"Dune et al. Reproductive Health (2017) 14:50DOI 10.1186/s12978-017-0310-9 RESEARCH Open Access Culture Clash? Investigating constructions of sexual and reproductive health from the perspective of 1.5 generation migrants in Australia using Q methodology 1,2* 2 2 1 T. Dune , J. Perz , Z. Mengesha and D. Ayika Abstract Background: In Australia, those who migrate as children or adolescents (1.5 generation migrants) may have entered a new cultural environment at a crucial time in their psychosexual development. These migrants may have to contend with constructions of sexual and reproductive health from at least two cultures which may be at conflict on the matter. This study was designed to investigate the role of culture in constructions of sexual and reproductive health and health care seeking behaviour from the perspective of 1.5 generation migrants. Methods: Forty-two adults from various ethno-cultural backgrounds took part in this Q methodological study. Online, participants rank-ordered forty-two statements about constructions of sexual and reproductive health and health seeking behaviours based on the level to which they agreed or disagreed with them. Participants then answered a series of questions about the extent to which their ethnic/cultural affiliations influenced their identity. A by-person factor analysis was then conducted, with factors extracted using the centroid technique and a varimax rotation. Results: A seven-factor solution provided the best conceptual fit for constructions of sexual and reproductive health and help-seeking. Factor A compared progressive and traditional sexual and reproductive health values. Factor B highlighted migrants’ experiences through two cultural lenses. Factor C explored migrant understandings of sexual and reproductive health in the context of culture. Factor D explained the role of culture in migrants’ intimate relationships, beliefs about migrant sexual and reproductive health and engagement of health care services. Factor E described the impact of culture on sexual and reproductive health related behaviour. Factor F presented the messages migrant youth are given about sexual and reproductive health. Lastly, Factor G compared constructions of sexual and reproductive health across cultures. Conclusions: This study has demonstrated that when the cultural norms of migrants’ country of origin are maintained it has a significant influence on how 1.5 generation migrants construct, experience and understand various aspects of sexual and reproductive health. Policy makers, health care professionals and resettlement service providers are advised to engage with migrant parents and youth in exploring, discussing, reframing and reconstructing SRH in an Australian context. Keywords: Q methodology, 1.5 generation migrants, Sexual and reproductive health, Australia, Cross cultural * Correspondence: [email protected] 1 School of Science and Health, Western Sydney University, Penrith, Australia 2 Centre for Health Research, School of Medicine, Western Sydney University, Locked Bag 1797, Penrith, NSW 2571, Australia © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Dune et al. Reproductive Health (2017) 14:50 Page 2 of 13 Plain English summary The influence of culture on sexual and reproductive In Australia, those who migrate as children or adoles- health and help-seeking cents (1.5 generation migrants) may have entered a new Cultural differences between a migrant’s country of cultural environment at a crucial time in their psycho- origin and that of immigration are linked to reduced sexual development. These migrants may have to help-seeking behaviour across a range of health out- contend with constructions of sexual and reproductive comes [7] and especially with regard to sexual and health from at least two cultures which may be in reproductive health (SRH) [8, 9]. SRH is of particular conflict. This study, using Q methodology, investigated note as many cultures have quite clear ideologies about the role of culture in constructions of sexual and sexuality, sexual behaviour and thus SRH [10]. Research reproductive health from the perspective of 1.5 gener- indicates that when migrants feel bound to constructions ation migrants. Analysis resulted in seven distinct yet of SRH as per their ethnic origins they may not interrelated factors. The findings of this study demon- utilise SRH services [8, 9]. Migrants may perceive these strate that young migrants vary in their acculturation services to be inappropriate or that seeking such services journeys. Notably, when the cultural norms of migrants’ would be perceived of negatively by their cultural group country of origin persist post-migration it has a [10]. For migrants arriving from countries with very significant influence on how 1.5 generation migrants different cultural, ethnic and religious values and beliefs construct, experience and understand sexual and repro- to those in Australia the process of adapting construc- ductive health. The findings indicate that as norms take tions, understandings and experiences of sexuality often on more cross-cultural constructions they can reshape results in a number of challenges [11]. to produce multicultural ways of understanding and Such differences and outcomes often relate to a wide experiencing sexual and reproductive health without range of SRH issues including, but not limited to, young migrants having to lose their relationship with abortion, contraceptives, gender and gender equality, their culture of origin. Policy makers, health care profes- sexual intercourse and behaviour, sexual pleasure and sionals and resettlement service providers are advised to satisfaction [12]. While these issues are integral to SRH engage with migrant communities, parents and youth in and help-seeking it is the processes of construction exploring, discussing, reframing and reconstructing SRH which encompass these concepts which are of interest in an Australian context. here. While much is known about the potential impact of culture on many aspects of SRH (e.g., contraceptive Background use, maternal health care or condom-use) little is known Migration within an international context has in- about the processes of construction that underlie creased exponentially especially in the past two de- migrants’ SRH experiences and decision making which cades [1]. Of particular note is the Australian context develop during childhood and adolescence. where over 27% of Australians were born overseas and another 20% have at least one parent born 1.5 generation migrants and constructions of sexual and overseas [2]. Notably, net overseas migration contrib- reproductive health and help-seeking utes to over 60% of Australia’stotal population Here SRH refers to “a state of complete physical, mental growth [3]. Australia has also committed to the re- and social well-being in all matters relating to the repro- settlement of over 12,000 new refugees in addition to ductive system. It implies that people are able to have a the current 13,500 new refugees arriving annually [4]. satisfying and safe sex life, the capability to reproduce, Australia thus provides a particularly rich case study and the freedom to decide if, when, and how often to do of a migrant-receiving country undergoing rapid so” [13]. Good SRH also includes SRH help-seeking and transformation. Australia has also been found to have involves access and utilisation of accurate sexual health pockets of cultural concentration which allows mi- information; safe, effective, affordable and acceptable grants to stay connected to key aspects of their contraception methods; and maternal health support culture such as their ethnicity, community, language [13]. The ways in which people from various, let alone, and religion [5, 6]. To that effect, it is likely that the cross/multicultural backgrounds construct and subse- maintenance and preservation of cultural and reli- quently engage with SRH concepts is not universal. gious norms of a migrant’s country of origin have a This is of particular relevance to 1.5 generation mi- significant influence on how migrants in this region grants who are culturally from two worlds. 1.5 gener- construct, experience, understand and manage their ation migrants are not conventional first generation health.Thisstudy wastherefore designed to investi- migrants, who are often adults eligible to emigrate on gate the role of culture in constructions of sexual and their own, nor are they the conventional second gener- reproductive health (SRH) and help-seeking behaviour ation migrant, the offspring of the first-generation from the perspective of 1.5 generation migrants. migrant born in the adoptive country. 1.5 generationDune et al. Reproductive Health (2017) 14:50 Page 3 of 13 migrants are often expected to uphold (by other mem- The authors indicated that while some studies attempt to bers of their cultural community) particular norms capture the construct of SRH in a multi-dimensional way about SRH [14] while at the same time adopting and the concept tends to be reduced to language preference or enacting Australian constructions of SRH [11]. Experien- migrant generation without the exploration of more cing a culture clash in this context may have immediate nuanced understandings. They emphasised that in order and far-reaching implications for the SRH and help- to better understand the relationship between accultur- seeking of 1.5 generation migrants. ation and SRH more nuanced measures are therefore Discourse around the experiences of 1.5 generation required. migrants, given their unique cross-cultural position, is increasing. Extant research has explored 1.5 generation Methods migrants experiences of sociocultural identity [15, 16], This paper is part of a larger project which aimed to effects of acculturation and discrimination on mental investigate the role of culture in constructions of SRH health [17], family reunification amongst Filipinos in and SRH help-seeking from the perspective of 1.5 France [18], belonging among diasporic African commu- generation migrants. Using a mixed methods approach nities in the UK [19] and the hybridity and intercultural- (i.e., questionnaire, Q methodology and interview) the ity of 1.5 generation Chinese migrants in New Zealand larger study sought to define the key aspects of one’s [20]. Although research related to this cohort of mi- culture and its messages about sexuality that shape how grants is emerging, few studies consider the nexus be- people within this cohort understand and experience tween 1.5 generation status and SRH. This is however SRH. This paper will focus on the results of the Q meth- an important area for consideration as cultural meanings odology portion of the project. and input are imbued into all elements of sexuality Q methodology allows for the sampling of subject- providing a significant framework for constructions of ive viewpoints, and can assist in identifying patterns, SRH and vice versa [21]. As Agocha, Asencio and including areas of difference or overlap, across Decena [22] explain, “the values, beliefs, and behaviours various perspectives on a given phenomenon [25]. Q associated with sexuality reveals a great deal about the methodology can be “described as ‘qualiquantilogical’ larger beliefs and values of the society they inhabit or combining elements from qualitative and quantitative from which they originate”. Considering 1.5 generation research traditions [26]. Watts and Stenner [25] migrants’ cross-cultural positionality taking time to indicate five steps for conducting a Q methodology consider and manage the expectations of two cultures study these include: 1) developing the concourse, 2) may result in delayed help-seeking leading to SRH issues developing the Q set, 3) selection of the P set, 4) Q becoming more serious (e.g., sexually transmitted infec- sorting, and 5) Q analysis and interpretation. tions (STIs) being transmitted to others or unmanaged pregnancy) [11, 21]. Concourse development and item sampling: Q set Recent research reinforces this connection between The concourse represents thoughts and opinions or ver- 1.5 generation migrants’ cross-cultural standpoint, sexu- balisations about the subject being studied. To develop ality and SRH. For instance, one paper compared sexual the concourse a literature review was conducted regard- partner risk among Latino adolescents (1.5, 2nd and 3rd ing migrants’ constructions of SRH and help-seeking in generation) in San Francisco [14]. The study found that Australia. In addition, related materials from online 1.5 generation migrants were more likely to be involved newspapers, websites and clinical guidelines were with risky sexual partner (e.g., one who was involved in reviewed to include constructions of SRH not captured gangs and/or drugs) and less likely to report it. Other in the literature review. research [23] which looked at the health of adolescents Semi-structured interviews were also conducted with in the US examined sexual behaviors across migrant two 1.5 generation migrants (1 female Indo-Australian generations and found that 1.5 and 2nd generation mi- and 1 male Nigerian-Australian). A total of 120 items grants were less likely than their 1st and 3rd generation were pooled from these steps. Included items were then counterparts to use birth control. Further, compared to grouped under four themes: the role of culture on 3rd generation migrants, 1st and 1.5 generation Latinas experiences of SRH; constructions and understanding of were less likely to report sexual intercourse. These SRH; the healthcare system and SRH help-seeking be- authors also note the importance and influence of haviour; and external perceptions of migrant sexuality. acculturation processes and generation on migrants’ Within each theme statements were again refined until a decision-making regarding SRH protective behaviours. A final set of items was prepared. This was performed with systematic review examining the correlates and predic- the purpose of ensuring that all aspects of the topic were tors of sexual health among adolescent Latinas in the covered and not inclined towards a particular viewpoint United States [24] discussed cross-generational research. [27]. The final phase consisted of refining the combinedDune et al. Reproductive Health (2017) 14:50 Page 4 of 13 pool of statements with the second, third and fourth au- were asked to answer a series of closed-ended questions thors which involved revision of statements, deletion of to gather socio-demographic data and understand the duplicates and the addition of other items. Finally, the extent to which their ethnocultural affiliations influenced items were piloted with six volunteers. Following their their identity. This information helped to contextualise feedback, the Q set was finalised and included 42 state- the results during factor analysis and interpretation. ments that broadly represented migrant constructions of SRH and help-seeking in Australia (see Table 3 in the Analysis and factor interpretation Results section). In order to identify perspectives shared by participants, a bi-person factor analysis was performed – a commonly Selection of participants: P set applied statistical method in Q methodology. Factor ana- With the help of community stakeholders 1.5 generation lysis begins with the calculation of correlation matrix migrants were recruited via advertisements posted at which reveals the degree of agreement or disagreement seven Western Sydney University campuses and sur- between the sorts or the similarity or dissimilarity in the rounding off-campus venues (e.g., major shopping malls, views of the Q sorters. From this matrix, initial sets of churches, transport stations, restaurants, multicultural factors were extracted using the centroid method. The and resettlement support centres). This was done in an extracted factors were then subjected to varimax rota- effort to strategically engage participants from several tion; varimax positions factors so that it maximizes the suburbs within the Greater Western Sydney region to amount of study variance explained [25]. It also provides ensure that the Q sorts collected were from as many a more manageable factor solution based on the majority ethnocultural groups as possible. Following an online perspectives [25]. Following rotation, factors for inter- survey examining 1.5 generation migrants’ experiences pretation were selected if they fulfilled two criteria: 1) of SRH and help-seeking, 42 out of 112 participants having at least two sorts significantly loading upon a agreed to take part in the Q sort activity. The other 70 factor and, 2) eigenvalues greater than one [31]. Conse- declined to participant due to personal time constraints. quently, a seven-factor solution became the best concep- According to Rogers [28], a sample of 40–60 partici- tual fit in this study (see Table 3 Q-set statements and pants is sufficient to establish the existence of particular factor array). For those participants, whose responses construct systems. loaded onto a factor, their responses to the post-Q ques- tions were examined to assist in identifying the meaning Q sorting of each factor. Participants performed the Q sorting task in three phases using web-based software Q-Assessor [29]. First, Results participants were instructed to rank-order the 42 state- The P set consisted of 1.5 generation migrants who ments beginning with those they most agreed with (+4) ranged in age from 18 to 39 (23 women, 17 men, and 1 to those they most disagreed with (-4). To do so partici- other gender; M =22.8, SD=4.4). Migrants had ar- age pants allocated statements into three clusters: Agree, rived in Australia as follows, Pre-1999 (4), 2000–2005 Disagree, Neutral. Participants then refined each cluster (19), 2006–2010 (11) and 2011–2015 (7). The majority of statements and sorted them in to a quasi-normal migrated from sub-Saharan Africa (18: 42.8%) with the distribution sorting grid (Fig. 1) - the standard tool for others migrating from South East Asia (8), East Asia (4), Q sorting [30]. After the sorting process, participants Eastern Europe (4), Western Europe (3), the Middle East Fig. 1 Q Sorting GridDune et al. Reproductive Health (2017) 14:50 Page 5 of 13 (2) and the Americas (1). Age upon arrival to Australia community and family would not be supportive (1: +2). ranged from 5 to 19 years with the majority (22: 52.3%) As such, these participants believed that the way SRH is having arrived between the ages of 11 and 15. Other par- dealt with in Australia is different than the way it is dealt ticipants arrived between the ages of 0–5 (1), 6–10 (12) with in their country of origin (9: +1). Given the rela- and 16–19 (6). Thirty-five (83.3%) participants came to tively more relaxed views of SRH in Australia partici- Australia with their immediate family members, 5 came pants noted that they did not want to pass on to future with extended family and 2 came alone. With regards to generations the values about SRH held in their culture religion, 23 (54.7%) identified as Catholic/Christian, 7 as of origin (8:-3). Islamic, 2 as Hindu, 2 as Greek Orthodox, 1 as Druze, Based on the post-Q questionnaire factor representa- and 5 indicated that they did not follow any religion. tives identified strongly with both their culture of origin The majority of participants (26: 61.9%) spoke a lan- and Australian culture (71.4%). With the majority being guage other than English at home and 16 only spoke from non-Western countries and identifying as religious English at home. Table 1 shows the socio-demographic these migrants may experience challenges in their efforts data for participants defining each factor. to compare, assess, review and re/construct their SRH The seven factors explained 52.95% of the total vari- values. ance. Composite reliability coefficients were examined to evaluate the construct validity for each factor, with all Factor B: Experiencing SRH through two cultural lenses the factors fulfilling the minimum acceptable value of> Factor B accounted for 9.51% of the total variance with 0.7 indicating that independent factors were identified. the Q sorts of 6 participants defining this factor. Factor Table 2 presents the characteristics of these factors. Fac- B demonstrated the influence of culture on SRH con- tor scores of each statement across all the seven factors structs within cross-cultural contexts. Socially partici- are provided in Table 3. Bracket notations are used to pants felt that Australians should take on SRH values show statement ranking within factor arrays: for ex- from migrant cultures (40: +4). Participants also believed ample, “(28: +4)” indicates that statement 28 was ranked that migrants who identify most as being Australian at +4 (strongly agree). have more SRH problems than other Australians (36: +3). This may be a criticism of Australian culture and its Factor A: Struggle between progressive and traditional influence on SRH. Criticism is also seen in migrants’ sexual and reproductive health values evaluation of their own cultures. Cultural support can be Factor A accounted for 9% of the total variance with the seen in participants’ belief that if confronted with an un- Q sorts of 7 participants defining this factor (seeTable 2). planned pregnancy their family and community would Factor A is characterised by comparisons of SRH values be supportive (4:-2). Even so, there was a moderate in Australia (relatively progressive) and migrants’culture sense that going to a clinic for an SRH issue without of origin (relatively traditional). Evidence of this may be family or community knowing was preferred (3: +2). It that women in their culture of origin do not have seems that the migrants had a more liberal set of SRH control over their SRH (11: -4) while no such gender values. This is reflected in the respondents’ belief that difference is perceived in Australia (20: +3). Further, par- how SRH is dealt with in Australia was not very different ticipants strongly agreed that Australians view migrants’ to their culture of origin (9:-3). They also believed that ideas of SRH as out-dated (42: +4).. This perspective of people born in Australia did not necessarily have an traditional versus progressive constructions of SRH is easier time with SRH compared to migrants like them- corroborated by the participants’ agreement that within selves (13:-2) or that non-migrants understood SRH their culture of origin SRH is a taboo subject (16: +4). differently than they did (26:-1). Participants perspectives on the differences between The post-Q questionnaire indicates that all exemplars cultures is also evident given their agreement with the strongly identified with their culture of origin (sub- idea that migrant SRH needs are different from those of Saharan Africa (50%), South East Asia (33.3%) and non-migrants (41: +3) and that health services can do Eastern Europe (16.6%)). This may explain their critique more than they are already doing to cater specifically to of how SRH is constructed in Australian culture. This is migrants’ SRH needs (35:-2). It may be these differences further corroborated as 83.3% strongly agreed or agreed which led migrants to believe that health care workers that they had a robust relationship with their community are minimally equipped to deal with their SRH needs based on their culture of origin. (29: +1). Even so, migrants indicated that if they needed to go to a clinic for an SRH issue they did not feel it ne- Factor C: Importance of the culture of origin cessary to hide this from their community or family Factor C accounted for 8.28% of the total variance with (3:-3). Family and community openness was, however, the Q sorts of 4 participants defining this factor. Factor moderate as participants felt that if they had an STI their C exemplars strongly believed that culture played a large"