The Journal of School Nursing2022, Vol. 38(2) 138–147© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520906591journals.sagepub.com/home/jsn
This study aimed to compare related factors of depressive symptoms among multicultural adolescents in South Korea. Crosssectional data were collected from 1,325 students studying in ninth grade (mean age: 14.97 ± 0.36 years) who had one Korean parent and one foreign-born parent. The score of depressive symptoms among girls (1.777 ± 0.550) was higher than boys (1.647 ± 0.512). The regression model—including demographic, psychological, and social factors—explained 38.3% of depressive symptoms among boys and 27.9% among girls. Body image satisfaction was the most powerful factor related to depressive symptoms in both boys and girls. Gender-differentiated factors identified in this study such as demographic, psychological, and social factors need to be studied while planning gender-tailored intervention programs to help relieve depressive symptoms among multicultural adolescents.
adolescents, body image, gender, depression, multiculture, risk factors, school nursing
A multicultural family in South Korea is defined as an international marriage between individuals belonging to two distinct cultures, including international immigrants or foreign workers (Ministry of Government Legislation, 2009). South Korea has been long described as an ethnically homogeneous country with a uniquely homogenous culture and racially homogeneous population, but the notable recent increase in multicultural families has rapidly transformed South Korea as a multicultural or multiracial country (The United Nations Educational, Cultural and Scientific Organization, 2009). The prevalence of international marriages has increased from 3.5% of total marriages in 2000 to 8.8% in 2018 (Statistics Korea, 2019). Specifically, the number of international marriages between South Korean men and foreign-born women dramatically increased from 6,945 in 2000 to 16,608 (73.2% of international marriage) in 2018, and the number of international marriages between South Korean women and foreign-born men also increased from 4,660 in 2000 to 6,090 (26.8% of international marriage) in 2018 (Statistics Korea, 2019). Therefore, the number of individuals, aged 9–24, raised in multicultural households in South Korea has rapidly increased from 14,654 in 2007 (0.2%) to 109,387 in 2017 (1.9%; Ministry of Government Legislation, 2011; Statistics Korea & Ministry of Gender Equality and Family, 2018). Even though the number of multicultural adolescents in South Korea has dramatically increased and would be expected to increase more in the near future, related health science research including nursing has still not provided a sufficient understanding of their health-care needs.
With an increase in international migration over recent decades, the health status of adolescents of immigrant or multicultural families poses as a major public health concern in many countries such as France (Chau et al., 2016), Canada (Pottie et al., 2015) and the United States (Udry et al., 2003). Multicultural adolescents reported higher health problems such as tiredness, headaches, and pains (Udry et al., 2003). They are more likely to experience bullying, peer aggression, and suicidal ideations and attempts (Chau et al., 2016; Pottie et al., 2015). Ethno-racial minority adolescents, such as those from immigrant or multicultural families, reported elevated stress, anxiety, and depressive symptoms due to confusion in self-identity, and negative image portrayed by the majority population (Chau et al., 2016; Pottie et al., 2015; Udry et al., 2003).
Depressive symptoms among adolescents are a major concern in South Korea because they often indicate a heightened risk of long-term depression later in life. These symptoms are also associated with unsocial behaviors such as adolescent delinquency, substance use, and suicidality (Chung & Joung, 2012, 2014; Copeland et al., 2013). In South Korea, the prevalence of depressive symptoms among students studying in seventh to ninth grades has increased from 2015 to 2017, and 25% of all school-age adolescents (20.3% boys and 30.3% girls) reported depressive symptoms in 2017 (Statistics Korea & Ministry of Gender Equality and Family, 2018). Based on the national monitoring report on depressive symptoms among multicultural students, these were more severe among students in seventh and ninth grade (1.713 ± 0.538/total 4 scores) compared to younger children in first and sixth grade (1.604 ± 0.528/total 4 scores; National Youth Policy Institute, 2019). Thus, additional research is necessary to understand the factors contributing to depressive symptoms among multicultural adolescents in South Korea and should be considered while planning appropriate preventive interventions for targeting depressive symptoms among multicultural adolescents.
Even when research participants were not multicultural adolescents, previous research on the correlations and profiles of depressive symptoms among adolescents has focused on the following three categories (Lim et al., 2016; Osok et al., 2018): (1) demographic characteristics, including gender, economic status, academic status, and weight category (Chung & Joung, 2012; Lim et al., 2016); (2) psychological factors, including body image satisfaction and self-esteem (Chung & Joung, 2012; Lim et al., 2016; Senin-Calderón et al., 2017); and (3) social factors including family support, friendships and peer group support, and community support (Lim et al., 2016; Quiroga et al., 2017). Some research included multicultural adolescents (Bahk et al., 2017; G. R. Park et al., 2016: S. Park et al., 2017; S. Park et al., 2018; Yi & Kim, 2017); however, previous research is quite different to the samples such as adolescents with foreign-born mothers (Yi & Kim, 2017) or adolescents with parent nationality (Bahk et al., 2017), and little is known about the systemic view of all factors for depressive symptoms that may be specifically prevalent or unique among overall multicultural adolescents in South Korea.
Therefore, this study aimed to analyze gender differences in depressive symptoms that are generally the most obvious findings in psychiatric epidemiology (Dardas et al., 2018). Based on the South Korean study of chronological trends marking the manifestation of depressive symptoms as children enter their adolescence years, the emergence of a defined gender gap becomes most prevalent in mid-teen adolescents (Lim et al., 2016), and the previous researches on multicultural teenagers (Bahk et al., 2017; S. Park et al., 2018) explained mental health symptoms differentiated to the gender: boys and girls. Thus, to incorporate information relative to gender-tailored intervention for depressive symptoms among these multicultural adolescents, this study was designed to compare and describe related factors of depressive symptoms between multicultural boys and girls who were students in third grade in middle school in South Korea (ninth grade in the U.S. educational system, about 15 years old).
This study conducted a secondary analysis of data retrieved from the 2016 Multicultural Adolescents Panel Study (2016 MAPS) to identify related factors of depressive symptoms among adolescents. This study was reviewed and approved by the institutional review board, Jeonbuk National University (IRB No: 2019-04-002).
The data were retrieved from the 2016 MAPS data set of the National Youth Policy Institute in South Korea, which was the latest data set open to researchers. Since 2012, the MAPS has been conducted annually to assess information related to demographics, environmental characteristics, and the status of social support for adolescents with multicultural backgrounds (National Youth Policy Institute, 2019). The questionnaires are available in 10 languages, namely Korean, English, Chinese simplified, Chinese traditional, Japanese, Filipino, Vietnamese, Mongolian, Russian, and Thai to support the students’ understanding. Participants in MAPS were selected using stratified sampling with probability proportional to size. The sample constituted students studying in third grade in middle school in South Korea, which is equivalent to ninth grade in the U.S. educational system, and approximately 15 years old. The data for 2016 MAPS were collected by computer-assisted personnel interviews from May to July in 2016 (National Youth Policy Institute, 2019).
The author obtained approval from the National Youth Policy Institute to use the original data set of MAPS. The obtained data sets included no personally identifiable information. Of the 1,325 adolescent students of ninth grade (mean age: 14.97 ± 0.36), only those with one South Korean parent and one foreign-born parent were selected in this study, thereby excluding participants with insufficient demographics (n = 306), and participants whose parents were both foreigners (n = 4), as explained in Figure 1.
The study aimed to examine the effect of 10 factors (independent variables) on depressive symptoms (dependent variable). Variables, their explanations, and categories are presented in Table 1. The definitions of these variables were based on MAPS guidelines and the 2017 Korean National Growth Charts (Korean Centers for Disease Control and Prevention, 2018; National Youth Policy Institute, 2019).
All statistical analyses, which included descriptive statistics, χ2 tests, independent t tests, analysis of variance (ANOVA), and hierarchical multiple linear regressions, were conducted using SPSS 25.0. The χ2 tests and independent t tests were conducted to examine gender differences in related factors of depressive symptoms. Independent t tests or ANOVA was conducted to examine the effect of the nine categorical variables of the gender, economic status, academic achievement, and weight categories on mean values of depressive symptoms for each participant. A Schéffe test was conducted to differentiate among three categorical variables. Pearson correlation analyses were conducted to examine the strength of associations between all continuous variables: self-esteem, body image satisfaction, family support, friends support, and community support. For all boys and girls, hierarchical linear regression analysis was conducted to ascertain the effect of factors on depressive symptoms among multicultural adolescents. Model 1 included demographic factors, namely economic status, academic status, and weight category. Model 2 included the factors of Model 1 and psychological factors, namely body image satisfaction and self-esteem. Model 3 included the factors of Model 2 factors and social factors, including family, friends, and community support.
Depressive symptoms were higher among girls (1.777 ± 0.550) as compared to boys (1.647 ± 0.512) as depicted in Table 2. One item in the depressive symptoms scale (not in Table 2) describes the suicidal ideation, and it was not differentiated on gender (boys: 1.36 ± 0.558, girls: 1.40 ± 0.597, t = –1.188, p = .235).
As shown in Table 2, compared to girls, boys were characterized as underweight (p < .001) with higher body image satisfaction (p = .008), higher family support (p = .002), and higher community support (p = .012). As shown in Table 3, both boys and girls with lower economic status and lower academic achievement reported higher depressive symptoms than respondents with higher levels of economic or academic status, respectively (for both groups, p < .001).
There were similar patterns of correlation between psychological factors (body image satisfaction and self-esteem) and social factors (support from family, friends, and community) and depressive symptoms between boys and girls (Table 4). There was a negative correlation between body image satisfaction and depressive symptoms in both boys (r = –0.483, p < .001) and girls (r = –0.423, p < .001). Self-esteem was negatively correlated with depressive symptoms in both boys (r = –0.494, p < .001) and girls (r = –0.417, p < .001). Moreover, there was a negative correlation between family support and depressive symptoms in both boys (r = –0.439, p < .001) and girls (r = –0.365, p < .001). Support from friends and peer groups and depressive symptoms were negatively related in both boys (r = –0.412, p <.001) and girls(r = –0.287, p < .001). Further, community support and depressive symptoms in both boys (r = –0.347, p < .001) and girls (r = –0.308, p < .001) were negatively related.
As shown in Table 5, Model 3 for boys, which includes demographic, psychological, and social factors, accounted for up to 38.3% of depressive symptoms (all p < .001). Body image satisfaction (β = –0.203, p < .001), economic status (β = –0.175, p < .001), community support (β = –0.150, p < .001), family support (β = –0.136, p < .001), self-esteem (β = –0.111, p = .017), academic achievement (β = –0.072, p = .030), and the weight category (β = –.070, p = .027) had negative associations with depressive symptoms. Contrary to girls, the negative association between weight category and depressive symptoms among boys was significant in Model 1 (p = .009), Model 2 (p = .004), and Model 3 (p = .027).
Contrastingly, Model 3 for girls, which includes demographic, psychological, and social factors, accounted for up to 27.9% of the depressive symptoms (p < .001). Body image satisfaction (β = –0.202, p < .001), economic status (β = –0.095, p < .001), self-esteem (β = –0.133, p = .005), family support (β = –0.137, p < .001), and community support (β = –0.122, p = .002) had negative associations with depressive symptoms. However, the association between academic achievement and depressive symptoms among girls was significant in Model 1(β = –0.119, p < .001), but not significant in Model 2 (p = .130) and Model 3 (p = .336).
This study among multicultural adolescents (aged about 15 years) who had one foreign-born parent and one Korean-born parent revealed that the prevalence and related factors of depressive symptoms varied according to gender: The score of depressive symptoms among multicultural girls (1.777 ± 0.550) was higher than that among multicultural boys (1.647 ± 0.512). These results were consistent with past findings (Bahk et al., 2017; National Youth Policy Institute, 2015) that concluded that there were gender differences in the prevalence of depressive symptoms among adolescents from both non-multicultural and multicultural families. Thus, among ninth-grade students of South Korean-born parents, depressive symptoms assessed by the same scale were higher in girls (1.863 ± 0.558) than in boys (1.701 ± 0.531; National Youth Policy Institute, 2015). These gender differences in depressive symptoms may be due to the difficulties that girls face during puberty and the transition from childhood to adulthood. Girls experience more stress and exhibit higher levels of depressive symptoms than boys of the same age (Dardas et al., 2018). Past research on multicultural teenagers (Bahk et al., 2017) reported similar gender differences in depressive symptoms between multicultural adolescents and adolescents belonging to South Korean families; however, the pattern of suicidal ideation and attempts among multicultural adolescents may differ according to the nationality of the parents. Additionally, past research reported a higher prevalence of alcohol use, smoking, drug use, sexual relations, unhappiness, and stress among multicultural adolescents as compared to adolescents from South Korean families (S. Park et al., 2018). Consistent with previous findings (Bahk et al., 2017; Dardas et al., 2018), the present findings indicate that mental health symptoms and health risk behaviors could be related to the cultural differences such as gender role, acceptance of alcohol use, substance use, suicide or death.
Multicultural adolescents with a lower economic status exhibited higher levels of depressive symptoms. In South Korea, the divorce rate within the first 5 years of marriage is significantly higher among multicultural couples (34.1%) when compared to South Korean couples (21.1%). Foreign-born mothers and children in multicultural families often face economic difficulties, racial discrimination, and language difficulties (Statistics Korea, 2019). Furthermore, adolescents raised by single parents are more likely to experience additional financial difficulty, thus exacerbating symptoms of depression (Bahk et al., 2017). Therefore, teachers and counselors should assess a student’s demographic information including economic status, family structure, relationships, language difficulties, discrimination experiences, and their mental health status when dealing with multicultural adolescents.
The present findings revealed that boys with lower academic achievement displayed higher levels of depressive symptoms. These results are consistent with past findings that reported a higher risk of suicidal ideation and attempts among American and South Korean adolescents with lower academic achievement (Chung & Joung, 2012). In a very competitive country like South Korea, intense peer competition to excel academically and thus earn admission in prestigious universities foment high anxiety, low self-esteem, and high depressive symptoms in students. Based on the previous study (Chung & Joung (2012), this study results allow us to hypothesize that multicultural adolescents could have some interrupting factors of their academic achievement such as fluency in Korean language, and multicultural boys would have more stress to the future life plan (i.e., entering university and getting a job), compared to multicultural girls.
The factor that most strongly influenced depressive symptoms in both boys and girls was body image satisfaction. Body image refers to an individual’s perception of his or her own body, and is a component of self-esteem (U.S. National Library of Medicine, 2019). Body image development usually begins during adolescence, between ages 12 and 15, and lower body image satisfaction presents risks of eating disorders and depressive symptoms (Senin-Calderón et al., 2017). The present findings revealed that multicultural adolescents with lower body image satisfaction or lower self-esteem reported higher levels of depressive symptoms. The findings also highlighted that being underweight was a related factor of depressive symptoms among boys. Present findings are consistent with previous researches conducted in Latin American countries (Perreira & Telles, 2014) and in the United States (Udry et al., 2003) on the health inequity among ethno-racial minority or multicultural population. Compared to adolescents from homogenous families, a high prevalence of emotional, health, and behavioral problems among multiracial or multicultural adolescents may be due to their struggle with identity formation, which leads to lower self-esteem and social isolation (Udry et al., 2003). Perreira and Telles (2014) in a study based on the Latin American national data set concluded that multicultural adolescents often face discrimination based on skin color, which results in poor health status (Perreira & Telles, 2014). The findings of a study conducted by Chung and Joung (2012), which compared the risk factors of suicidality among adolescents from the United States and South Korea, reported that lower body image satisfaction and heightened concerns about body weight increased the risk of suicidality only among South Korean adolescents. Bahk et al. (2017) posit that the nationality of the parents may influence the depressive symptoms among adolescents. For example, the prevalence of depressive symptoms among the offspring of Asian mothers such as Japanese or Korean-Chinese was lower or similar to that of the offspring of Korean parents; however, the offspring from the other ethnic background reported higher depressive symptoms than the offspring from Asian or South Korean parents. Present findings and previous researches (Bahk et al., 2017; Chung & Joung, 2012; Perreira & Telles, 2014; Udry et al., 2003) showed that in South Korea’s largely homogenous environment, multicultural adolescents are found to be more exposed to racism, teasing, bullying, or violence victimization simply because their appearance may be seen as strange or different (S. Park et al., 2017). Adolescents victimized by bullying and violence are linked to psychiatric problems, suicidal ideation, and suicide attempts (Yen et al., 2015).
Considering the aforementioned social factors, both boys and girls who reported higher levels of support from family and community exhibited lower levels of depressive symptoms. The South Korean government has enacted measures to prevent social discrimination according to the Multicultural Families Support Act (Ministry of Government Legislation, 2009). However, national legislation has not been successful in curbing social discrimination or preventing situations that trigger depressive symptoms in multicultural adolescents. Recent research reports that more than 10% of multicultural adolescents in South Korea face social discrimination from friends, teachers, relatives, neighbors, or strangers. These experiences of ethnic discrimination or conflict are more likely to augment depressive symptoms and suicidal ideation (S. Park & Lee, 2016; S. Park et al., 2016). This study highlights the importance of family and community intervention to promote mental health among the increasing population of multicultural adolescents. Parental support may protect adolescents from developing depressive symptoms after exposure to violence (Quiroga et al., 2017). Additionally, the provision of multiple channels of communication with family members or friends to discuss personal issues can be effective in helping adolescents overcome depressive symptoms (Lim et al., 2016).
There are several limitations to this study. The present findings, based on a cross-sectional survey, are limited in scope to interpret the causality between related factors and depressive symptoms. Moreover, since the participants belong to the school-age population, the results cannot be generalized to understand depressive symptoms among multicultural adults. Additionally, the present findings, based on secondary analysis of the existing national data set, do not fully assess other physiological or hormonal changes during pubertal age, which may influence the symptoms of depression (Dardas et al., 2018).
Despite the increase in the number of multicultural adolescents over the past 20 years, research in health sciences, including nursing, has not studied the specific mental and physical health-care needs of these individuals. The results of this study may be used by school nurses, pediatric nurses, community nurses, or health-care providers to shape interventions that describe multiple intertwined factors and can be tailored to the gender of multicultural adolescents. The effort of family members, school authorities, and community to instill a sense of connectedness and belonging while encouraging body image satisfaction and self-esteem may aid multicultural adolescents and their families to overcome depressive symptoms.
School nurses, families, teachers, and health-care professionals who provide counseling services to adolescents suffering from symptoms of depression should assess both demographic and social factors while discussing personal issues and developing comprehensive support plans. As the number of immigrants increase, school nurses in other countries of the world have the opportunity to deal with multicultural adolescents from various racial or cultural background. This study can be helpful for school nurses and researchers who counsel multiracial or multicultural adolescents in South Korean backgrounds for understanding their mental stress and planning intervention programs for them.
Additionally, consistent with past research, the present findings highlight the need for gender-tailored intervention programs to alleviate depressive symptoms among multicultural adolescents. The findings of this study may facilitate the development of these programs. For example, this study highlights the importance of body image satisfaction and self-esteem on the mental health status of multicultural adolescents. Assessing the nationality of parents would be important, but school nurses, teachers, and health-care personals should be aware of their assessment not to be misunderstood as racial discrimination. Based on present findings, an intervention program to alleviate depressive symptoms among girls should assess body image and pubertal changes to understand their emotional status. Conversely, a similar program for boys should assess academic stress, body image, and weight. Counseling multicultural adolescents about career plans including university majors or future job prospects may help in reducing academic stress. Moreover, organizing selfsupport groups may help in strengthening self-esteem and improving body image satisfaction.
As the multicultural population will have been increasing, the longitudinal research for depressive symptoms from childhood to adulthood could plan for understanding their mental health needs and planning the national health policies for them. The variables in this study would be helpful to plan future studies. Future research to examine health behaviors and mental health symptoms, such as depressive symptoms and suicidal behaviors, and gender differences among multicultural adolescents in South Korea is necessary to understand their inequity and cultural diversity.
Furthermore, to develop effective policies and programs to advance the understanding of mental health needs of the fast-growing multicultural population, counselors, adolescents, and other support personnel should collectively work toward alleviating depressive symptoms, while promoting diversity and curbing discrimination. The development of ethnic identity during the period of early adolescence is that adolescents’ understandings of their ethnic groups are shaped by interactions and messages transmitted from family and society and actually experience (Rivas-Drake et al., 2009). Therefore, non-multicultural and multicultural adolescents in South Korea should be encouraged to live harmoniously and accept diversity while upholding their respective cultural heritages. In addition, fostering more confident body image satisfaction and positive self-esteem may help in relieving symptoms of depression. Adults in schools and throughout communities must become role models to promote multicultural coexistence within South Korea. School nurses, teachers, and health-care professionals who counsel multicultural adolescents play an important role in transmitting significant discrimination (S. Park et al., 2016) to multicultural adolescents or positively change the school or community environment surrounding multicultural adolescents. Moreover, to reduce multicultural adolescents, the related institution and policy makers should assist their learning and try to make a positive educational setting and job market in South Korea.
In the era of globalization, the proportion of multicultural families will continue to increase not only in South Korea but also worldwide. Further investigation regarding the depressive symptoms of multicultural adolescents in school, community, and clinical settings is necessary to develop methods to relieve depressive symptoms.
Both authors contributed to the conception of the manuscript, acquisition, and analysis of data involved, drafting process, critical revisions, and final approvals. They agree to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Kyoung Hwa Joung, PhD https://orcid.org/0000-0002-7221-3414
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Kyoung Hwa Joung, PhD, RN, is an associate professor at the Department of Nursing, Jeonju University, Jeonju, South Korea.
Sung Suk Chung, PhD, is a professor at the Department of Statistics and Institute of Applied Statistics, Chonbuk National University, Jeonju, South Korea.
1 Department of Nursing, Jeonju University, South Korea
2 Department of Statistics and Institute of Applied Statistics, Jeonbuk National University, Jeonju, South Korea
Corresponding Author:Kyoung Hwa Joung, PhD, Department of Nursing, Jeonju University, 303, Cheonjam-ro, Wansan-gu, Jeonju, Jeonbuk, 55069, South Korea.Emails: hwa0607@naver.com; joungkyounghwa@gmail.com
