Is Pacific language ability protective of prevalence of mental disorders among Pacific peoples in New Zealand?

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Is Pacific language ability protective of prevalence of mental disorders among Pacific peoples in New Zealand?

Eirenei TAUA’I,

¹

Rosalina RICHARDS,

²

Jesse KOKAUA

^2*

ABSTRACT

Aims: To explore associations between experiences of mental illness, migration status and languages spoken among Pacific adults living in New Zealand.

Methods: SURVEY FREQ and SURVEY LOGISTIC procedures in SAS were applied to data from Te Rau Hinengaro: The New Zealand (NZ) Mental Health Survey, a survey of 12,992 New Zealand adults aged 16 and over in 2003/2004. Pacific people were over sampled and this paper focuses on the 2374 Pacific participants but includes, for comparison, 8160 non-Maori-non-Pacific (NMNP) participants.

Results: Pacific migrant respondents had the lowest prevalence of mental disorders compared to other Pacific peoples. However, Pacific immigrants were also less likely to use mental health services,

suggesting an increased likelihood of experiencing barriers to available mental health care. Those who were born in NZ and who were proficient in a Pacific language had the lowest levels of common mental disorders, suggesting a protective effect for the NZ-born population. Additionally, access to mental health services was similar between NZ-born people who spoke a Pacific language and those who did not.

Conclusions: We conclude that, given the association between Pacific language and reduced mental disorder, there may be a positive role for Pacific language promotion in efforts to reduce the prevalence of mental health disorder among Pacific communities in NZ.

Keywords: Language, Pacific, Mental health, Culture, New Zealand

INTRODUCTION

The World Health Organization defines mental health as a “state of well-being in which; every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.¹ In Aotearoa New Zealand (NZ), Pacific people have higher rates of mental disorders than other New Zealanders, with almost half (47%) of Pacific people having experienced a mental disorder at some stage during their lifetime, and a quarter experiencing a mental disorder in any given year.² Despite the higher prevalence of mental disorders, there appears to be substantial gaps in access to mental health services for Pacific peoples.³ For moderate mental disorder, just over a quarter of Pacific people received treatment (in the previous 12 months) compared with more than a third of the general population. For serious mental disorder, only a quarter had accessed mental health services compared with 58% of all

New Zealanders with a serious disorder.² Sadly, at the most severe end of mental health needs, Pacific peoples were more likely to be admitted to adult acute mental health or forensic inpatient services than other New Zealanders.⁴

*Corresponding author: Jesse Kokaua.

[email protected]

1.Summer student, Department of Preventive and Social Medicine, Health Sciences, University of Otago, Dunedin, New Zealand [email protected]

2. Department of Preventive and Social Medicine, Health Sciences, University of Otago, Dunedin, New Zealand.

Received: 08.01.2018; Accepted: 10.02.2018

Citation: Taua’I E, et al. Is Pacific language ability protective of prevalence of mental disorders among Pacific peoples in New Zealand? Pacific Health Dialog 2018;21(1):10-16 DOI:

10.26635/phd.2018.902.

Copyright: © 2018 Taua’I E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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11 There is substantial diversity within the Pacific

population of NZ, both in terms of ethnicity, place of birth and fluency in heritage languages.⁵ This diversity is echoed in differences in mental disorder prevalence within Pacific communities in NZ, including across place of birth and age of migration (child versus adult). The 12 month prevalence rate of any mental disorder for NZ- born Pacific people was 31.4% compared to 15%

for Pacific peoples who had migrated at the age of 18 years or over.³ Additionally, age at migration appeared to be related to the elevated risk of serious mental disorder, with 6.8% of NZ-born Pacific peoples experiencing this compared to 3.7% of Pacific people who migrated in adulthood. Further differences have also been observed in treatment seeking, with NZ-born Pacific peoples having higher use of mental health services compared to Pacific peoples who migrated at an early age.^{3, 6}

Recent research has sought to inform development of appropriate mental health services by foregrounding Pacific perceptions of mental health and experiences of health services.^7-9 Aspects of these Pacific-centered and strength-based approaches include the need to acknowledge the impact of migration experiences on health,¹⁰ and the potential role of cultural identity in supporting good health.^{11, 12} NZ based research suggests that retaining strong cultural links is related to better health outcomes among Pacific individuals.^{10, 12} This may include feelings of belonging and connectedness with Pacific communities as well as more specific cultural skills such as fluency in Pacific language, traditional dance or participation in other culturally significant events.^{10, 12, 13}

The focus of this study is on language, specifically, the ability to speak Pacific heritage languages, and its relationship with mental health outcomes.

Language is an important element of cultural identity for Pacific communities,^13-16 however, historically there has been prevailing perception that proficiency in English (even at the expense of their Pacific language) would lead to better education and employment opportunities. This sometimes resulted in active discouragement of speaking heritage language.^{16 17}In recent times, maintaining the richness of Pasifika languages in NZ has been an ongoing quest, as Pasifika communities work to get the NZ government to acknowledge languages as a high priority.^{15, 17} Given the emerging literature about cultural identity and health, and the importance of language in maintenance of culture, it seems timely to more closely explore the role language has in promoting wellbeing. The aim of this study is to explore the associations between experience

of mental illness, migration status and languages spoken among Pacific adults living in NZ.

METHODS Participants

The data reported here is sourced from Te Rau Hinengaro: The NZ Mental Health Survey 2003/4.¹⁸ Full details are available elsewhere but, in summary, Te Rau Hinengaro was a general population survey involving face-to face interviews with 12,992 adults aged 16 and over.¹⁸ Interviews were conducted by professional lay interviewers from October 2003 to December 2004 with a response rate of 73.3%. Māori and Pacific peoples were oversampled relative to their proportion in the population in order to ensure robust statistical estimates. This paper includes all 2374 Pacific participants. Some comparisons are made with the 8160 in an

‘Others’ category which refers to non- Māori non- Pacific respondents. Thus, 10,524 non-Māori adults were included in this study, very few Māori were born outside New Zealand.

Measures

Mental Disorders were assessed with the World Mental Health-Composite International Diagnostic Interview (WMH-CIDI), now the CIDI 3.0.¹⁹ The 12-month mental disorders include:

mood disorders (major depressive disorder, dysthymia, bipolar disorder); anxiety disorders (panic disorder, agoraphobia, specific phobia, social phobia, obsessive compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder); and substance use disorders (alcohol abuse and dependence, drug abuse and dependence). All participants answered questions relating to service use and less common disorders, while a subset of participants went on the answer questions about other more frequent occurring disorders in a long form of the interview. Two categories of comorbid disorders have been created: dual diagnosis, is a combination of substance and other mental disorders; and comorbidity, refers to any psychiatric co-morbidity.

Treatment seeking was assessed by asking participants about treatment sought in the past 12 months for a mental health problem. The treatment sectors included in this analysis include any health care (either mental health specialty or general medical sectors).

Ethnic groups were determined using the ethnicity question from the 2001 NZ Census of Population and Dwellings.²⁰ Other demographic factors were also collected; languages spoken, age

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12 at migration and place of birth were included in

this analysis. For some analyses, Pacific participants divided into Three separate groups:

those born in New Zealand (NZ-born) who spoke a Pacific language; NZ-born who didn’t speak a Pacific language; and, Pacific immigrants, born in their respective Pacific nation.

Ethics approval

Ethical approval was obtained to conduct this study from the Department of Preventive and Social Medicine at the University of Otago (Reference number: HD15/057) and consultation was also carried out with the Ngāi Tahu Research Consultation Committee.

Statistical analysis

Twelve-month and life time prevalence estimates for mental disorders and service use indicators among Pacific peoples were calculated using PROC SURVEYFREQ in SAS version 9.3.²¹ Multiple logistic regression models, using PROC SURVEYLOGISTIC, were employed to estimate the comparative effects of factors on 12-month and lifetime prevalence of mental disorder.

RESULTS

Language proficiency

Pacific peoples who had migrated to NZ at an older age were more likely to be proficient in a Pacific language than those who migrated as children or who were born in NZ (Table 1).

Within specific ethnic communities there was a strong association between age at migration and language proficiency among Cook Islands

immigrants and a weaker gradient for Samoan and Tongans.

Mental Health

The findings for 12-month prevalence of mental disorders reiterate previously published findings from this survey that Pacific people had 40%

higher odds of having ‘any’ mental disorder in a 12- month period (Table 2). This difference was no longer significant when adjusted for age and sex, suggesting the difference is explained by differences in age and sex distributions between the two groups. Pacific peoples had higher odds of alcohol related disorders (60% higher), were half as likely to make use of mental health services, and only 60% as likely to access any health services for a mental health problem.

In terms of lifetime prevalence, almost half (46.4%) of Pacific populations in NZ have experienced a mental health disorder within their lifetime (Table 2). Of these mental health disorders, the most common among Pacific people were anxiety disorders (27.7%), mood disorders (19%) and substance related mental disorders (18.8%). There has been some evidence to suggest that lifetime prevalence estimates using survey methods tend to underestimate the true lifetime prevalence by as much as 10%.¹⁹ However, the increased frequencies in some less common disorders, even though underestimated, allow for improved comparative analyses.

Despite comparable levels of prevalence of common mental disorders and increased odds for substance related disorders, Table 2 also shows that only 25.2% had approached any services about a mental health problem.

Table 1: Percent of Pacific populations who speak their Pacific languages; Island group by migrant status

NZ-born Younger

Immigrant Older Immigrant

% (95%CI) % (95%CI) % (95%CI)

Total 48.7 (43.6-53.8) 86.5 (81.4-91.5) 98.0 (96.8-99.2) Samoan 64.1 (58.2-70) 93.2 (89.1-97.3) 96.1 (92.6-99.7) Tongan 52.4 (36.3-68.5) 85.4 (71.6-99.2) 96.8 (94.2-99.3) Cook

Islands 19.1 (12.5-25.8) 74.1 (60.9-87.4) 97.3 (95.1-99.5)

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13 Table 2: Prevalence of mental health disorders, Pacific vs Non Maori/Non Pacific

Pacific Pacific vs NMNP

Prevalence (%) Odds Ratio Adj Odds Ratio

12 Month

Any 24.9 (21.6,28.2) 1.4 (1.1,1.7) ** 1.2 (0.9,1.4) ns Anxiety 16.2 (13.7,18.6) 1.2 (1,1.4) ns 1 (0.8,1.3) ns Mood 8.7 (6.7,10.8) 1.2 (0.9,1.5) ns 1 (0.8,1.3) ns Alcohol 4.8 (3.4,6.2) 2.3 (1.5,3.3) *** 1.6 (1.1,2.3) * Substance 5.3 (3.9,6.7) 2 (1.4,2.9) ** 1.4 (1,2) ns Dual diagnosis 3.3 (2.2,4.4) 2.2 (1.5,3.3) ** 1.5 (1,2.2) ns Comorbidity 8.6 (7,10.1) 1.2 (1,1.5) ns 1 (0.8,1.3) ns MH service use 3.2 (2.3,4.1) 0.6 (0.4,0.8) ** 0.5 (0.4,0.7) **

Any Service Use 8.7 (6.9,10.5) 0.7 (0.5,0.8) ** 0.6 (0.5,0.8) ***

Serious 5.9 (4.6,7.1) 1.5 (1.1,1.9) ** 1.2 (0.9,1.6) ns Moderate 11.5 (8.9,14.2) 1.3 (1,1.8) * 1.1 (0.8,1.5) ns Interference 23.5 (18,29.1) 1 (0.7,1.5) ns 1 (0.7,1.4) ns Suicide Ideation 4.6 (3.1,6) 1.6 (1.1,2.4) * 1.3 (0.9,1.9) ns

Lifetime

Any 46.4 (42.4,50.5) 1.4 (1.2,1.7) *** 1.3 (1.1,1.6) **

Anxiety 27.7 (24.7,30.8) 1.2 (1,1.5) * 1.1 (1,1.4) ns Mood 19 (16.3,21.7) 1 (0.8,1.2) ns 0.9 (0.7,1.1) ns Alcohol 17.9 (15,20.7) 2.1 (1.7,2.7) *** 1.9 (1.5,2.4) ***

Substance 18.8 (15.9,21.7) 2.1 (1.7,2.6) *** 1.8 (1.4,2.2) ***

Dual diagnosis 13.5 (11,15.9) 2 (1.6,2.6) *** 1.7 (1.3,2.1) ***

Comorbidity 24 (21,27) 1.4 (1.2,1.7) ** 1.3 (1,1.5) * MH service use 15.3 (12.3,18.2) 0.6 (0.4,0.7) *** 0.5 (0.4,0.7) ***

Any Service Use 25.2 (21.6,28.7) 0.5 (0.4,0.6) *** 0.5 (0.4,0.6) ***

NOTE: * = p-val <0.5; **=p-val<0.01; ***=p-val<0.0001; ns=not significant; Adjusted rates take into account differences in age and sex distributions between Pacific and NMNP

Immigration status, mental health and language As shown in Table 3, NZ-born Pacific were more likely to be seen by a mental health specialist service over the past 12 months for a mental health problem compared to those who immigrated from the Pacific. They also had at least 60% higher odds for any mental disorders, anxiety, mood and substance disorders are than those of migrant Pacific peoples. There were insufficient numbers to show a significant difference in odds ratio for alcohol disorders.

Over the course of their lifetime, NZ-born Pacific respondents also had increased odds for all disorders and also for help seeking in mental specialist and other health services. Thus, birth in NZ for Pacific peoples would appear to lead to increased risk of mental disorder over the course of their lifetime. But also two to three times higher odds of seeking help for their mental illness.

When the influence of language ability is added to the analysis, overall it was found that the odds of

accessing services among people with proficiency in a Pacific language are less than half those observed among non-speakers. As almost a reversal of the results for lifetime disorders among NZ-born Pacific, Pacific language speakers had significantly less risk of mental disorders as well as lower use of mental health services.

Impact of Pacific language ability on NZ-born Pacific peoples:

The last two columns of Table 3 report odds of mental health outcomes for NZ-born given their language ability compared with migrant Pacific peoples. The latter are treated as though they all speak a Pacific language for this piece of analysis.

Non-Pacific language speaking NZ-born Pacific peoples, compared with Pacific immigrants had significantly higher odds of common mental twelve-month disorders and most lifetime disorders. Treatment sought for a mental health problem was also higher for non-Pacific-speaking NZ-born Pacific peoples. It was also higher for Pacific language speakers.

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14 Table 3: Odds Ratio of disorder by migrant status and/or language ability

NZ-born Pacific

language

NZ-born non speaker vs

migrant NZ-born speaker vs migrant

12 Month

Any 1.7 (1.1,2.4) * 0.6 (0.4,0.8) * 2.1 (1.3,3.3) * 1.3 (0.9,2.1) ns Anxiety 1.6 (1.1,2.4) * 0.7 (0.4,1.1) ns 1.7 (1.1,2.9) * 1.5 (0.9,2.5) ns Mood 1.6 (1,2.5) * 0.5 (0.3,0.8) * 2.1 (1.3,3.5) * 1.1 (0.6,1.9) ns Alcohol 1.5 (0.8,2.8) ns 0.8 (0.4,1.4) ns 1.7 (0.9,3.3) ns 1.4 (0.7,2.9) ns Substance 1.8 (1,3.1) * 0.7 (0.4,1.3) ns 1.9 (1,3.5) ns 1.7 (0.9,3.3) ns Dual diagnosis 1.4 (0.6,3.1) ns 0.6 (0.3,1.3) ns 1.8 (0.7,4.3) ns 1 (0.4,2.8) ns Comorbidity 1.6 (1,2.6) ns 0.7 (0.4,1.1) ns 1.7 (1,2.9) * 1.5 (0.8,2.7) ns MH service use 4.3 (2.3,7.7) *** 0.4 (0.2,0.8) * 5 (2.5,9.8) *** 3.7 (1.7,7.9) * Any Service Use 2.9 (1.8,5) *** 0.4 (0.2,0.7) * 3.6 (2,6.5) *** 2.4 (1.3,4.5) * Serious 1.2 (0.7,1.9) ns 1.1 (0.6,2.1) ns 1 (0.6,2) ns 1.3 (0.7,2.4) ns Moderate 1.7 (1.1,2.6) * 0.5 (0.3,0.7) * 2.3 (1.4,3.7) * 1.2 (0.7,2.1) ns Interference 1.3 (0.7,2.3) ns 0.8 (0.4,1.8) ns 1.3 (0.6,3) ns 1.3 (0.6,2.6) ns Suicide Ideation 1.4 (0.7,2.9) ns 1.1 (0.5,2.3) ns 1.1 (0.5,2.3) ns 1.8 (0.8,4.2) ns

Lifetime

Any 1.8 (1.3,2.6) * 0.5 (0.4,0.8) * 2.2 (1.4,3.5) * 1.5 (1,2.4) ns Anxiety 1.6 (1.1,2.3) * 0.6 (0.4,1) * 1.9 (1.2,2.9) * 1.4 (0.9,2.1) ns Mood 1.4 (1.1,2) * 0.7 (0.5,0.9) * 1.6 (1.1,2.4) * 1.3 (0.9,1.9) ns Alcohol 2 (1.4,2.9) * 0.6 (0.4,0.9) * 2.1 (1.3,3.3) * 1.8 (1.2,2.8) * Substance 2 (1.4,2.9) * 0.5 (0.4,0.8) * 2.3 (1.5,3.5) * 1.8 (1.2,2.7) * Dual diagnosis 2.4 (1.5,4) * 0.5 (0.3,0.8) * 2.9 (1.7,5.2) * 2.1 (1.2,3.5) * Comorbidity 2.6 (1.8,3.7) *** 0.5 (0.3,0.8) * 2.9 (1.8,4.6) *** 2.3 (1.5,3.6) * MH service use 3.2 (2,5.3) *** 0.6 (0.4,1) * 3 (1.7,5) *** 3.5 (1.9,6.4) ***

Any Service Use 2.3 (1.6,3.4) *** 0.6 (0.4,1) * 2.3 (1.5,3.6) * 2.3 (1.4,3.9) *

NOTE: * = p-val <0.5; **=p-val<0.01; ***=p-val<0.0001; ns=not significant; all odds ratios take account for differences in age distributions between the respective groups

There are fewer significant differences observed between NZ-born Pacific language speakers and Pacific migrants, particularly among common mental disorders (Mood and Anxiety disorders).

However, their odds for substance related and other comorbidities, though reduced compared with non-speakers of a Pacific language, were also higher suggesting some protective feature of being able to speak a Pacific language but not enough to fully mediate any increase in the odds of a lifetime substance related and other comorbid disorders.

These findings suggest an association between NZ-born Pacific people’s language ability and their odds of having had any lifetime mental disorders and the most common 12-month disorders. However, there is less of an association for help-seeking, as both NZ-born speaker and non-speakers alike appear more likely to seek help. Thus, speaking a Pacific language did not

pose a barrier to a NZ-born Pacific person seeking treatment for their mental health problem.

DISCUSSION

Mental health remains a priority area for Pacific health in NZ. The findings of this study echo earlier research that suggested Pacific migrants have better mental health outcomes, particularly when viewed over the course of a lifetime, compared to Pacific people born in NZ.⁶ Conversely, NZ-born had higher use of mental health services than older migrants, which raises questions of the adequacy of current services for Pacific peoples who speak English as second language, and the need for appropriate translation services and/or Pacific language speaking mental health professionals.

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15 Where this study adds to previous work is the

novel finding that Pacific languages had a protective effect against common mental disorders, with NZ-born Pacific people who were proficient in a Pacific language having better mental health than those who were not.

Additionally, this group also still showed the higher levels of service use typical of NZ-born Pacific, when compared to older immigrants. This is reassuring, as it seems that the mental health benefits of being multilingual in this generation are not offset with barriers to service access when needed.

The findings of our study extend those of earlier publications that explored the benefits of bilingualism in NZ, supporting language as a form of cultural engagement and expression which may improve mental wellbeing for Pacific populations. Our results suggest that language, whether as a surrogate indicator of cultural association or otherwise, is linked to improved mental wellbeing, in terms of reduced levels of common mental illness.

Limitations of this study include the close focus on migration and language, without consideration of the latter’s connection to wider cultural constructs. Te Rau Hinengaro ¹⁸ was not designed to tease out the complex issue of how Pacific peoples are embedded in their indigenous cultures. Also, like many other studies of mental health which use measures and protocols derived from western perspectives, this study has restrictions in that different cultures are likely to have different understanding about mental health and wellbeing; how they experience and interpret behavioural or other symptomology and its effects upon an individual or more particular a collective such as wider family or communities.

Further research on these findings is recommended to unpack the relationship between culture and wellbeing, and why language is protective against lifetime poor mental health, in the hope that this may help to find tools that can reduce the burden that poor mental health places on Pacific communities in NZ.

CONCLUSION

Overall, this piece of research suggests that proficiency with a Pacific language has a positive impact on prevalence of mental illness, among Pacific peoples born in NZ. Additionally, this group also enjoyed better access to treatment for a mental health problem than those who migrated at an older age. These results add weight to efforts to support Pacific languages in the NZ context,

adding potential mental health benefits to other positive elements of multilingualism.

REFERENCES

1. World Health Organisation. Mental Health: A State of Wellbeing: World Health Organization; 2014 [Available from:

http://www.who.int/features/factfiles/men tal_health/en/ accessed November 2017.

2. Foliaki S, J. K, D. S, et al. Twelve-month and lifetime prevalences of mental disorders and treatment contact among Pacific people in Te Rau Hinengaro: the New Zealand Mental Health Epidemiology Survey. In: Oakley Browne MA, Wells JE, Scott KM, eds. Te Rau Hinengaro: the New Zealand Mental Health Survey. Wellington: Ministry of Health 2006.

https://www.health.govt.nz/system/files/d ocuments/publications/mental-health- survey.pdf

3. Foliaki SA, Kokaua J, Schaaf D, et al. Twelve- month and lifetime prevalences of mental disorders and treatment contact among Pacific people in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry 2006;40(10):924-34.

http://onlinelibrary.wiley.com/doi/10.1111 /j.1440-1614.2006.01912.x/full

4. Ministry of Health. Te Orau Ora: Pacific Mental Health Profile. Wellington, New Zealand:

Ministry of Health, 2005.

https://www.mentalhealth.org.nz/assets/R esourceFinder/2005-

pacificmentalhealthprofile.pdf

5. Ministry for Pacific Peoples. Contempory Pacific Status report. Wellington, New Zealand: Ministry for Pacific Peoples, 2016.

http://www.mpia.govt.nz/assets/Uploads/

Contemporary-Report-Web.pdf

6. Kokaua J, Schaaf D, Wells JE, et al. Twelve- month prevalence, severity, and treatment contact of mental disorders in New Zealand born and migrant Pacific participants in Te Rau Hinengaro: The New Zealand Mental Health Survey. Pacific health dialog 2009;15(1):9-1.

https://www.ncbi.nlm.nih.gov/pubmed/19 585730

7. Samu KS, Suaalii-Sauni T. Exploring the

‘cultural’in cultural competencies in Pacific

(7)

16 mental health. Pacific Health Dialog

2009;15(1):120-30.

https://www.tepou.co.nz/uploads/files/res ource-assets/exploring-the-cultural-in- cultural-competencies-in-pacific-mental- health.pdf

8. Suaalii-Sauni T, Wheeler A, Saafi E, et al.

Exploration of Pacific perspectives of Pacific models of mental health service delivery in New Zealand. Pacific Health Dialog 2009;15(1):18-27.

https://www.tepou.co.nz/uploads/files/res ource-assets/exploration-of-Pacific-

perspectives-of-Pacific-models-of-mental- heath-service-delivery-in-New-Zealand.pdf 9. Mila-Schaaf K, Hudson M. The interface

between cultural understandings:

Negotiating new spaces for Pacific mental health. Pacific Health Dialog 2009;15(1):113- 19. https://www.tepou.co.nz/uploads/files/res ource-assets/the-interface-between-

cultural-understandings-negotiating-new- spaces-for-pacific-mental-health.pdf

10. Borrows J, Williams M, Schluter P, et al. Pacific Islands Families Study: The association of infant health risk indicators and acculturation of Pacific Island mothers living in New Zealand. Journal of Cross-Cultural Psychology 2011;42(5):699-724.

https://studydaddy.com/attachment/3596 4/journal_of_cross-cultural_psychology- 2011-borrows-699-724.pdf

11. Manuela S, Sibley CG. The Pacific Identity and Wellbeing Scale (PIWBS): A culturally- appropriate self-report measure for Pacific peoples in New Zealand. Social indicators research 2013;112(1):83-103.

https://link.springer.com/article/10.1007/

s11205-012-0041-9

12. Manuela S, Sibley CG. Exploring the hierarchical structure of Pacific identity and wellbeing. Social indicators research 2014;118(3):969-85.

https://www.researchgate.net/profile/Chri s_Sibley/publication/258164767_Exploring _the_Hierarchical_Structure_of_Pacific_Identi ty_and_Wellbeing/links/5555035308ae980 ca60ad680.pdf

13. Starks D, Taumoefolau M, Bell A, et al.

Language as a marker of ethnic identity in New Zealand’s Pasifika communities.

Proceedings of the 4th International Symposium on Bilingualism, 2005:2189-96.

http://www.lingref.com/isb/4/171ISB4.PD F

14. Starks D. The changing roles of language and identity in the New Zealand Niuean community: Findings from the Pasifika Languages of Manukau Project. International Journal of Bilingual Education and Bilingualism 2006;9(3):374-91.

http://www.tandfonline.com/doi/abs/10.1 080/13670050608668655

15. Hunkin GA. “To Let Die” The state of the Samoan language in New Zealand.

AlterNative: An International Journal of Indigenous Peoples 2012;8(2):203-14.

http://journals.sagepub.com/doi/abs/10.11 77/117718011200800208

16. McCaffery J, McFall-McCaffery JT. O Tatou Ō Aga'I I Fea?/'Oku Tau Ō Ki Fe?/Where Are We Heading? Pacific languages in Aotearoa/New Zealand. AlterNative: An International Journal of Indigenous Peoples 2010;6(2):86-121.

http://journals.sagepub.com/doi/abs/10.11 77/117718011000600203

17. Tima MTiT. Youth participation: does it have a place in the Samoan traditional church?

Exploring youth perceptions of the EFKS in South Auckland. Auckland University of

Technology, 2013.

http://aut.researchgateway.ac.nz/bitstream /handle/10292/7721/TimaT.pdf?sequence

=3&isAllowed=y

18. Oakley Browne MA, Wells EJ, Scott KM. Te Rau Hinengaro: The NZ Mental Health Survey 2003/4. Wellington, New Zealand: Ministry

of Health, 2006.

https://www.health.govt.nz/system/files/d ocuments/publications/mental-health- survey.pdf

19. World Health Organization. The World Mental Health Composite International Diagnostic Interview. 2015, 2017.

20. Statistics New Zealand. Census–major ethnic groups in New Zealand. Wellington, New

Zealand 2013.

http://www.stats.govt.nz/Census/2013- census/profile-and-summary-

reports/infographic-culture-identity.aspx 21. SAS [program]. North Carolina: SAS Institute

Inc, 1999.