Mental health and wellbeing of ethnic migrant women and girls in Aotearoa New Zealand: a scoping review

Women constitute nearly half of global migrants.¹ They migrate for different reasons. While some pursue more equal development possibilities in wealthier countries, which increasingly demand care work,² others accompany their husbands or partners, becoming “trailing spouses”.³ As economic migrants, these women often take up specifically gendered roles in the global labour market, e.g., care work, nursing or factory work.³ Some women may migrate to escape restrictive gender norms.⁴ Those with refugee backgrounds or asylum seekers may have dealt with physical and sexual violence, loss of family members and persecution—which are risk factors for poor mental health and have major implications for access to care.^5,6 Irrespective of the reason, migration is a stressful process that poses a significant risk to the mental health and wellbeing of migrant women.⁵

Women’s migration experiences are frequently shaped by the intersection of gendered inequalities (such as access to nutrition, education, income and safety) and migration-related social inequalities (such as legal dependency on spouses, greater involvement in caregiving roles, lack of employment in the new country).⁷ Unlike their male counterparts, women are more likely to experience intersectional discrimination of both racism (from the host society) and sexism (including from their own communities), which creates distinct social and health inequities.⁵ For example, families and male partners may demand gender roles and attitudes from women, which may conflict with how most women live their lives in their new country.⁵ Migration has also been consistently identified as a significant risk factor for family violence in minority communities.⁸

Since the 1986 immigration reforms in Aotearoa New Zealand (New Zealand), there has been a significant increase in migration from Asian, and Middle Eastern, Latin American and African (MELAA) countries. These population groups are some of the fastest growing in New Zealand, constituting 19.2% of the total population.⁹ Of these, at least half are women.⁹ The Asian and MELAA groups, usually being presented as distinct population groups, have high heterogeneity regarding country of origin, visa status (e.g., temporary workers, international students, refugees etc.), time of residence in New Zealand and degree of integration into the New Zealand society. Furthermore, this group also presents varied social markers (e.g., age, religion, sexuality, socio-economic status) and settlement patterns (rural versus urban centres).¹⁰

In 2018, less than a quarter of the Asian and MELAA populations was born in New Zealand, indicating a high proportion of them are first-generation migrants who have been living in New Zealand for varied periods.¹⁰ The limited evidence that exists highlights that Asian and MELAA communities experience several health inequities in New Zealand, including high rates of cardiovascular diseases,^11,12 diabetes,¹³ low birth weight,¹¹ mental health issues¹⁴ and high risk of stroke.¹¹ At the same time, these communities show lower access rates to health services and healthcare utilisation, including primary care enrolment, screening services, mental health services, disability support and aged residential care.¹⁵

A recent review identified significant structural barriers, i.e., policies and frameworks that create inequitable access to healthcare services.¹⁶ These included cost of healthcare, limited access and quality of interpreter services (language barriers), short-duration appointments with long waiting times, difficulty navigating the health system and logistical barriers such as lack of knowledge on how to access health services. Language and cultural differences between service users and service providers have also been shown to reduce access to specialised services, such as mental health.¹⁷

The Asian and MELAA populations in New Zealand are projected to constitute over 25% of the total population by 2043.¹⁸ Understanding the mental health needs of Asian and MELAA women and girls and providing culturally and gender-responsive services can no longer be overlooked. The first step involves revealing what is currently known. Thus, we conducted a scoping review to identify and synthesise the existing literature relating to mental health and wellbeing of Asian and MELAA women and girls in New Zealand (both New Zealand born and migrants). The ultimate objective was to describe evidence gaps that need to be addressed to improve mental health outcomes for this population.

Methods

This review focussed on research on the mental health of Asian and MELAA women and girls living in New Zealand (both New Zealand–born and migrants). Research articles published up to July 2023, in English, that used quantitative, qualitative or mixed methods to measure or focus on specific dimensions of mental health of women/girls in New Zealand who self-identify as Asian and MELAA (irrespective of age or sex assigned at birth) were included. Studies with additional types of participants were included only if disaggregated data for Asian and MELAA women/girls were provided. Studies with data from different countries, including New Zealand, on the mental health of migrants, ethnic groups or women, were included only if disaggregated data for Asian and MELAA women/girls in New Zealand were provided.

Based on the eligibility criteria and medical subject headings related to mental health conditions described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), separate search strategies were created for four databases: American Psychological Association (APA) PsycInfo, CINAHL, Embase (Ovid) and MEDLINE (Ovid) (see Appendix). Following the search, all identified citations were collated and uploaded into EndNote 21 (Clarivate Analytics, PA, USA), and duplicates were removed. One reviewer (JVDA) screened titles and abstracts and assessed them against the inclusion criteria, consulting the wider research group for clarifications. Potentially relevant sources were retrieved in full for detailed assessment against the inclusion criteria. Reference lists of included studies were screened for additional sources of evidence. Grey literature (e.g., reports, policy literature, working papers, government documents) was not included.

Data were extracted (by JVDA) using a data extraction table developed for this review to document general information about each study (e.g., study design, participant characteristics, methods) and findings related to the review question, i.e., mental health and wellbeing of Asian and MELAA women and girls. These included data on the prevalence or incidence of a broad range of mental health conditions and psychological factors that could influence mental health and wellbeing (e.g., quality of life, life satisfaction, sense of connectedness and sense of belonging). No contact was made with the authors of the included study for any additional data.

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines¹⁹ to report the study findings, which include the study characteristics, mental health outcome measures and the outcome data.

Results

The searches retrieved 1,573 records, of which 226 were identified as duplicates and removed. The title and abstracts of the remaining 1,347 records were screened, and the full text was reviewed for 157 studies. Only 24 studies met the inclusion criteria and were included in this review. Most excluded studies either did not report the participants’ gender or ethnicity, or did not provide disaggregated data for them (Figure 1).

View Figure 1, Table 1–2.

1. Overview of the included studies

Overall, the included studies provided data on approximately 15,000 Asian and MELAA women and girls aged over 12 years living in New Zealand. They were published between 1992 and 2023. All studies provided data on Asian women. Three studies exclusively investigated Asian women.^20–22 Seven studies focussed on Asian populations, including women and men,^23–27 or boys and girls.^28,29 The other 14 studies also included MELAA participants but only two reported disaggregated data for MELAA women and girls.^30,31

In terms of specific population groups, two included studies focussed on secondary school and/or undergraduate students.^32,33 Seven studies focussed on perinatal women.^31,34–39 Only one of these studies provided disaggregated data for MELAA women/girls.³¹ The other six studies with perinatal women were analyses from the Growing Up in New Zealand study (GUiNZ) that separately reported data for Asian women/girls but combined the data for MELAA women/girls in the “other” category (including other ethnicities).^34–39 In addition, five studies investigated New Zealand residents over 15 years old,^30,40–43 providing data mostly on Asian women/girls—only one also provided disaggregated data for MELAA women.³⁰

The included studies investigated a wide range of concepts and outcomes related to mental health and mental wellbeing, which can be reported into two broad domains. First, prevalence and symptoms of mental health conditions and psychological wellbeing (n=18).^{20,23–31,33,34,37,39–43} Second, associations of socio-demographic factors with mental health conditions (n=9).^{20–23,32,35,36,38,41} Three studies reported findings related to both domains.^20,23,41 The tables of included studies presented exclusively describe the key findings specific to Asian and MELAA women and girls.

2. Prevalence and symptoms of mental health conditions and mental wellbeing

The review findings highlight the use of a variety of approaches to measure the prevalence of mental health conditions and mental wellbeing. The first approach was using questionnaires and scales or reviewing secondary mortality data to identify the prevalence of mental health conditions in Asian and MELAA women and girls and assess symptoms (n=10) (Table 1a). These included minor psychiatric symptomatology (i.e., higher levels of distress that could lead to psychiatric disorders; n=1),²⁰ eating disorder symptomatology (n=2),^24,25 general mental health (n=2),^23,41 depression (n=4),^32,35,36,38 stress (n=2),^34,39 self-esteem and life satisfaction (n=1)³³ and suicide (n=1).²⁸

The second approach to assess the prevalence of mental health conditions was used in five studies (Table 1b). It involved analysing medicine prescription and use for specific conditions, viz., dementia,³⁰ depression in pregnancy^31,37 and psychosis.^42,43

The third approach was through the proxy indicator of mental health service use (Table 1c). Three studies provided data related to the use of support services, i.e., for autism spectrum disorder (ASD),²⁹ public mental health services⁴⁰ and a helpline for Chinese speakers.²⁷

3. Associations of mental health with socio-demographic factors

Among the 24 included studies, nine analysed a range of factors commonly associated with mental health outcomes (Table 2). Two studies explored the impact of migration or refugee status.^21,22 Three studies examined associations of socio-demographic factors (such as age, education, socio-economic status and depressive symptoms) with perinatal depression,^36,38 one with minor psychiatric morbidity²⁰ and two with general mental health.²³ One study investigated intimate partner physical conflict and prenatal perceived stress.³⁵ One study estimated the impact of neighbourhood fragmentation (described as compositional factors that can fragment social connections within a neighbourhood)⁴¹ and another investigated the relationship between sexuality and gender with depressive symptoms, suicide attempts and the wellbeing of secondary school students.³²

Discussion

To the best of our knowledge, this is the first scoping review to examine the available evidence on mental health and wellbeing of Asian and MELAA women and girls in New Zealand and identify related knowledge gaps. The included studies estimated outcomes through symptom screening and proxy measures (prescription medicine use and factors associated with mental health) and association with different socio-demographic factors. Nevertheless, this review revealed a lack of robust data to estimate population-level prevalence rates or service use for mental health conditions in Asian and MELAA women and girls in New Zealand. Where these data exist, they are drawn from studies that have focussed on very few mental health conditions, are limited to certain population groups (e.g., specific ethnic groups within Asian communities) and are not evenly distributed across all settings (e.g., outside Auckland) in which Asian and MELAA women and girls live. This review provides limited data on Asian and MELAA migrant women and girls, particularly from smaller ethnic sub-groups and indicates that data for other intersecting groups (such as the rainbow community and women with disabilities) are even more scarce.

The included studies provided information regarding the prevalence of only a few mental health conditions—ASD,²⁹ dementia,³⁰ depression,^34,39 eating disorders,^24,25 minor psychiatric morbidity,²⁰ psychosis^42,43 and suicide.²⁸ Where data were available, they indicated gender differences in the Asian sub-group. Asian women/girls were at higher risk of depression,²⁶ being prescribed antipsychotics,⁴³ experiencing a minor mental health condition²³ or having body dissatisfaction than their male counterparts.²⁵ On the other hand, Asian women/girls represented fewer cases of young suicide deaths,²⁸ adult schizophrenia⁴² and young ASD diagnoses.²⁹ In addition, while Asian and MELAA women/girls and men/boys presented similar rates of public mental health services use,⁴⁰ Asian women/girls were more likely to use the helpline for Chinese speakers.²⁷

Differences between ethnic groups in women were also noted, with Asian women and girls at higher risk of antenatal depression than European women and girls.³⁹ However, at the same time, Asian women and girls had lower rates of antenatal antidepressant use compared to European women and girls,^31,37 suggesting limited access to mental health services. The findings also suggest a negative association between poor mental health outcomes and a range of socio-demographic factors, such as migration or refugee status,²² gender identity and sexuality³² and intimate partner conflict.³⁵ Furthermore, prevalent structural barriers to health services access in New Zealand¹⁶ were reported by migrant and refugee women.^21,22 These included financial constraints (cost of healthcare), language barriers (access and quality of interpreter services), lack of information on the health system and health services (obstacles navigating the health system) and logistical barriers (lack of knowledge on how to access health services). Thus, Asian and MELAA women and girls may need targeted support to know where and how to seek culturally responsive mental health services.

Asians are a very heterogeneous group comprising 37 sub-ethnicities. However, most studies that provided disaggregated data limited them to Asian women and girls, as they constitute most of the ethnic minority population in New Zealand.⁴⁴ Using “Asians” as a category is ineffective, as it masks the lived realities and specific needs of smaller ethnic groups within the Asian ethnicity.⁴⁵ This issue is also observed in the broad and diverse MELAA group. Despite Asian and MELAA communities being one of the fastest growing communities, we found only three studies that specifically investigated the mental health of Asian women, ^20–22 and none focussed on MELAA women. Even for the Asian community, only a few sub-ethnic groups (i.e., Bhutanese, Chinese, Indian, Korean and Pakistani) were included.

New Zealand has a growing population of Asian and MELAA ethnic migrant women and girls.⁴⁴ However, lack of funding for studies focussed on their health⁴⁶ leads to scarce mental health research for these women and girls. Our scoping review indicates very little data on Asian and MELAA women and girls, with a small range of conditions studied and few Asian and MELAA sub-groups. Data specific to Asian and MELAA women and girls need to be recognised as a priority area to support clinical practice and evidence-based designing, planning and implementation of policies and programmes for these populations. Future studies could sample Asian and MELAA women and girls to achieve adequate explanatory power. We also recommend studies with the general population to provide disaggregated data for all gender and ethnic groups, separately and combined, when applicable. Cross-sectional studies are needed to expand the current limited number of culturally validated measurement tools. It is also important to engage Asian and MELAA communities in research and policy spaces, including their voice in decision-making.

Most studies (n=17) provided data that could only be partially extracted due to a lack of disaggregated data for Asian and MELAA women/girls for all the relevant outcomes. Three studies did not report the total number of participating Asian and MELAA women/girls.^31,38,43 Thus, the exact number of Asian and MELAA women and girls included in this review is unclear (approximately 15,000). Seven studies included MELAA women and girls but did not provide disaggregated data for this group.^34–39 Five studies analysing results from the GUiNZ survey did not provide disaggregated data for Asian women and girls in all analyses related to perinatal depression.^34,36–39 Three studies compared outcomes related to mental health between ethnic groups but did not account for gender.^30,40,42 Another three studies also did not account for gender and ethnicity combined in all analyses.^26,33,43 Three studies with Asian participants also did not provide disaggregated data for women/girls for all outcomes.^23,24,27

Thus, we could not extract all relevant data, even though they existed in the raw dataset. Similarly, many studies did not meet the inclusion criteria due to a lack of disaggregated results for women/girls, Asian and MELAA participants, or both combined (e.g., outcomes reported for women/girls and Asian and MELAA participants but not for Asian and MELAA women/girls). The way through which authors reported outcomes limited the findings of this review. Authors face word limits for publications and report what is relevant to their research questions. Data on small or minority population groups may be lost in primary studies with diverse populations and no disaggregated data.

The main strengths of this review include its focus on Asian and MELAA women and girls, and its robust search process, adapted to four databases, using an extensive list of medical subject headings (and their synonyms) related to mental health conditions, with no date limits. We included both quantitative studies measuring indicators of mental health and wellbeing and qualitative studies revealing the perspectives of Asian and MELAA women and girls on their experience as migrant or ethnic women in New Zealand. This review only included published research articles. Other types of studies could complement the available evidence if ethnicity and gender disaggregated data are provided.

This review highlighted that peer-reviewed studies investigating the mental health and wellbeing of Asian and MELAA women and girls in New Zealand are scarce. The available evidence has heterogeneous populations and outcomes. Most data were drawn from studies that did not specifically investigate mental health issues in Asian and MELAA women/girls and frequently did not present disaggregated data for Asian and MELAA women/girls for all reported outcomes. Thus, this review indicates significant gaps in our understanding of the mental health needs of these populations. The lack of relevant data implies that the current policies, service provisions and resource allocations may not align with present needs, relying instead on sporadic and, in some instances, obsolete data. With growing populations in New Zealand, studies focussed on Asian and MELAA women and girls represent a key priority to enhance their wellbeing and promote equitable health outcomes. Additional data could inform the development and implementation of policies, strategies and programmes that address the needs of these growing populations and provide culturally and gender-responsive services.

View Appendix.