Gender Norms, Discrimination, Acculturation, and Depressive Symptoms among Latino Men in a New Settlement State

Abstract

Purpose

Drawing from major theoretical and conceptual frameworks on minority men’s mental health, we designed the current observational study to assess the associations of gender norms, discrimination, and acculturation with clinically significant depressive symptoms (CESD≥16) among a sample of immigrant Latino men in North Carolina.

Methods

We used data from a baseline survey of men (n=111) recruited for a peer-led health intervention. To assess the associations with depressive symptoms, we performed descriptive and bivariate analyses, followed by multiple logistic regression.

Results

Men in the sample tended to be young (mean age 18.5 years), recent immigrants (70.3% immigrated after age 16), and to have incomplete high school education (76.5%). About half (51.4%) reported experiencing discrimination due to their ethnicity and more than a third (37.8%) reported experiencing discrimination due to their race. Using the short form Conformity to Masculine Norms instrument, their mean masculinity score was 52.0; their average 12-item Short Acculturation Scale for Latinos score was 21.8. More than one-quarter of participants (26.1%) had clinically significant depressive symptoms. Multiple logistic regression models showed among this sample of immigrant Latino men in the Southeast, traditional masculine norms—but not perceived discrimination nor acculturation—were associated with clinically significant depressive symptoms.

Conclusions

Our results suggest a potential future avenue for intervention research: testing whether changing gender norms could result in improvements to mental health.

Introduction

Depression is a major mental health issue in the United States. In 2018, approximately 17.3 million US adults, about 7.1% of the adult population, reported having one or more major depressive episodes in the past year.1 Depression can result in disability, reduced family engagement, work productivity, and social functioning; and death.

Depression reporting varies by both gender and race/ethnicity. In nationally representative studies, men are consistently less likely to report a recent major depressive episode than women. In 2017, 8.7% of women and 5.3% of men indicated that they had experienced a major depressive episode in the prior 12 months.1 Latinos are less likely than non-Hispanic Whites to report mental health concerns, including depression. Among racial/ethnic groups, American Indians/Alaskan Natives (8.0%) and non-Hispanic Whites (7.9%) are most likely to report a recent major depressive episode, compared with 5.4% of Latinos, 5.4% of non-Hispanic Blacks, and 4.4% of Asians.2

Although the true prevalence of depression is similar between Latinos and non-Hispanic Whites,3 Latinos are less likely to seek help for mental health concerns and to receive appropriate treatment. In the general population, about half of persons with depressive symptoms get treatment,4 but one study found that among Latinos only 36% received treatment for past-year depression.5 More recent data show that, among the general adult and adolescent population aged ≥12 years, non-Hispanic Whites have more than three times the prevalence of antidepressant use of Latinos (16.5% compared with 5.0%); antidepressant use was also low among non-Hispanic Blacks (5.6%) and Asians (3.3%).6 Within every racial/ethnic group, higher proportions of females than males reported taking antidepressant medication.6

Among immigrant Latino men in the United States, experiences of discrimination, idealization of rigid traditional norms of masculinity, and the stress associated with crossing between distinct cultures may contribute to poor mental health, including depression. Prior research has established a link between perceived discrimination and mental health,7–10 and between acculturative stress and mental health 3,7,11 for Latino men. Other research suggests a link between gender norms and mental health.12,13 Specifically, conceptual models of gender role conflict posit that when men cannot meet traditional norms and ideals of masculinity, they lose self-esteem and experience stress.12

In the United States, gender role conflict (ie, the disconnect between masculine gender norms and ideals and an individual’s ability to enact them) may be particularly detrimental to mental health for non-White men. In the face of social, political, and economic marginalization, racial/ethnic minority men may experience discordance between ideal masculine gender roles (eg, providing financially for their family, receiving respect) and what they are able to enact or display, contributing to stress and risk of depression. Further, masculine gender norms among racial/ethnic minority men may contribute to reduced care-seeking for mental health concerns, based on ideas about manhood and perceived expectations.13–15

For immigrant Latino men, another potential point of discordance between ideal and enacted roles relates to immigration. The migration experience itself may involve violence or trauma for some of these men. Once in the United States, immigrants, particularly those who lack legal documentation, are further marginalized through both overt and hidden means, including exclusion from equitable opportunities for education, jobs, housing, and social status. With the recent rapid growth of the US Latino population, North Carolina is a new settlement state for immigrant Latinos. North Carolina was home to an estimated 75,000 Latinos in 1990, growing to 800,000 in 2010 and just over 1 million Latino residents in 2019, reflecting growth rates exceeding neighboring southern states.16 A lack of linguistically and culturally appropriate services in new settlement states may contribute to the likelihood of poor health outcomes for immigrant Latinos who experience multiple social, economic, and logistic barriers to health and health care.17

Since much of the research on immigrant Latinos in the United States has been conducted in established Latino communities in California, New York, Texas, and Florida, little is currently known about the determinants of depression in new settlement states—places that may have limited time or capacity to integrate and build equitable opportunities for a newer and growing Latino population. New Latino settlement states, such as those in the South, have more recent and rapidly growing Latino populations16,18 and may provide unique contexts to study determinants of men’s health.19–21

Drawing on prior empirical research on the mental health of Latino men and conceptual models of gender role conflict, we designed the current analysis of cross-sectional data. Little research has examined how masculine norms, racial/ethnic discrimination, and acculturation to US mainstream culture are associated with mental health symptoms for US Latinos. To our knowledge, no research to date has examined how these measures jointly relate to mental health among Latino men in a new settlement state. Therefore, drawing from theoretical and conceptual frameworks for minority men’s mental health, we designed the current observational study to assess the research question: Are masculine norms, experiences of racial and/or ethnic discrimination, and acculturation associated with clinically significant depressive symptoms in a sample of Latino men in a new settlement state?

Methods

Design and Sample

The data used in this analysis are baseline data from a study of immigrant Latinos participating in a lay health advisor HIV prevention intervention known as The Latino Partnership, which worked within men’s soccer teams in rural North Carolina.22 Established as part of an ongoing community-based participatory research (CBPR) partnership, The Latino Partnership study gathered data from lay health advisors and a sample of the men they would be advising, their soccer teammates. To be included in The Latino Partnership study, participants had to self-identify as a Latino/Hispanic man, be aged ≥18 years, and provide informed consent. Each participant received a $30 incentive for completion of the baseline assessment. The original Latino Partnership study was approved by the Wake Forest School of Medicine Institutional Review Board, and the current secondary data analysis was approved by the University of North Carolina at Greensboro Institutional Review Board.

For the current analysis, we focused on the 124 participants with baseline data. Thirteen cases were removed due to missing data, resulting in a final sample of n=111.

Study Variables

The dichotomous dependent variable was clinically significant depressive symptoms, as measured by a score of 16 or higher (out of 20) on the Center for Epidemiologic Studies Depression (CES-D) scale.23 The CES-D asks respondents to rate the frequency with which they experienced symptoms such as poor appetite, restless sleep, and feelings of loneliness in the past week, using a 5-point Likert scale (“rarely or none of the time” [0], “<1 day” [1], “some or little of the time, 1-2 days” [2], “occasionally or a moderate amount of time, 3-4 days” [3], “most of all of the time, 5-7 days” [4]).

We measured acculturation using the 12-item Short Acculturation Scale for Latinos (SASH),24 which assesses language use, media, and ethnic socialization using a 5-point Likert scale ranging from 1 point (only Spanish) to 5 points (only English); higher scores indicate greater acculturation to US mainstream culture (score range 5-60). For masculine gender norms, we used a 23-item short form of the Conformity to Masculine Norms Inventory (CMNI),25,26 which evaluates conformity to a variety of traditional masculine gender norms. Response options are on a 4-point Likert scale from strongly disagree (0) to strongly agree (3), and items are summed to create a scale score ranging from 0 to 69. We measured perceived discrimination using two single items: “Since coming to the US, I often have the feeling that I am being treated unfairly because of my ethnicity” and “Since coming to the US, have you ever experienced discrimination or been the victim of violence due to your race?” Response options are on a 4-point Likert scale from strongly disagree (0) to strongly agree (3).

We used self-report items to measure demographic characteristics including age, education, income, employment, and country of origin. Age at migration was dichotomized as those who came to the United States when aged ≤16 years, and those who came when aged ≥17 years.

Data Analysis

We examined sample characteristics using descriptive statistics, including frequencies and percentages, or means and standard deviations. We assessed the reliability of each scale with standardized Cronbach’s alpha. To assess the associations of discrimination, acculturation, and conformity to masculine norms with clinically significant depressive symptoms, we performed logistic regression analysis using SAS PROC GLIMMIX clustering for soccer teams. We chose control variables (age, age at immigration, and education) for entry into the model based on theory and extant literature. We used P<.01 to assess statistical significance for initial bivariate analyses and P<.05 for the final adjusted multivariate analysis.

Results

Participant Characteristics

As shown in Table 1, the immigrant Latino men in the study group tended to be young, with a mean age of 18.5 years. Most were relatively recent immigrants, with 70.3% having arrived in the United States when aged >16 years. More than three-quarters of participants (76.6%) had less than a high school education. About half (51.3%) reported experiencing discrimination due to their ethnicity and more than a third (37.8%) reported experiencing discrimination due to their race. Their mean Conformity to Masculine Norms Inventory score was 52.0 out of 69; their average 12-item Short Acculturation Scale for Latinos score was 21.8. More than one-quarter of participants (26.1%) had clinically significant depressive symptoms.

Table 1. Sample characteristics by depression symptoms, immigrant Latino men, N=111.

	No depression symptoms, CESD<16; n=82	Clinically significant depression symptoms, CESD≥16; n=29	Total, N=111
	Mean (SD)	Mean (SD)	Mean (SD)
Current age	18.5 (6.15)	18.6 (3.48)	18.5 (5.56)
Conformity to masculine norms	51.33 (5.26)	53.84 (4.02)	51.98 (5.07)
Acculturation	22.51 (6.93)	19.79 (5.12)	21.80 (6.59)
	% (N)	% (N)	% (N)
Age at immigration to US (yrs)
0-16	30.5 (25)	27.6 (8)	29.7 (33)
>16	69.5 (57)	72.4 (21)	70.3 (78)
Education
<high school	74.4 (61)	82.8 (24)	76.6 (85)
12+	25.6 (21)	17.2 (5)	23.4 (26)
Perceived discrimination due to ethnicity
Strongly agree/agree	48.8 (40)	58.6 (17)	51.3 (57)
Strongly disagree/disagree	51.2 (42)	41.4 (12)	48.7 (54)
Perceived discrimination due to race
Strongly agree/agree	36.6 (30)	41.4 (12)	37.8 (42)
Strongly disagree/disagree	63.4 (52)	58.6 (17)	62.2 (69)

Bivariate Associations

In bivariate analyses (not shown), conformity to masculine norms and acculturation were associated with clinically significant depressive symptoms. Greater conformity to masculine norms and lower acculturation were independently associated with greater odds of depressive symptoms. Perceived discrimination due to ethnicity and due to race suggested an association in the predicted direction (depressive symptoms increasing as either form of discrimination increased) but were nonsignificant in bivariate analyses.

Multivariate Analysis

The results of multiple logistic regression modelling are shown in Table 2. After controlling for age, age at immigration, and education, traditional masculine norms, but not perceived discrimination nor acculturation, remained associated with clinically significant depressive symptoms: AOR 1.12 (95% CI 1.00-1.25) for conformity to masculine norms; AOR 1.87 (95% CI 0.61-5.73) for ethnic discrimination; AOR .74 (95% CI 0.23-2.35) for racial discrimination; AOR .94 (95% CI .87-1.02) for acculturation.

Table 2. Adjusted odds ratios for the associations of demographic, attitudinal, and behavioral characteristics with clinically significant depressive symptoms, immigrant Latino men, N=111.

Variable	AOR (Crude OR)	95% CI	P
Perceived ethnic discrimination	1.87 (1.42)	.61-5.73	.269
Perceived racial discrimination	.74 (1.23)	.23-2.35	.606
Conformity to masculine norms	1.12 (1.08)	1.00-1.25	.047a
Acculturation	.94 (.95)	.87-1.02	.112
Age	.95 (1.00)	.84-1.08	.447
Age at immigration to US	.63 (.97)	.16-2.48	.504
Education	.91 (.59)	.27-3.01	.872

a. P<.05.

Discussion

In this study group of young, immigrant Latino men in North Carolina, a new settlement state, we found a high prevalence of clinically significant depressive symptoms in the past week, with more than one-quarter of men reporting these symptoms. These men also reported high levels of perceived discrimination due to their ethnicity or their race, with more than half reporting ethnicity-based discrimination and more than one-third reporting race-based discrimination. We also found low levels of acculturation and moderately high levels of endorsement of traditional masculine norms. In contrast with prior studies, our adjusted regression model showed that discrimination and acculturation were not associated with depressive symptoms in this group of recent immigrant Latinos in North Carolina. However, adherence to traditional masculine norms, as measured by CMNI score, is significantly associated with depressive symptoms.

The high prevalence of clinically significant depression among our sample is of potential concern. There is a need for mental health services to meet the needs of immigrant Latinos.27 In new settlement states including North Carolina, very few mental health services are culturally and linguistically appropriate and financially accessible. Unmet mental health needs can have serious and lasting consequences for the individuals experiencing depression (eg, problems at school, with jobs, and within relationships; unhealthy coping mechanisms including substance use and violence), their families, communities, and society at large.28 Recent research indicates that new models for service provision are emerging for immigrant Latinos, including in non-traditional immigrant destinations.29 These promising models should be rigorously evaluated and scaled up if they are effective, culturally responsive, and sustainable.

Although each of the factors theorized to be associated with immigrant Latino men’s depressive symptoms showed the expected association in bivariate analyses, several of these associations became nonsignificant when the factors were included together in multivariable analysis. The results suggest that more traditional beliefs about ideal masculinity are the most salient individual characteristic associated with clinically significant depressive symptoms; neither perceived discrimination, cultural dissonance, nor low SES—all factors that might limit a Latino man’s opportunities to achieve “success”—appear to be important once masculine norms are accounted for. From the perspective of gender role conflict, our findings underscore the primacy of norms of masculinity in predicting depressive symptoms among young, recent immigrant Latino men.

Study Limitations

The results of this study should be interpreted with a few limitations in mind. First, this was a cross-sectional analysis with a small, relatively homogeneous sample. As the analysis was cross-sectional, we were unable to ascertain risk or determine causality. In terms of socioeconomic status (SES), men in the sample were low- to mid-SES. In a more socioeconomically diverse and larger sample, we would be able to test whether SES moderates the association between conformity to masculine norms and depressive symptoms. It is possible that holding traditional masculine norms manifests as depressive symptoms more strongly for low SES men compared with higher SES men. Future research should examine depressive symptoms in more socioeconomically diverse sample of immigrant Latino men to explore whether the traditional masculine norms-depressive symptoms association holds across socioeconomic groups.

Regarding understanding how traditional norms of masculinity are associated with mental health outcomes including depressive symptoms, our study included one measure of traditional masculine norms, the CMNI. This measure may not fully capture positive aspects of traditional masculine norms, such as mastery and assertiveness, that may be protective for men’s mental health.12 Sample size limitations also prevented us from applying more complex models testing the intersectionality of masculinity, SES and acculturation.

Conclusion

More than 6 million men in the United States have depression, and more than one-third of these men are members of racial/ethnic minority groups.30 Since Latinos experience many barriers to mental health care access, from cost to mistrust,31 it is concerning that current public health efforts to address the mental health needs of Latino immigrant men are limited. Future multi-component interventions to improve mental health care access and treat depressive symptoms among immigrant Latino men may include components to address masculinity.32 Future intervention research should test whether modifying rigid and traditional masculine gender norms could result in enhanced coping strategies and improvements to mental health.