INTRODUCTION
Korea has long been known as a homogeneous society with a tight sense of national identity and little ethnic diversity. However, the number of foreigners in Korea has increased over the past decades. According to updated statistics, as of November 2022, the number of immigrants was 2,258,248, accounting for more than 4.4% of the total Korean population and 25 times higher than in the early 1980s [1]. The number of immigrants decreased compared to 2019 (over 2.5 million) due to the coronavirus disease 2019 (COVID-19) pandemic but has begun to increase again [1,2]. They come from all over the world, including China, Southeast Asian countries (except Singapore), South Asia, and Central Asian countries, and account for a high proportion [3]. Additionally, repatriated overseas Koreans accounted for a significant proportion of the population. The main reasons for immigrating to Korea include work, international marriage, and study [2,3]. Korea’s rapid economic growth in recent decades, coupled with its developed education system, has attracted many people seeking jobs and educational opportunities. This reality has a strong impact on the labor market, Korean social life, and welfare. Furthermore, the increasing number of immigrants has increased the burden and raised many problems for the national healthcare system. Research on the mental health of immigrants may be essential for policymakers on issues related to immigrants so that they can have a stable and secure life while studying and working.
Anxiety and depression are among the most common mental illnesses that directly affect a patient’s quality of life. Statistics from the World Health Organization have shown that approximately 3.8% of the population suffers from depression, including 5% of adults and 5.7% of the elderly (over 65 years old) [4]. Anxiety and depression disorders affect every aspect of life, including relationships with family, friends, and the community [5]. It is also the main factor associated with functional limitations in activities of daily living [6,7]. The early detection of related symptoms may reduce the risk of anxiety or depression. In particular, the frequency of feelings of anxiety or depression is an early and common warning sign of the risk of these diseases if mental and medical interventions are not promptly received [8].
The prevalence and factors associated with anxiety and depression have been extensively studied in recent years [9-14]. The target populations included children, adolescents, the elderly, females, and people with certain medical conditions. However, few studies have been conducted on anxiety or depression feelings were found among immigrants in Korea. A recent study reported problems related to anxiety disorders among immigrants in Korea during the COVID-19 pandemic [15]. However, possibly due to the lack of information related to legal status, native country, health status, and disability, this study did not reveal all the potential factors affecting anxiety disorders. Other recent studies also reported depression among immigrants in Korea but only focused on a specific group, such as married immigrants or workers [16-18]. Furthermore, these studies did not mention the legal status of immigrants. To our knowledge, no study has fully evaluated the influence of legal and health status factors on anxiety and depressive disorders among immigrants in Korea. This driving force prompted us to conduct this study.
This study evaluated the influence of sociodemographic and health parameters on the presence of anxiety and depression among immigrants. Therefore, this study may contribute to promoting policies that reduce the prevalence of anxiety and depressive disorders among immigrants in the future. This study is based on insights from a nationwide survey conducted in 2020.
METHODS
1. Study Design and Participants
This study used data from a survey on the Health Rights of Migrants and the Improvement of the Medical Security System (HRMIMSS) conducted in 2020 by the National Human Rights Commission of the Republic of Korea and published by the Korea Social Science Data Archive and Seoul National University in 2023 [19]. This structured nationwide survey collected data from immigrants residing in South Korea through face-to-face interviews. The questionnaire was translated into the following 14 languages: Chinese, Vietnamese, Thai, Filipino, Indonesian, Mongolian, Cambodian, Nepali, Burmese, Russian, Arabic, French, English, and Korean. In total, 1,060 immigrants from various countries were surveyed. The HRMIMSS survey focused on the conditions of residence and living of immigrants, such as sociodemographics, awareness of health status, physical or mental disabilities, chronic diseases, utilization of medical services, and awareness of information regarding national health insurance. Thus, the data from this survey were appropriate for examining anxiety and depression among immigrants in South Korea. Detailed information about the HRMIMSS survey is available on the survey organization’s website. This cross-sectional study used publicly available data. The institutional review boards of the authors’ affiliated institutions confirmed that ethical approval was not required.
For the research question “Have you ever felt very anxious or depressed during the past year in Korea?” from the HRMIMSS survey, we only included participants who stayed for 1 year or longer in this study. We also eliminated participants who did not respond to the current status of residence, income, and employment or did not complete the survey questionnaire. In total, 746 immigrants were included in the final screening. Figure 1 illustrates the participant selection and dropout processes.
2. Covariates
The presence of anxiety or depression (yes/no) analyzed in this study corresponded to the response to the question, “Have you ever felt very anxious or depressed during the past year in Korea?” Sociodemographic and health-related parameters of immigrants were considered risk factors for anxiety and depression in our research criteria. Sociodemographic parameters included age, sex (male/female), native country, legal status, place of residence (Seoul metropolitan area or other areas), living with family (yes/no), fieldwork, and monthly income. For the native country, immigrants were organized into six groups based on their geographic, linguistic, and cultural proximity, including (1) South Asia (Bangladesh, Sri Lanka, India, Pakistan, and Nepal), (2) Southeast Asia (Myanmar, Thailand, Vietnam, East Timor, Indonesia, Cambodia, and Philippines), (3) Eastern Asia (China, Japan, and Mongolia), (4) Western Asia (Yemen, Syria, Iraq, Azerbaijan, and Iran), (5) Russia/Central Asia (Russia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan), and (6) Africa (Nigeria, Liberia, Uganda, Tunisia, Morocco, Cameroon, Ivory Coast, Democratic Republic of Congo, Angola, Kenya, South Africa, Ethiopia, Tanzania, Sudan, Algeria, Egypt, and Libya) [20]. Legal status was also divided into six groups based on the current visa status: (1) labor, including E-6, E-7, E-9, E-10, and H-2 visas; (2) students, including D-2, D-4, and D-10 visas; (3) residence, including F-2, F-5, F-6, and D-8 visas; (4) overseas Koreans, F-4 visas; (5) refugees, G-1 visas; and (6) unregistered, including illegal residents and workers [21]. The field of work included manufacturing, construction, agriculture/livestock/fishery, and service/others. Health-related parameters included being covered by national health insurance (yes/no), self-rated health (good/fair/poor), presence of chronic diseases (yes/no), presence of physical or mental disabilities (yes/no), and presence of difficulties in accessing medical services (yes/no) to answer the question “You are injured, sick, or in a medical facility due to a health problem. Have you ever needed or not received a diagnosis, test, or treatment?” The associations between the covariates in this analysis are shown in Figure 2.
3. Statistical Analysis
We determined the frequencies of anxiety and depression among immigrants based on sociodemographic and health-related parameters. Bivariate analyses were performed to estimate the frequencies of anxiety and depression. A two-sided Fisher’s exact test was used to calculate P-values for differences in the frequency of anxiety or depression across immigrant characteristics [22]. Statistical significance was set at P<0.05. difference. To examine the risk factors associated with the frequency of anxiety or depression, a multiple logistic regression model was used, and “no feelings of anxiety or depression” was designated as a reference. The presence of anxiety or depression was considered the dependent variable, whereas all sociodemographic and health-related parameters were considered predictors. Multiple regression analysis enables the estimation of the association between a given independent variable and the outcome while holding all other variables constant, thereby automatically adjusting for potential confounding variables [23]. The Wald test was used to calculate the P-value for parameter estimation, and the likelihood-ratio chi-square (LRC) test was used to assess the model fit [24]. We report the odds ratios (ORs) obtained by exponentiating the regression coefficients and the corresponding 95% confidence intervals (95% CIs). OR represents the relative risk ratios of anxiety OR depression associated with a one-level change in the respective predictors. All analyses were conducted using R software ver. 4.3.2 (The R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
1. Sociodemographic Characteristics and Frequency of Anxiety or Depression Feelings
Sociodemographic characteristics and the frequency of anxiety or depression among immigrants are shown in Table 1. We analyzed 746 immigrants in Korea, of whom 417 were female (55.9%), and 329 were male (44.1%). The ages of the immigrants ranged from 19 to 72 years, with a mean age of 37.02 years. Those of prime working age (26–55 years) accounted for the majority of the study population (84.05%). Immigrants from Southeast Asia accounted for the highest proportion (44.77%), followed by those from Eastern Asia (27.08%), Russia, and Central Asia (16.76%); South Asia and Africa accounted for relatively small proportions. Those with labor visas accounted for the highest proportion (47.59%), followed by overseas Koreans (18.36%). Unregistered persons accounted for a fairly high proportion (15.68%), whereas refugees accounted for 4.69%. More than three-quarters of the immigrants surveyed resided in the Seoul metropolitan area (77.48%), and more than 40% lived with their families. They also worked extensively in the manufacturing sector (51.74%). Approximately 61.66% of the immigrants had a monthly income of 1.5–2.5 million won, while 26.54% had a monthly income of less than 1.5 million won.
As shown in Table 1, the overall frequency of anxiety and depression was 31.77%, but no significant differences in the rates between the age groups were observed. This rate was 38.3% in females, which was significantly higher than that in men (26.62%). There was a significant difference in the frequency of anxiety and depression according to immigrants’ native country. Accordingly, this rate was low among immigrants from South Asia (17.86%) and high among those from West Asia (66.67%) and Africa (64.29%). Regarding legal status, the frequency of anxiety or depression was high among those with student visas (60.53%), residence visas (51.56%), or refugees (48.17%), and lowest among those with labor visas (23.66%). No significant differences in the frequency of anxiety or depression were found to be related to the place of residence. Meanwhile, this rate among those living with their families was 43.48%, which was significantly higher than 23.94% among those not living with their families. Those working in the agriculture, livestock, and fishery fields had the lowest rates of anxiety or depression (24.39%) compared to other fields. Meanwhile, the percentage of those with a monthly income of less than 1.5 million won was high (44.95%).
2. Frequency of Anxiety or Depression Feelings according to Health-Related Parameters
Frequencies of anxiety and depression according to health-related parameters among immigrants are shown in Table 2. Approximately 90% of the respondents reported fair or good health. The frequency of anxiety or depression increased significantly with decreasing health status and was highest among those who self-reported poor health (52%). Those with chronic diseases accounted for only a small percentage in this study (11.93%), but their rates of anxiety or depression were significantly higher (58.43%). The same was true of those with physical or mental disabilities (69.23%). Approximately 25% of respondents reported difficulties in accessing health services. The rate of anxiety or depression in this group was 69.23%, which was significantly higher than the 30.42% rate among those without difficulties. Additionally, no differences in the frequency of anxiety or depression were observed with respect to national health insurance coverage.
3. Sex-Differentiated Effects on the Frequency of Anxiety or Depression Feelings
Figures 3 and 4 show the sex-specific impacts of sociodemographic and health-related parameters on the frequency of anxiety and depression among immigrants. Overall, the rates of anxiety and depression were significantly higher among females than among males. However, in several immigrant groups, the results showed that the frequencies of anxiety and depression were significantly lower in females than in males. As illustrated in Figures 3 and 4, this rate for mature male working-age immigrants (over 55 years old) was 57.14%, which was significantly higher than that for females (40.62%). The same was also true for some other groups, such as those with student visas (78.57% versus 50.03%) or overseas Koreans (44.23% versus 28.41%); those working in construction (35.29% versus 24.97%) or the service field (59.52% versus 44.22%); those with poor self-rated health (56.25% versus 48.84%); those with chronic diseases (62.79% versus 54.35%) or physical or mental disabilities (70.02% versus 58.75%%); and those with the presence of difficulties in accessing medical services (64.47% versus 56.14%). Additionally, no significant differences in the frequency of anxiety or depression were observed between males and females among immigrants from Eastern Asia, Russia, Central Asia, those living with their families, and those with a low monthly income.
4. Multiple Logistic Regression Analysis
The results of the multiple logistic regression analysis of feelings of anxiety or depression among immigrants are presented in Table 3. The small P-value obtained from the LRC test (<0.001) demonstrates the adequacy and robustness of the model. This shows the varying influences of factors on the frequency of anxiety or depression among immigrants. Except for the place of residence and national health insurance coverage, other factors had significant effects on the frequency of anxiety or depression. The relative risk of anxiety or depression in the mature working-age group was 1.8 times higher than that in the early working-age group (18–25 years old). Immigrants who were not from South or Southeast Asia had a significantly higher relative risk of anxiety or depression than those from Western Asia (OR, 5.9; P<0.001) or Africa (OR, 6.5; P<0.001). Compared to those with labor visas, the relative risk of anxiety or depression feelings was 5.5 times higher in those with student visas. This number for those with residence visas was 2.5, for overseas Koreans was 1.3, and for refugees was 1.6. The relative risk of anxiety or depression was significantly higher in those living with their families (OR, 1.512; P<0.001), those with chronic diseases (OR, 2.751; P<0.001), those with disabilities, and those with difficulties in accessing medical services (OR, 5.861; P<0.001). Immigrants working in construction had a relative risk of anxiety or depression feelings 1.33 times higher than those working in manufacturing. Those working in agriculture, livestock, and fishery fields had the lowest relative risk of anxiety or depression (OR, 0.669; P<0.001). The same was true for those with poor self-rated health compared to those with good health.
DISCUSSION
Anxiety and depression are among the most common mental illnesses that directly affect a patient’s quality of life [4]. Early detection of related symptoms may reduce the risk of anxiety or depression diseases [8]. While recent studies have focused on analyzing anxiety or depression in children, adolescents, females, the elderly, and people with certain medical conditions [9-14], few studies related to anxiety or depression have been conducted among immigrants in Korea [15-18]. In particular, no study has fully evaluated the influence of legal and health status factors on anxiety and depressive disorders among immigrants in Korea. This study analyzed the influence of sociodemographic and health parameters on the frequency of anxiety and depression among immigrants in Korea based on insights from a nationwide survey conducted in 2020.
We found that groups of immigrants aged over 55 years and those of African or West Asian origin had a high relative risk of anxiety or depression feelings (1.83 times higher than those aged 18–25 years and 5.90 times higher in West Asia, 6.46 times higher in Africa than in South Asia). For immigrants aged over 55 years, owing to declining health and lack of agility at work, their job opportunities were significantly reduced, and they could be sacked at any time [25]. This may explain why they easily experience feelings of anxiety or depression. For immigrants of African or Western Asian origin, significant differences in language, culture, and cuisine may have made it more difficult to assimilate, making them more susceptible to anxiety or depression than those from East Asia or other regions [26]. Future in-depth interview studies of immigrants of African and Western Asian origin should be conducted.
Our findings also showed a high relative risk of anxiety or depression among immigrants with student visas (5.49 times higher than those with labor visas). The reality showed that immigrants with labor visas focused only on earning and working. A stable income helps them afford a better life. Meanwhile, immigrants with student visas mostly come from countries with less developed economies than Korea. In addition to adapting to the different conditions of school life, language, culture, and cuisine in Korea, most international students have to work outside; most international students have to work outside factories, restaurants, and deliveries to pay tuition fees and subsistence. Some of them also bring their entire families with them, so an economic burden is always present [27,28]. The stressful study hours combined with hard physical work seem to be more stressful than ever before.
We found that the relative risk of anxiety or depression among immigrants significantly increased with poor self-rated health, chronic diseases, disabilities, and difficulties in accessing health services. Poor health, chronic diseases, and disabilities may significantly reduce employment opportunities, particularly affecting activities of daily living and making them feel dependent, thus increasing their susceptibility to anxiety or depression. This finding aligns with previous studies [7,8]. Furthermore, difficulties accessing medical facilities may cause immigrants to lose confidence and feel abandoned, especially during the COVID-19 pandemic. This underscores the need for governmental policies related to the healthcare of immigrants with poor health, chronic diseases, and disabilities.
Interestingly, we analyzed the sex-differentiated effects of sociodemographic factors, legal status, and health parameters on the frequency of anxiety or depression. Overall rates of anxiety and depression were significantly higher among females than among males in general. However, in several immigrant groups, the frequencies of anxiety and depression are significantly lower in females, especially among those with health problems and illnesses. Males often perceive themselves as primary economic providers for their families, a cultural norm particularly prevalent in East Asian countries [29]. Therefore, illness, disease, or disability may significantly impede their ability to fulfill this role. Furthermore, males may have less robust mental resilience compared to females [30], potentially exacerbating their frequency of anxiety or depression.
Although the effects of sociodemographic and health-related parameters on the frequency of anxiety or depression have been thoroughly analyzed, the current study has several limitations. First, the cross-sectional design prevented the establishment of a cause-and-effect relationship. Second, the study relied on secondary data from a nationwide survey in Korea conducted through face-to-face interviews, which may have limited the generalizability of the findings because of potential social desirability bias or incomplete responses from the participants. Third, the study did not include factors related to health behaviors (such as smoking, alcohol consumption, and physical activity), social activities, or religion, as these were not reported in the survey data. Additionally, the study did not include data on coronavirus infection, as it was not available in the database, it was not included in this study.
In conclusion, this study demonstrated the frequency and risk factors associated with anxiety and depression among immigrants. Overall rates of anxiety and depression were significantly higher in females than in males. High relative risks were observed in immigrant groups aged over 55 years, those of African or West Asian origin, and those with student visits. Additionally, this rate significantly increased with poor self-rated health, chronic diseases or disabilities, and difficulties in accessing health services. These findings have important implications for policymakers aiming to reduce the likelihood of developing anxiety or depression in the future and enhance the quality of life of immigrants in Korea.
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