result from these pressures [6–8].

Kuan suggested that the health and well-being of female foreign spouses is a critical issue [9]. Furthermore, the social, cultural, and economic adjustment required during the process of adaptation can be stressful. Immigration has been linked to mental health, but the nature of the association has changed over time. Early notions of immigration and mental health were built on the premise that people encounter difficulties and obstacles as they settle into a new society [10]. The cultural differences not only cause mental disability, but they also contribute to other problems, including difficulties in interpersonal relationships with partners and others [11]. Integration, and the adjustment to a new relationship and a new environment, can affect the health of an individual. Cultural differences, changes in life pattern, and feelings of hopelessness are risk factors for deviations from health. When immigrants have difficulty in adapting to new social and cultural norms, mental health problems such as depression, schizophrenia, and anxiety can be manifested [12, 13].

However, despite the increasing visibility of transnational female foreign spouses in communities across the island of Taiwan, little is understood about their health, especially their mental health. The lack of health data about these women has become a critical issue as health care providers try to become responsive to the pressing needs of female foreign spouses who come from different cultures and potentially speak or read little or no Chinese. In order to help these female foreign spouses to adjust, it is necessary to understand better the experiences and concerns of these women, who bring their own cultural backgrounds, perceptions, and experiences into the homes of their husbands in Taiwan. Therefore, an understanding of the health care needs and mental health, as well as its related factors, of this specific group in Taiwan is an important issue for mental health nurses.

The specific aims of this study were: (1) to investigate the mental health status, as well as factors related to mental health, of female foreign spouses from Vietnam, Indonesia, and mainland China in transnational marriages, and (2) to understand the mental health care needs of these women.

This study provides valuable information on the mental health status of female foreign spouses in transnational marriages in Taiwan. Mental health has become a critical issue recently in the study of female foreign spouses. Spouses in transnational marriages are faced with the stresses associated with being away from their country of origin and with cross-cultural marriage. The present paper attempts to explore the mental health issues of these women, and to make general conclusions about their adjustment after immigration. This study also examined and identified various needs in relation to mental health. Furthermore, personality and mental health care needs factors were also found to be the potential threat to mental health.

Common problems, such as cultural adaptation, economic and language difficulties, and a lack of social support and ethnic identity, might mean that women in transnational marriages represent a high risk population with respect to mental health. In addition, factors such as effects on the self of family and social-cultural background might result in potential mental health problems when individuals become maladjusted [22]. Obviously, Chinese spouses tend to have better mental health status and less mental health care needs than Vietnamese or Indonesian spouses in the present study. There were around 20% and 27% of the Vietnamese and Indonesian spouses of this study, respectively, had a CHQ score ≥4, which can be compared with 18% in native Taiwanese women in our previous study [23]. This result indicated that these women in the current study had poorer mental health than those studied by Shu [23]. An important issue in social psychological research on mental health is the existence of stressful life circumstances that are rooted in the social role of the individual. Immigration is a stressful life experience that leads to cultural differences and conflicts, language barriers, and economic and societal changes, which in turn cause changes in interpersonal relationships, values and attitudes, and necessitates time to adjust. These changes can have negative effects on personal health [24, 25]. Due to the similar social cultural background and language among China and Taiwan, hence, Chinese spouses suffer less likely psychological stress in living Taiwan, comparing with Vietnamese or Indonesian spouses. Vietnamese or Indonesian spouses also further need more assistance from friends and more comfort from religion than Chinese spouses.

Furthermore, it has been documented that many immigrant wives from Southeast Asia become pregnant soon after settling in Taiwan. Therefore, the difficulties involved in adapting to both a new marriage and a new culture are compounded by the challenges of giving birth and new motherhood. Most of the marriages of these female foreign spouses were arranged through matchmaking agencies. The relationship with the husband needs time to establish. In addition, because of the duty to continue the bloodline of the husband, these female foreign spouses not only face cultural differences but must also deal with the experience of giving birth to a baby. Although the female foreign spouses came to Taiwan for a better life, in general, the social-economic class of husbands involved in transnational marriages in Taiwan is low. There is also a lack of social support. Immigrants are often discriminated against, do not have close friends, and are unemployed; these factors also influence the indicators of depression and anxiety [26].

Good mental health implies that the individual has a stable personality and therefore can maintain a concordant relationship with the external environment. Mental health is affected by social structure, culture, and environment. The pursuit of the life task is an individual process and relates to personal beliefs and characteristics [27]. Our study showed that female foreign spouses with neuroticism were more likely to cause mental health care needs and to develop mild psychiatric symptoms than those without neuroticism. Research has shown that neuroticism is correlated with physical symptoms of mental health [28].

However, we found that the female foreign spouses did not identify their own health needs. Individuals commonly do not seek health care if they are unaware of their needs or do not identify the resources they could claim. From the responses of the participants, the need for assistance from the family was their first priority. The need for assistance from friends also played an important role. The stigma of acknowledging mental health problems poses a significant barrier to seeking help [29]. It seems that building a basic trusting relationship with such individuals is the first step. In an alien land, where the language, values, work atmosphere, and patterns of socialization are different from those in their own country, woman might become completely lost. Using further analysis of multiple linear regression, the dimensions of knowledge of the level of their own psychological disturbance, of friends assistance, and of religion comfort were potential threat factors in increasing mild psychiatric disorders. By SEM model, the findings also provided an evidence that higher degree of mental health care needs was related to greater likelihood of mild psychiatric disorder, especially the dimensions of knowledge of the level of their own psychological disturbance, of psychological professional services, of religion comfort, and of folk therapy. As description in the previous paragraph, Vietnamese or Indonesian spouses tend to have more likely mental health care needs than Chinese spouses, and then further indirectly caused more psychological stress, even leaded more mild psychiatric disorders. From the results of this study, we have a better understanding of how to assist these female foreign spouses, particularly focus on the psychological counseling and religion therapy in the Indonesian and Vietnamese spouses.

The psychosocial health of female foreign spouses is compromised not only as a consequence of having to cope with the usual demands of new motherhood and physical health problems but also as a result of loneliness caused by isolation and a lack of social support [30, 31].

In general, physical health is given much greater priority than mental health. These female foreign spouses and their families did not perceive the stress of transnational marriage and its effects on mental health to be a problem. They considered it to be a self-inflicted abnormal behavior to seek attention. Thus, an examination of the use of mental health services by this population is necessary.

There are some limitations of this study. Firstly, the design lacked a control population of native Taiwanese women. In order to reduce the effect of this limitation, we used a previous study as a reference for comparison. Secondly, we used a convenience sample. A variety of women in transnational marriages have complicated reasons for coming to Taiwan. Therefore, it is difficult to make generalizations from our results. Thirdly, the cross-sectional design might not manifest the true situation comprehensively. It might be necessary to follow up the process of adaptation, adjustment, and incorporation into society regularly.

According to Helman [4], "culture is a set of guidelines which individuals inherit as members of a particular society, and which tells them how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or gods, and to the natural environment" (p. 2). The context of culture comprises historical, economic, social, political, and geographical elements. Thus, people from different countries can have different cultural backgrounds that cause them to think, experience life, and behave differently. As a result, a move to another country is an important event for people, and can alter their life dramatically.

Transnational marriages have become a popular social phenomenon. Several issues arise in association with transnational marriage. The need to adjust to an alien culture causes female foreign spouses to suffer from more pressures and conflicts than local mothers. A previous study showed that foreign-born mothers, especially those who could not speak the local language, had higher levels of depression and anxiety than native-born mothers [32]. In the same study, the researchers also found that children of native-born mothers performed better in developmental evaluations than those of foreign-born mothers.

As a result of "mail-order" marriages and unskilled migration, the above study reported an unmet need for social and economic security to ensure safe maternal practices and to reduce the challenges that face immigrant women in Southeast Asia countries. This paper seeks to fill that gap in documentation. A review article concluded that the transition to motherhood is an overwhelming experience. At present, "mail-order" brides from Southeast Asia make up the majority of transnational marriages. Furthermore, it has been documented that immigrant wives from Southeast Asia generally become pregnant soon after settling in Taiwan. The challenges of new motherhood are compounded, therefore, by the difficulties involved in adapting to both a new marriage and a new culture.