Introduction

The USA is home to the largest immigrant population of any country in the world. In 2018, 13.7% of the US population (greater than 44 million people) were foreign-born [1]. Asian immigrants comprise one of the fastest growing racial/ethnic groups in the USA; notably, the population of Chinese immigrants has increased dramatically since 1980 and now represents almost 6% of US foreign-born residents [2]. Although Chinese immigrants may initially report better physical health and lower chronic disease risk compared with their US-born counterparts upon migration [3], empiric data indicate that immigrants face significant risk for mental distress including high prevalence of depression and anxiety [4, 5]. Indeed, mental health concerns have been documented among Chinese immigrants, with rates of depression ranging from 11 to 51% [6, 7].

Migration-related stressors can have a considerable impact on psychological functioning and adjustment [8, 9]. Immigrants experience considerable levels of acculturative stress (i.e., the stress of adapting to a new culture), including language challenges and often extensive changes in employment and social networks (e.g., separation from family members and friends). In a prior study, 70% of Asian American immigrants reported experiencing acculturative stress [8], and emerging evidence demonstrates that these stressors can contribute to depressive symptoms among Chinese immigrants [10].

On the other hand, factors that enhance resilience to stress—such as social support—can confer protection from depressive symptoms [11,12,13]. Cohen and Wills described two potential mechanisms via which social support may have beneficial effects: (1) by contributing directly to overall well-being (main effect hypothesis) or (2) by mitigating or “buffering” the detrimental effects of stress on depressive symptoms and other mental and physical health outcomes (stress-buffering hypothesis) [14]. That is, under the stress-buffering hypothesis, the association between stress and depressive symptoms is lessened under conditions of high support. Studies of Asian Americans have demonstrated that greater social support attenuated the association of various stressors with psychological distress [9] and mental health outcomes [15] including depressive symptoms [12], thus providing support for the stress-buffering hypothesis. In contrast, data from the National Latino and Asian American Study (NLAAS) found that social support was directly associated with lower depressive symptoms (main effect hypothesis), but did not moderate the association of acculturative stress and depressive symptoms [16]. However, these studies did not focus solely on immigrant samples, but included a mixture of foreign-born and US-born individuals.

In addition, the positive effects of social support may vary by gender. Although women frequently report higher levels of social support [17], men may reap the protective benefits at lower levels of support than women do. For example, in a study of older Japanese adults, emotional support was associated with better self-rated health among men—but not women—despite men reporting overall lower levels of support [18]. Prior studies have also observed a gender effect, with the benefits of social support being more pronounced among men than women [19, 20]. Therefore, the present study examined associations among acculturative stress, social support, and depressive symptoms among Chinese immigrants and explored whether the effects of social support varied by gender. Specifically, it was hypothesized that acculturative stress would be positively associated with depressive symptoms, whereas social support would be inversely associated with depressive symptoms. In addition, it was hypothesized that the relationship between acculturative stress and depressive symptoms would be attenuated or lessened among those individuals with high social support (i.e., the stress-buffering hypothesis), but that the moderating effect of social support would be more apparent among men given prior evidence of gender differences in social support benefits.

Methods

Study Sample and Procedures

A convenience sample of 650 healthy adult Chinese immigrant men and women was recruited between January 2016 and May 2019. Eligibility criteria were as follows: Chinese heritage, age 35–65 years, and immigration from Asia as an adult (age 18 + years). Exclusion criteria included the following: self-reported history of diabetes, cancer, auto-immune disorders, or HIV infection; current use of anti-inflammatory medications; current pregnancy or breastfeeding; and inability to provide informed consent. The study was approved by the Fox Chase Cancer Center Institutional Review Board, and all participants provided a written informed consent to participate.

Study interviews were conducted in either English or Chinese in the participant’s preferred dialect (Mandarin or Cantonese) by multilingual study staff. Of the 650 participants, 30 individuals were missing data on relevant variables or covariates (13 individuals were missing data on length of US residence, 9 were missing data on marital status, 6 were missing data on acculturation, 1 was missing data on self-rated health, and 1 had incomplete data on multiple study measures). Therefore, the final sample for the present analysis included 620 participants.

Measures

Sociodemographic Characteristics and Covariates

Participant characteristics including age, gender, marital status, highest level of education, occupation, and length of US residence were assessed. Occupation was categorized into four categories, based on categories used in our own and prior research [21, 22]: blue collar (e.g., farmer/farm worker, machine or vehicle operator, craftsworker (such as baker, mechanic, and tailor), or service worker (such as janitor, hairdresser, and waitress)), clerical or sales worker (e.g., secretary, dispatcher, sales representative), white collar (e.g., manager, administrator, professional (including accountant, engineer, doctor, computer programmer)), or unemployed. Self-employment was categorized with white collar occupations.

Acculturation was assessed using an abridged version of the General Ethnicity Questionnaire-American version (GEQ-A) [23], which includes 11 items assessing the participant’s exposure to or familiarity with American people, culture, and activities. Each item is rated on a scale from 1 (least acculturated) to 5 (most acculturated), and level of acculturation is computed as the mean score across the 11 items. The scale has been commonly used in studies of Chinese Americans [24, 25] and demonstrated high internal reliability in the present sample (Cronbach’s α = 0.86). Additionally, given extensive data demonstrating that self-rated health is associated with depressive symptoms, participants were asked to rate their health using a widely used single-item ordinal measure with 5 levels (excellent, very good, good, fair, and poor). Similar to prior studies, responses were dichotomized into two categories: excellent/very good/good versus fair/poor [26]. This item is frequently used as an indicator of general health status in epidemiologic and population health research [26], including among Chinese populations [27, 28].

Acculturative Stress

Acculturative stress was measured using the Migration-Acculturation Stressor Scale (MASS) [29], which is comprised of 22 potential acculturative stressors, including cultural, social, and functional difficulties. For each item, participants were asked if they had encountered that difficulty in the past year, with answers ranging from 1 (no) to 5 (very much). Examples of MASS items include difficulties with language, housing, unfamiliar environment, making friends, cultural differences, missing family, missing their homeland, loneliness, and discrimination. Total level of acculturative stress was calculated by summing across all items, with higher scores representing greater stress. The MASS has been validated among Chinese immigrant populations [30,31,32,33] and had high internal reliability in the present sample (α = 0.89).

Social Support

Social support was assessed using the Provisions of Social Relations Scale (PSR) [34, 35]. This 15-item measure assesses respondents’ perceived support from family members (6 items) and friends (9 items). Response options range from 1 (very much) to 5 (not at all). A total PSR score was computed as the sum across all 15 items, where a higher score represents greater perceived support. The PSR has been used successfully with Chinese [36] and Korean immigrants [35] and had high internal reliability in the present sample (α = 0.91).

Depressive Symptoms

Depressive symptoms were assessed using the 20-item Center for Epidemiologic Studies-Depression (CES-D) scale [37]. The CES-D is designed for use in large-scale studies, and it has been widely used in Chinese populations [38] including a multiethnic cohort study in the USA [39]. Each item asks respondents to rate how often they experienced a particular symptom (e.g., poor appetite, restless sleep) in the past week, with response options ranging from 0 (rarely or none of the time) to 3 (most or almost all the time). Responses are summed across the 20 items, with higher scores representing greater depressive symptoms. A score of 16 or greater may identify individuals at risk for clinical depression [40]. Internal reliability of this scale was high in the present sample (Cronbach’s alpha = 0.89).

Statistical Analysis

Data analyses were conducted using SPSS version 26 and R version 3.6.1. Preliminary analyses were performed to characterize the sample in terms of demographic and psychosocial variables. Next, correlational analyses and one-way analyses of variance (ANOVAs) were performed to examine potential sociodemographic and psychosocial correlates of depressive symptoms. Associations of acculturative stress and social support with depressive symptoms were examined in the entire sample using regression analyses. Then, to assess whether associations of acculturative stress and social support with depressive symptoms varied by gender, separate regression analyses were performed by participant gender. Regression analyses controlled for relevant demographic covariates. In the regression equation, three blocks of variables were entered sequentially (nested models). The blocks were comprised of the following: (a) level of acculturation, length of US residence, and any sociodemographic covariates identified as significantly correlated with depressive symptoms in preliminary analyses (i.e., marital status, self-rated health); (b) main effects of acculturative stress and social support; and (c) the product term representing the two-way interaction (i.e., acculturative stress × social support). All tests of statistical significance were performed using two-tailed tests.

Results

Participants were on average 51 years of age and had lived in the USA for a mean of 20 years (Table 1). The majority of participants (89%) were currently married. There was a diverse range of education level with over 58% of participants reporting a high school education or lower. More than 16% of participants reported their health to be fair or poor, and 13.1% had a CES-D score of 16 or higher.

Table 1 Demographic and psychosocial characteristics by gender
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Gender differences were observed in age, length of US residence, marital status, occupation, and social support (Table 1). Men were slightly older (M = 52.05 years, SD = 7.70) and had lived in the USA for a greater length of time (M = 21.89 years, SD = 9.12) compared with women (age, M = 50.35 years, SD = 7.56; length of US residence, M = 18.83 years, SD = 8.64). In addition, a greater proportion of men were married (94.6%) and worked in blue collar occupations (50.8%) compared with women (married, 85.0%; blue collar occupation, 27.6%). Women reported higher levels of social support (M = 63.43, SD = 8.39) compared with men (M = 61.92, SD = 9.91). No other gender differences were observed.

Correlates of Depressive Symptoms

First, we examined potential covariates of depressive symptoms. Age, occupation, and education levels were not associated with depressive symptoms. Married participants reported lower levels of depressive symptoms (M = 6.83, SD = 7.48) compared with unmarried participants (M = 9.04, SD = 8.06), p = 0.02. Participants with fair/poor self-rated health reported higher levels of depressive symptoms (M = 11.12, SD = 9.32) compared with participants with good to excellent self-rated health (M = 6.26, SD = 6.90), p < 0.001.

Next we examined associations among levels of acculturation, length of US residence, acculturative stress, social support, and depressive symptoms (Table 2). Patterns of associations were similar across both men and women. Specifically, living in the USA for more years was associated with greater acculturation and lower levels of acculturative stress. Depressive symptoms were positively associated with acculturative stress (all p values < 0.001) and negatively associated with social support (p values < 0.001).

Table 2 Correlations among Study Variables
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Associations of Stress and Social Support with Depressive Symptoms

Regression analyses were performed to examine associations of acculturative stress and social support with depressive symptoms (Table 3). In both the pooled sample and gender-specific analyses, the covariates of marital status, acculturation, length of US residence, and self-rated health were entered into the regression equation in step 1. Participant gender was also added as a covariate in the pooled analysis. In step 2, the independent variables of acculturative stress and social support were added. The interaction of acculturative stress × social support was entered in step 3.

Table 3 Associations of acculturative stress and social support with depressive symptoms
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Results from the pooled analysis revealed significant main effects of acculturative stress (β = 0.31, p < 0.001) and social support (β = − 0.35, p < 0.001) on depressive symptoms in step 2. In step 3, the interaction term of acculturative stress and social support was statistically significant (β = − 0.81, p < 0.001). Acculturative stress remained significantly associated with depressive symptoms (β = 1.11, p < 0.001) in step 3, but the association of social support with depressive symptoms was attenuated and no longer statistically significant (β = 0.05, p = 0.64).

We repeated the regression analyses separately by participant gender. As seen in Step 2, acculturative stress was positively associated with depressive symptoms among both men (β = 0.34, p < 0.001) and women (β = 0.29, p < 0.001). Social support was negatively associated with depressive symptoms among men (β = − 0.37, p < 0.001) and women (β = − 0.32, p < 0.001). The addition of acculturative stress and social support in step 2 accounted for a 31% increase in the explained variance in depressive symptoms among men and an additional 20% of explained variance in depressive symptoms among women.

In step 3, the interaction of acculturative stress and social support was statistically significant among men (β = − 0.89, p < 0.001). We plotted the regression of depressive symptoms on acculturative stress at high and low levels of social support (see Fig. 1). Findings indicate that acculturative stress was positively associated with depressive symptoms, but only under conditions of low social support. Under conditions of high social support, the association between acculturative stress and depressive symptoms was attenuated, thus suggesting that social support had a moderating role on the effect of acculturative stress on depressive symptoms.

Fig. 1
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Social support moderates the association between acculturative stress and depressive symptoms among Chinese immigrant men, but not women

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Among women, the interaction of acculturative stress and social support was not statistically significant (β = − 0.43, p = 0.21) and did not explain any additional variance in depressive symptoms. Fair/poor self-rated health and acculturative stress remained significantly associated with depressive symptoms in step 3 after the addition of the interaction term.

Discussion

In the present study of US Chinese immigrants, over 13% of respondents reported depressive symptomology, as assessed by the CES-D with the standard cutoff score of 16 or higher. This finding is comparable with other studies that have also utilized the CES-D and reported rates of 8–14% in Chinese Americans [41, 42], but lower than the 26% prevalence rate reported by Li and colleagues [43]. As expected, acculturative stress was positively associated with depressive symptoms, confirming the detrimental consequences that can accompany the process of cultural adaptation and adjustment. Stressors related to the immigrant experience are commonly linked to poor mental health, and our study findings are consistent with data from the National Latino and Asian American study ([9, 44]) and studies of college students [45], which have reported that acculturative stress is a risk factor for psychological distress and decrements in well-being among Asian Americans [46].

Importantly, this study contributes to the existing literature by highlighting potential gender differences in the moderating role of social support. There is a robust body of research investigating how gender relates to social support and coping with stress [47, 48]. Studies have reported that women more often serve as social support providers and are more likely to report seeking and receiving emotional support compared with men [49]. Gender norms and gender role socialization are likely key factors contributing to the observed differences. Although sex-linked biologic factors (e.g., sex hormones) are known to partially contribute to differences in the development and prevalence of depression observed between men and women [50, 51], social support has been less well-studied with respect to biologic differences and more generally studied in terms of gender norms. Indeed, studies have found gender roles to be more closely aligned with social support patterns, more so than biologic sex [47, 49, 52]. Female gender norms usually encompass features such as being supportive, warm, and emotionally expressive. In contrast, male or masculine role norms have not traditionally emphasized being nurturing, but rather have highlighted traits such as independence and self-reliance [53]. Thus, differences in social support behavior have been primarily attributed to gender role socialization, rather than sex-linked factors [47].

Although higher levels of social support were associated with lower levels of depressive symptoms among all participants, the protective effects of social support with regard to buffering the negative consequences of acculturative stress were less pronounced among women. Why this moderation effect was not observed among women is less clear. One potential explanation may be due to differences in length of US residence. In this sample, women tended to be more recent immigrants compared with men. A meta-analysis and systematic review reported that a shorter length of residence is associated with a greater prevalence of depression [54]; this association has been attributed, in part, to the generally higher levels of acculturative stress experienced in the early post-migration period. The significant disruptions encountered during this phase may account for the absence of stress buffering among women in our sample.

Studies in other populations have also reported that the effect of social support on other outcomes, such as health-related quality of life, varies by gender with men reaping the benefits of social support more than women do [20]. For example, among Taiwanese military personnel, social support moderated the association of stress with mental and physical health among men, but not among women [55]. Due to gender differences in perceived support [48], social networks may exact more of a “cost” from women who often are support providers to others or have significant caregiving responsibilities associated with their social roles. As a result, the protective effects of social support may be evident for women only at higher levels of support. In addition to gender norms, Chinese cultural values and norms, such as a patriarchal social context in which Chinese women often hold subordinate roles to men, may also influence how social support is perceived, received, and provided by Chinese American women [56]. Thus, the differential pattern of findings observed in the present study warrants further investigation into the possible limitations of social support for Chinese American women.

There are several limitations of this study. First, the cross-sectional study design does not allow us to examine the temporal nature of these associations or enable any inferences about possible causal mechanisms that may exist. As depression can make it more difficult for one to manage or cope with stress [57], we cannot rule out the possibility that individuals who were experiencing depressive symptoms were more likely to report higher levels of acculturative stress. Future longitudinal studies will help clarify the temporal nature of these associations. Second, the study sample was a convenience sample of foreign-born Chinese Americans who had immigrated as adults and had been living in the US for on average 20 years. As a result, the present findings may not generalize to more recent immigrants, for whom the burden of acculturative stress may be greater. Nonetheless, the present findings contribute to the growing literature on migration-related stress and psychological well-being among Chinese immigrants and represent one of the first studies to highlight key gender differences in the moderation of stress effects on depressive symptoms in this population.

In sum, accumulating data suggest that Chinese immigrants experience considerable acculturative stress, which can have a detrimental impact on mental health. In light of studies demonstrating that acculturative stress is not only associated with poorer mental health, but also with greater self-reported disability [58], it is critically important to understand and address the migration-related stressors and challenges that can impair emotional health and well-being. Future studies may draw upon evidence-based strategies to assist Chinese Americans in managing depression [59] or in enhancing social support and social networks [60] to help Chinese immigrants feel more connected and integrated within their communities. Such programs may be successful in not only addressing the acculturative stressors and challenges faced by immigrants but also providing essential mental health benefits and promoting overall well-being.