An integrative theoretical framework of acculturation and salutogenesis

Abstract

During the last two decades, the number of international migrants worldwide has constantly risen. In this context, cross-cultural dimensions of psychological disorders receive increased attention, especially depression, anxiety and post-traumatic stress disorders among the migrant population. In this paper we propose a theoretical framework for the understanding of migrant mental health. This framework combines elements from Berry's acculturation model and Antonovsky's salutogenic theory. The former illustrates the main factors that affect an individual's adaptation in a new cultural context. The term acculturative stress denotes unresolved problems resulting from intercultural contact that cannot be overcome easily by simply adjusting or assimilating. The latter specifies the relationship between culturally associated stress and mental health more distinctive, introducing the concepts of generalized resistance resources and sense of coherence that determine mental health outcomes of migrants during acculturative stress periods. Specifically, we provide an integrative framework of acculturation and salutogenesis that helps to integrate inconsistent findings in the migrant mental health literature. The current paper focuses on the effect of resource factors for positive mental health outcomes in the migrant population and summarises some implications for future research activities.

Introduction

During the last two decades we have observed an increasing number of international migrants worldwide. Whereas the estimated total number of international migrants was about 155 million in 1990, the total number has increased to about 213 million in 2010. Furthermore, the annual rate of change of the migrant stock amounts to 1.8% in the last 10 years (United Nations Population Division, 2009). Human beings move from country to country, from one culture setting to another, for various reasons. This means that the social group of migrants within a country is very heterogeneous, which combines individuals who move to study, seek better employment, attempt to better their future, or to avoid political and religious persecution. The focus in this paper is on migrants in general, who leave their country of birth for another emigration country.

As a result of the expanding number of international migrants, there has been an increased interest in analysing the relationship between migration and mental health in recent years, with publications of numerous books, reports and journal articles. However, epidemiological evidence on that matter is limited, because empirical findings are controversial and their interpretations are difficult in view of different sampling and assessment methods. For example, after a systematic review, Lindert et al. (2009) included 35 studies in a meta-analysis with prevalence rates of depression between 3% and 81%, of anxiety between 5% and 90%, and of post-traumatic stress disorder (PTSD) between 4% and 68% in the migrant population. Moreover, meta-analyses found no conclusive evidence for a large increase in the risk of mental disorders associated with the migratory process (Fazel et al., 2005; Swinnen & Selten, 2007). With respect to the particular case of PTSD, the meta-analysis of Fazel et al. (2005) substantiated that refugees could be about 10 times more likely to meet this diagnostic category than the age matched general population, nevertheless they included a wide range of findings regarding the prevalence of PTSD from 3% to 44% in their analysis.

The specific relationship between migration and mental health still remains ambiguous. In view of the vast number of publications, we became aware of the complex combinations of biological, psychological, and socio-cultural factors of migration mental health. Given the complexity of this multitude of determinants, it seems to be impossible to study this matter satisfactorily without discussing methodical problems such as the limited cross-cultural validity of assessments.

On the other hand, we ascertain that most of these published empirical studies are not theory driven. In our view, the fact that research designs are deficiently grounded in theory is one major reason for the diversity of study outcomes. Our point is that a conceptual model is needed to understand and to explain the migration–mental health relationship. Consequently, the primary objective of this paper is to elaborate a theoretical framework for the understanding of migrant mental health that combines elements from Berry (2006a, 2006b) acculturation model and Antonovsky's (1987) salutogenic theory, assuming that migration is not inevitably related to mental health problems, and that migration is not, by definition, a risk factor.

Acculturative stress and mental health

Cross-cultural research has piled up a huge number of investigations into long-term psychological consequences of the acculturation process, evidenced by a historical analysis of empirical studies (Brouwers et al., 2004). A widely accepted classical definition of acculturation reads:

Acculturation comprehends those phenomena which result when groups of individuals having different cultures come into continuous first hand contact, with subsequent changes in the original culture patterns of either or both groups. (Redfield et al., 1936, p. 149)

Thus, migrants face two cultures. In line with Hofstede (1991), we understand culture as software of the mind, reflecting specific patterns of thinking, feeling and acting. Hofstede's definition reads:

Culture is always a collective phenomenon, because it is at least partly shared with people who live or lived within the same social environment, which is where it was learned. Culture consists of the unwritten rules of the social game. It is the collective programming of the mind that distinguishes the members of one group or category of people from others. (1991, p. 6)

Migrants have left their social environment behind, in which they were socialized, still carrying those earlier acquired patterns of thinking, feeling, and acting with them. When stepping into a new culture, people from the host population show an unfamiliar programming of the mind, that migrants must learn to deal with. From this perspective, migration is prone to conflict and might be prematurely understood as a fundamental life event that induces disintegration, suffering, and ill health. As Hofstede (2009) puts it: ‘Culture is more often a source of conflict than of synergy. Cultural differences are a nuisance at best and often a disaster.’ Such intercultural contact includes several conflicts. There are conflicts through the new roles played in the new place of residence, conflicts through change of status, specific practices, beliefs and values, and conflicts through acquisition of a new language. All of them may become significant daily stressors. Obviously, these stressors are not a one-way street to mental health problems. Therefore, our subject of interest is to explain how migrants are able to successfully adapt to new cultural contexts by productively managing tension states that cultural conflicts bring about. We will return to the distinction between stress and tension later.

With respect to the question of acculturation outcome, Berry (1997) outlines four acculturative strategies used by immigrants (see Figure 1 ): An immigrant with the strategy of integration is capable of maintaining the culture of origin while adopting the new culture context; an immigrant with the strategy of assimilation adopts the new culture context to the disadvantage of that of origin; an immigrant with the strategy of separation keeps the culture of origin and rejects the culture of the receiving society, and at last an immigrant with the strategy of marginalization abandons all cultural identity. Research on these acculturation strategies has revealed that integration is associated with the best psychological and socio-cultural adaptation (Liebkind, 2008; Sam & Berry, 2006; Scottham & Dias, 2010). Assimilation and separation achieve a medium degree of acculturative stress and adaptation problems. However, marginalization has been associated with the highest risk of adaptation difficulties.

Figure 1. Four acculturation strategies (adapted from Berry, 1997).

Without explicitly relating to these four acculturation strategies, Berry (1997, 2006a) presents a process model of acculturation describing how groups and individuals experience and manage the process of acculturation. In particular, his understanding of acculturative stress offers a conceptual and empirical framework explaining the relationship between migration and mental health. The general framework distinguishes between the acculturation as a cultural or group phenomenon, and the psychological acculturation on the individual level. This distinction is important to consider the psychological changes that migrants in all groups experience.

In Figure 2, Berry's framework (1997, 2006a) is shown delineating the process of psychological acculturation as illustrated by five main events over time. Intercultural contact experiences and migration-associated life events are common starting points (first step).

Figure 2. General framework for understanding acculturation (Berry, 2006a).

In the second step, individuals evaluate and appraise the degree of difficulties caused by these life events. Individuals are variably involved in this appraisal process, depending on three differing conceptual approaches specifying the degree of difficulties that exist during acculturation (see Figure 2). This variability starts from simple behavioural shifts like ways of speaking, dressing, or eating. This first approach is usually non-problematic and considers psychological changes to be rather easy to accomplish. The second more problematic approach produces acculturative stress when greater levels of conflict are experienced. In this case unresolved problems resulting from intercultural contact cannot be overcome easily by simply adjusting or assimilating. The acculturative experiences are evaluated to be problematic but controllable and resolvable. In view of the third approach, psychopathology, acculturation is related to major intercultural difficulties and is almost always seen as problematic. This may lead to serious psychological disturbances, such as depression and anxiety (Hovey & King, 1996; Revollo et al., 2011).

The third main event (step three) over the time of acculturation is the individual's practice of strategies to deal with difficult and problematic experiences. This should not be equated with the four acculturation strategies described before. Berry (1997) alludes to Lazarus and Folkman's (1984) transactional stress theory. Accordingly, acculturative stress is mediated by (1) the individual's appraisal of the acculturative experiences (primary appraisal) and (2) the social and cultural resources which the individual has access to (secondary appraisal). Acculturative stress results if internal or external demands are subjectively taxing or exceeding the resources of the migrant individual. Two major coping efforts are distinguished: Problem-focused efforts include learning new skills and developing new standards of behaviour. Emotion-focused efforts are directed towards regulating the emotional response associated with the problem and include strategies such as wishful thinking, minimization, and avoidance.

A complex set of immediate effects such as physiological and emotional reactions are included in the fourth main event during the psychological process of acculturation. Depending on the three conceptual approaches, stress will range from relatively low, when behavioural shifts have taken place, to high levels, when acculturative problems have been overwhelming during the approach of psychopathology.

The chain of five main events presented in Figure 2 completes the process with the last main event of possible long-term outcomes and various kinds of adaptation. We want to point out that this chain is a simplification of adaptation processes. For example, Searle and Ward (1990) proposed and validated a distinction between psychological and socio-cultural adaptation, which we do not consider any further. The former is a set of internal psychological outcomes including individual's satisfaction, overall psychological well-being, and self-esteem. The latter is a set of external psychological outcomes concerning how a successful acculturating individual is able to manage the activities of daily intercultural living, particularly in the areas of family life, work, and school. The two forms of adaptations are supposed to be empirically related.

Current literature reviews demonstrate that the flow of this framework is a very complex phenomenon and highly variable (Bhugra, 2004). Not every individual migrant goes through the same process. The psychological acculturation and adaptation outcomes depend on a wide range of moderating factors that exist prior (age, gender, education, motivation, personality, culture distance) and during (acculturation strategies, coping, social support) migration (Berry, 1997, 2006b). Many empirical studies back up the differing roles these factors play and draw ambiguous conclusions (Bhugra, 2004). As a consequence, there is a lack of clear association between acculturation and mental health, and the applicability of Berry's models is limited.

As one plausible explanation of these controversial findings, attention has been drawn to the ‘healthy migrant effect’, which describes the fact that first-generation immigrants are often healthier and have significantly longer life expectancies than the non-immigrant population. There is evidence that migrants are not random samples of their home countries but rather a ‘positively selected’, prime-aged group with high motivation and resources to carry out an international move. They are more educated and in better psychological and physical health than nonimmigrants (Feliciano, 2005; Palloni & Arias, 2004). Thus, for a basic understanding of the psychological acculturation processes, it is essential to understand the context of resources, which the individual holds available, whether these are psychological, social, institutional, or cultural. From this perspective, acculturation experiences can challenge migrant individuals. Resources and adequate strategies influence the outcome of coping processes and lead to variable degrees of adaptation. In many empirical studies, resources such as age, gender, language, social support, or occupational status, have in fact been examined (Bhugra, 2004); however, these studies are largely disconnected from theory. Little work has been done to investigate resources and its functions with respect to migration mental health in a conceptual framework. We suppose that Antonovsky's (1979, 1987) salutogenic model might contribute to the understanding of migrant mental health and explain the controversial findings.

The salutogenic model

The salutogenic model focuses on people's resources and capacities to create health. Antonovsky (1979, 1987) formulated a general theory of health and illness, in which migration as an enduring and demanding change in one's life situation is a special case.

The starting point of the salutogenic model is sociological in nature (see Figure 3). A person is born and raised into a certain historical and socio-cultural context which provides a spectrum of prospects and obstacles for ontogenetic development. These personal, physical, and social environments involve certain health-enhancing resources as well as certain health-threatening hazards. It is Antonovsky's (1987) credo that life is inherently stressful, and that health is an exception to the rule. At every point in time, a living organism faces a multitude of forces that move the organism towards a condition of maximum disorder, or ‘dis-ease’. Hence, Antonovsky is particularly interested in those ‘salutary’ forces that prevent the organism from breaking down.

Figure 3. Simplified diagram of Antonovsky's (1987) salutogenic model.

The human being is considered as a highly complex bio-psycho-social system equipped with self-regulatory capabilities such as self-reflection, anticipation, and problem-solving. On the other hand, this inherent complexity is linked with a high rate of conflicts, or stressors. These stressors – that result from different kinds of inconsistencies on the intrapersonal, interpersonal, or intergroup (intercultural) level – bring about psychophysiological tension states. Antonovsky draws an important distinction between stressor and tension. The main point is that a stressor is not detrimental to health per se; it is the unresolved conflict which causes ‘dis-ease’. The inherent self-regulatory competencies are the main reason why human beings are not completely at the mercy of conflicts, or stressors. Tension states can have pathological, neutral, but also beneficial outcomes. Human beings stay healthy, if they succeed in managing, or down-regulating, the tension state. In this regard, conflicts are forces that enable psychological processes of development, personal growth, and mental health. Two concepts explain this self-regulatory process: generalized resistance resources and sense of coherence.

Generalized resistance resources operate as a means for system re-organization, or tension management. They are called generalized because they can be applied in different situations under different circumstances, and the term resistance means that they promote capability for resistance, or resilience. Generalized resistance resources are environmental and personal factors. They have in common that they afford life experiences (see Figure 3) which are characterized by consistency, participation, and a balance between overload and underload. Examples are constitution, competencies, personality traits, social support, social stratum, cultural stability, etc. These life experiences accumulate over the life-span and bring about the sense of coherence – a global orientation which represents an individual's self-preserving competence.

A strong sense of coherence is characterized by high comprehensibility of one's world (i.e. stimuli and situations make sense and are understood as cognitively clear and structured information and not as chaotic), high manageability of one's outcomes, (i.e. demanding situations will be perceived as controllable, because internal and/or external resources are available that meet the stress load), and high meaningfulness of one's life (i.e. life emotionally makes sense, which means that it is worthwhile to invest energy and to engage personally in solving problems and meeting demands in life). These three components make up the sense of coherence and should not be separated from one another. Antonovsky (1987) supposed that this life orientation is shaped by the end of young adulthood (by the age of 30 years). Unless radical, enduring changes in one's life situation occur (e.g. migration, traumatic experiences), it would remain stable over the lifespan.

As illustrated in Figure 3, the sense of coherence determines an individual's health level which is conceptualized as a continuum. Individuals holding a strong sense of coherence will be located towards the ‘health-ease’ pole, because they are resourceful and because they are competent in coping with (potential) stressors. Contrariwise, individuals holding a weak sense of coherence will experience their world as more chaotic and will suffer from ‘dis-ease’, because resources are scarce or inadequate. Like Berry (1997) in his acculturation model, Antonovsky (1987) rests on Lazarus and Folkman's (1984) transactional stress theory when explicating the coping process.

Antonovsky (1987) suggests that the sense of coherence works like a filter for information processing. In a first appraisal of a potentially stressful situation, individuals with a strong sense of coherence are supposed to evaluate stimuli as neutral, whereas rather incoherent individuals would experience these stimuli as incriminating (primary appraisal I). In the further course of stimuli evaluation, the highly coherent person can effectively differentiate if the stimulus or stimuli are irrelevant to one's well-being, threatening or even benevolent. If a stimulus is potentially threatening, the highly coherent person can trust in having adequate resources to cope with the situation. A strong coherent person is supposed to evaluate stressors as principally positive or irrelevant for his or her well-being (primary appraisal II). Finally, highly coherent individuals should have a clearer and a more differentiated instrumental problem perception; their emotions should be less diffuse and, therefore, be less debilitating (primary appraisal III).

A strong coherent person has brought his or her unique human capabilities of self-reflection, anticipation, and problem-solving, to virtual perfection. He or she has a high motivation for coping with stressful situations. He or she is able to choose the best and most adequate resources to meet the demands imposed by the conflict which may be due to inconsistencies within the person and/or the situation. His or her coping capabilities are high, flexible and adaptive. The successful use of adequate resources results in reduction of long-term tension. Short-term tension is not detrimental for an organism, if a phase of recovery follows. Long-term tension disrupts self-regulatory processes and leads to ill health.

Antonovsky claims that the sense of coherence determines a variety of health dimensions such as mental health, well-being, life satisfaction, physical health, functional health, and the like (see the reviews by Antonovsky, 1993; Bengel et al., 1999; Eriksson & Lindström, 2005, 2006, 2007). In our own gerontological research, we could substantiate these assumptions, too. In addition, we could show that various bio-psycho-social resources are substantially related with the sense of coherence. Moreover, we could show that the sense of coherence is a mediator of the relationship between resistance resources and health level as it pools generalized resistance resource-influences on health (Wiesmann, 2006; Wiesmann & Hannich, 2008, 2010, 2011; Wiesmann et al., 2009a, 2009b). Finally, empirical studies bolster the salutogenic hypothesis that a strong sense of coherence is positively associated with ‘adapative’ (e.g. problem-focused behaviour) and negatively associated with ‘maladaptive’ (e.g. denial) coping strategies (Amirkhan & Greaves, 2003; Ben-David & Leichtentritt, 1999; Cohen et al., 2008; Ebert et al., 2002; Edwards & Holden, 2003; Fok et al., 2005; Gallagher et al., 1994; Heiman, 2004; Johnson, 2004; Kalimo & Vuori, 1990; Kristensson & Öhlund, 2005; Margalit et al., 1992; McSherry & Holm, 1994; Pallant & Lae, 2002).

Salutogenesis and culture

As already noted, the development of a strong or a weak sense of coherence, respectively, is strongly dependent on the structural, or the socio-cultural context, which in turn determines the individual's social identity (Tajfel & Turner, 1979) and, in Hofstede's (1991) terms, programming of the mind. In a given culture, the sense of coherence is strengthened by the availability of generalized resistance resources (salutogenic factors) and weakened by the preponderance of stressors, or conflicts. Antonovsky (1993) claims that his sense of coherence (SOC) construct has a crosscultural character.

The SOC is, hopefully, a construct … which is universally meaningful, one which cuts across lines of gender, social class, region and culture. It does not refer to a specific type of coping strategy, but to factors which, in all cultures, always are the basis for successful coping with stressors. This, of course, does not mean that different groups will have an equally strong average SOC. (Antonovsky, 1993, p. 726)

International empirical research backs up the cross-cultural character of the sense of coherence. According to Eriksson and Lindström's (2005) review, the sense of coherence questionnaire has been used in 32 different countries and 33 languages, ‘in both Western countries and countries such as Thailand, China, Japan, and South Africa. Therefore, the SOC scale seems to be a cross culturally applicable instrument’ (p. 462).

According to Antonovsky, migration might represent a radical change in socio-cultural influences and structural living conditions that might shatter a strong sense of coherence. On the one hand, the change might be a rather fundamental one because the spectrum of resources in the ‘new’ culture is different, and because the intercultural experiences turn out to be more unexpected. As a consequence, the comprehensibility of the new culture, the manageability of outcomes and meaningfulness of one's life might be threatened. On the other hand, a strong sense of coherence might instigate adequate coping strategies that help a migrant to adapt to this new cultural environment. In contrast, the migrant with a moderate sense of coherence will move to a lower level over time, and for a migrant with a weak sense of coherence, life in the new culture becomes a vicious circle. There is scarce empirical evidence of salutogenesis and migration.

Evidence of salutogenesis in migrants

As mentioned previously, a variety of empirical studies elucidate the relationship between acculturation and mental health, investigating uncountable intervening and outcome variables. But there is only scarce evidence concerning the implications of the sense of coherence as a predictor of psychological adaptation for migrants. The analyses of Ying and co-workers (Ying & Akutsu, 1997; Ying et al., 1997) support the mediating role of sense of coherence using a sample of 2234 South Asian refugees immigrated to California. The path analytical results support the hypothesis that the sense of coherence, showing the highest beta coefficient, serves as a significant mediator of the effects of resistance deficits and resources on psychological dysfunction, demoralization and happiness. Thus, in particular, a low subjective sense of their world as comprehensive, manageable, and meaningful is significantly linked with migrant mental health problems.

Sundquist et al. (2000) analysed data from a random national sample of 1980 participants of five ethnic groups who immigrated to Sweden. Consistent with our theoretical framework of acculturation and salutogenesis, a low sense of coherence was a substantial explanatory variable for psychological distress in men and women, adjusted for age, migration status, poor knowledge of Swedish, poor control, economic difficulties, and contemporary educational attainment. In addition, a low sense of coherence seemed to be a stronger risk factor for psychological distress than exposure to violence before migration.

Another study focused on the risk and resources factors of mental health outcomes of 308 Pakistani immigrants residing in Canada for one to five years (Jibeen & Khalid, 2010). Results from hierarchical multiple regression analyses indicated that acculturative stress, demographic characteristic, sense of coherence, coping strategies and perceived social support emerged as significant predictors of positive well-being. All of these variables accounted for 45% of the variance in the prediction of positive well-being.

Lam (2007) examined the impact of perceived racial discrimination, conceptualized as a life stressor of the acculturation process, on psychological distress, mediated by the sense of coherence among 122 Vietnamese American college students. The results show that higher levels of perceived racial discrimination were associated with a reduced sense of coherence and with higher levels of depression and anxiety. Applying path analyses, Lam (2007) found that the association between perceived racial discrimination and depression, and perceived racial discrimination and anxiety were mediated by the sense of coherence.

Ying et al. (2000) examined the contribution of domain-specific cultural orientation and racial discrimination to the sense of coherence in 122 American-born and 231 immigrant Chinese American college students. Ying et al. (2000) operationalized cultural orientation in the three domains of language, social affiliation, and cultural pride. Berry's acculturation strategies were used to classify cultural orientation in each domain: bicultural/integrated, assimilated, separated, and marginal. At first, the two groups did not differ significantly in their level of sense of coherence, but American-borns reported that they experienced racial discrimination less often than immigrants. With respect to language, American-borns were more likely to be assimilated, while immigrants were more likely to be separated and bilingual. With respect to social affiliation, immigrants were more likely to be separated while American-borns were more likely to be assimilated and bicultural. No difference in cultural pride could be found between the two groups. Ying et al. (2000) also investigated the contribution of cultural orientation and racial discrimination to the sense of coherence, using separate regression models for both groups. With respect to the American-borns, only one cultural orientation in the language domain was a significant predictor for sense of coherence, bilinguals reporting higher sense of coherence than those assimilated in language. With respect to the migrant sample, coherence varied by cultural orientation in all three life domains. Again, bilingual immigrants had a higher sense of coherence than those assimilated in language. The bicultural affiliation was related with a low sense of coherence compared with primarily American affiliations. Immigrants who expressed pride in both cultures reported a higher sense of coherence than those who were separated, assimilated or marginal.

Ying et al. (2001b) examined the network composition, social integration, and sense of coherence in a group of 353 Chinese American students at a public university. Students with a racially/ethnically mixed network reported a greater sense of coherence than those with an ethnically same network, and greater integration was associated with greater sense of coherence. The authors conclude that more diverse networks offer the reward of increased competence and better person–environment fit. Similar results were found in another subsample of 291 Asian American students (Ying et al., 2001a): Greater cross-racial engagement was positively associated with the sense of coherence.

An integrative model of acculturation and salutogenesis

Having reviewed both the theoretical and empirical contributions to explain the relationship between acculturation and mental health in migrants, we suggest an integrative and simpler model. Indeed, although we agree with Berry that acculturation is a multifaceted process, we consider his model to be too complex to be empirically tested. According to Berry's framework, adaptation processes are highly variable. Our point is that our integrative model focuses on processes that transcend specific migrant groups and situations.

First, we simplify the model by summarizing moderating factors prior to and during the acculturation process as generalized resistance resources and sense of coherence. Second, we think that Berry's three conceptual approaches – behavioural shifts, acculturative stress, and psychopathology – are very difficult to operationalize. It is unclear under what circumstances a migrant is engaged in one of the three approaches. We think, in the prototypical case, a migrant faces rather unproblematic situations as well as controllable and uncontrollable stressors, and we would also surmise that the number of stressors is not constant but varies from time to time. As it is not clear what makes up the boundaries, we would renounce this three-fold distinction. Third, it is unclear in what way acculturation strategies sensu Berry (see Figure 1) and the psychological acculturation processes as illustrated by the five main events (see Figure 2) are related. In addition, Berry does not explicate hypotheses concerning the formation of acculturative strategies on the individual level. Therefore, we supplement Berry's valuable concept of acculturation strategies in our integrative model. From a salutogenic point of view, we provide different perspectives of both formation and effects of acculturation strategies that trigger psychological acculturation processes.

We present our model in Figure 4, in which the sense of coherence, generalized resistance resources, and acculturative strategies are the key variables explaining migrant mental health. As can be seen, the migrant faces two cultures. We call the culture in which a person was socialized culture 1, and culture 2 denotes the ‘new’ culture in which he or she has migrated. The individual has developed a sense of coherence in culture 1 (SOC-C1), which is connected with respective generalized resistance resources (GRRs-C1). Stepping into the new culture, the SOC-C1 is transformed to SOC-C2, reflecting immediate migration influences, and culture 2 also offers a range of new resources (GRRs-C2).

Figure 4. Integrative framework of acculturation and salutogenesis.

SOC-C1 and GRRs-C1 give distinction to the migrant's acculturative strategies which determine how the individual arranges and frames his or her intercultural contacts. In line with Berry (1997), we would differentiate integration, assimilation, separation and marginalization strategies, that are shaped by both one's social identity, reflecting in-group norms and non-immigrant out-group representations (Tajfel & Turner, 1979), and one's personal identity, such as individual characteristics and competencies. From a clinical point of view, Güc (1991, 2010) reported on adaptation strategies of families and pointed out the effects of low resilience and resources of families who fail orientation in the new and the former culture. We suppose that migrant's utilization of integrative strategies is linked with high SOC-C1, while marginalization strategies are accounted for by low SOC-C1. Although there are no empirical data about migrants’ sense of coherence prior to acculturation, we indirectly infer from the ‘healthy migrant effect’ based on epidemiological data (Feliciano, 2005; Palloni & Arias, 2004) that a strong SOC-C1 predicts successful migrant adaptation. Furthermore, we would suggest that a migrant's acculturative strategy determines the availability and acquisition of culture 2 resources, and vice versa, that a respective acculturation strategy is also shaped by culture 2 resources (such as migration programmes and policies). Berry (2010) provides empirical evidence for this relationship. In accordance with salutogenic theory, Lam (2007) found a negative correlation between the perceived racial discrimination and the sense of coherence.

In contrast to Berry, we do not differentiate between conceptual approaches specifying a priori levels of acculturative stress. We suggest that migration in itself is a (series of) life event(s) implying radical and enduring changes in one's life situation and might threaten the sense of coherence (SOC-C2). A strong SOC-C2 would help the migrant to successfully mould his or her acculturation process. This assumption has been supported by four empirical studies so far (Jibeen & Khalid, 2010; Sundquist et al., 2000; Ying & Akutsu, 1997; Ying et al., 1997). We would suppose that migrants following one of the four acculturation strategies differ in their extent of the sense of coherence. There is only one investigation (Ying et al., 2000) which interrelates acculturation strategies and the sense of coherence in immigrant college students.

Our model supposes that a migrant's acculturative strategy has an impact on the selection, quality, and frequency of intercultural contacts affording acculturation experiences. In this regard, Ying et al. (2001a) found a positive correlation between cross-racial engagement and the sense of coherence.

Intercultural contacts may be conflictual and bring about psychophysiological tension states. Low coherent migrants would appraise the conflict situation as a stress episode taxing or exceeding their reserves, whereas high coherent ones would either appraise the situation as rather unproblematic, because adequate resources are available, or as a challenge. Respective coping efforts lead to immediate effects of tension management that determine the acculturation outcome, such as mental health. Finally, a positive acculturation outcome can be considered as a resource (GRR-C2), which is in turn beneficial for coping with future stressful situations. In line with this assumption, Ying et al. (2001b) summarized that high diversity of social networks is linked with increased competence and better person–environment fit.

Conclusions and outlook

Overall, we conclude that the prediction of migrant mental health outcomes using Berry's (1997) model of acculturation is limited. As a consequence, we formulated an alternative acculturation framework which is rooted in health promotion theory (Antonovsky, 1996). We presented a parsimonious model explaining the relationship between migration and mental health, integrating an acculturation and salutogenesis perspective. Focusing on the acculturation strategies, the sense of coherence, and generalized resistance resources, our model is able to better explain the controversial findings in migrant mental health research. Our point is that migration is not per se a negative life event, or a stressor, and that migration processes depend on the individual's subjective appraisal.

More specifically, we can infer from our model a series of hypotheses with respect to migrant mental health outcomes that can be empirically tested. In this respect, our integrative model is innovative in that it allows for formulating new hypotheses. As our review showed, there is only scarce evidence concerning the impact of the sense of coherence on acculturation processes and psychological adaptation. For example, empirical data exist with respect to immigrants’ sense of coherence neither on their arrival in the host country nor at an earlier date in their country of origin.

We strongly recommend longitudinal research designs. Ideally, research designs should be prospective in nature in order to map cause-effect relations. It would also be important to follow an intercultural perspective and include migrant groups from different parts of the world.

Furthermore, we argue for a standardized measurement of model variables in order to reduce measurement error and increase the comparability of international studies. The sense of coherence questionnaire has proven to be interculturally applicable. It would be a major aim for future research to construct cross-culturally valid assessment instruments for GRRs, acculturative orientation, coping efforts, and mental health.

More empirical evidence concerning the significance of the sense of coherence for understanding acculturation processes holds important practical implications for primary health care and policy makers. Migration programmes should aim at bolstering migrants’ sense of coherence by identifying resource factors, providing adequate bio-psycho-social resources, and promoting the migrant's ability to comprehend, manage, and find meaning in their new society. In this manner, we put emphasis on inclusion strategies which identify and overcome the barriers that inhibit migrants’ choices and ability to achieve their full potential. Bearing this intention in mind, intervention programmes should be characterized by an understanding of migrant values, preferences, and resources in order to ensure effective mental health promotion.

Acknowledgement

We thank Ulrike Plötz for editorial help with the manuscript.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.