We conducted a cross-sectional online survey between July and August 2020 that included items to assess mental health, discrimination, social support, and perceptions about community strengths. Those eligible to participate had to identify as female, be age 18 or over, be born in Brazil, speak and read either Portuguese or English, and currently reside in the U.S. We recruited a convenience sample through announcements on Brazilian social media pages (e.g., Facebook, WhatsApp), and outreach by our collaborations with local community social service providers and advocacy organizations. Those interested in participating were directed to the survey URL, where they were provided with detailed information required for informed consent. After reviewing informed consent information, they were required to click a box stating their consent prior to proceeding to survey items. Participants could choose to complete the survey in English or Portuguese. After completing the survey, respondents were provided with a link to a separate URL to provide contact information if they wanted to receive a $20 Amazon gift card for survey completion, which took an average of 18.5 minutes.
Measures
Mental health: We assessed depressive symptomatology (the primary outcome) with the 10-item version of the Center for Epidemiological Study Depression scale (CES-D) (15,16). The CES-D has been widely validated (17), including among Brazilians (18). The 10-item version asked about the respondent’s experiences in the past week, for example: “I was bothered by things that usually don’t bother me,” “I did not feel like eating; my appetite was poor,” and “I felt depressed.” Responses are on a scale of 0-3 (0 =Rarely or none of the time
[less than 1 day], 1= Some or a little of the time [1-2 days], 2 = Occasionally or a moderate amount of time [3-4 days], 3 = Most or all of the time [5-7 days]). We calculated a score by totaling all items (after reversing the positive mood items); possible scores range from 10-40, with higher scores indicating higher levels of depressive symptomatology. The CES-D-10 lists the threshold for depressive symptoms as a score greater than or equal to 10. Although scoring above a 10 does not directly correlate with a formal diagnosis, it does indicate a need for direct clinical assessment (19).
Discrimination: We used the validated 5-item Everyday Discrimination Scale (EDS) (20,21), which assesses perceptions of being treated unfairly by other people due to personal attributes such as race, ethnicity, age, gender, socioeconomic status, weight, sexual orientation, or other individual characteristics. The EDS has been used with immigrant populations, including Brazilian immigrants (see Molina et al., 2018), as well as with Brazilians in Brazil (22). Survey items assess the frequency of discriminatory experiences (“In your day-to-day life, how often do any of the following things happen to you?”), including instances where: “You are treated with less courtesy than other people,” and “You are treated with less respect than other people are.” Respondents are then asked to estimate the frequency of each of these experiences (0=never, 1=less than once a year, 2=a few times a year, 3=a few times a month, 4=at least once a week, 5=every day). We created a score by summing responses, such that higher scores indicate higher levels of discrimination (possible score range: 5-30).
Social support: We used the validated Oslo Social Support Scale (OSSS) to assess social support (24,25). The OSSS examines the perceived depth and breadth of access to social networks with three questions: “How many people are so close to you that you can count on them if you have great personal problems?” (none, 1-2, 3-5,>5) “How much interest and concern do people show in what you do?” (none, little, uncertain, some, a lot), and “How easy is it to get practical help from neighbors if you should need it (very difficult, difficult, possible, easy, very easy). An additional point was added to the score if the participant reported being married. The summed score can range from 3-15, with higher scores indicating stronger social support.
Perceived community strengths: The community strengths (CS) measure included four items to assess the perceived strengths of Brazilian immigrant communities. Items were created by the study investigators based on findings from our prior qualitative studies (3,26) and were cognitively tested among five Brazilian immigrant women prior to use Participants reported how strongly they agree to strongly disagree with the following items: “We are resilient and strong,” “We work harder than most,” “We have close-knit families,” and “We are willing to help one another.” Response options were on a 5-point Likert scale (1= strongly agree to 5= strongly disagree). To create a score, we summed responses across items to create a score that could range from 1 to 20.
Socio-demographic characteristics: We utilized items from the Brazilian Census (27) to assess socio-demographic characteristics such as race/ethnicity (White, Black, Indigenous, Asian, Pardo [“mixed”]), and educational attainment (less than primary education, primary education but incomplete secondary education, complete secondary but incomplete tertiary education, complete tertiary education or more, don’t know). Items from the Behavioral Risk Factor Surveillance System (28) were utilized to assess age in years (continuous), household income (less than $10,000, $15,000-$25,000, $25,001 - $50,000, $50,0001- $75,000, <$100,000, don’t know), and insurance status (insured, uninsured). We also asked participants how many years they had lived in the U.S., what languages they spoke (Portuguese, English, Spanish, other languages (please specify), what languages they spoke at home (Portuguese only, some Portuguese and some English, English only, other (please specify) and whether they were currently affiliated with a religion (yes, no).
All survey items were pre-tested in Portuguese among five Brazilian immigrants for item flow and comprehension. Afterward, the instrument was translated into Portuguese by a certified American Translators Association translator and reviewed by native Portuguese speakers.
Analysis
Missing data analytics were performed and suggested that 2% of the data on variables to be analyzed were missing, and these were subsequently imputed using multiple imputation with m = 10 imputations. Descriptive statistics, including percentages, means, standard deviations, and ranges were examined for all variables. To examine the structure and internal consistency of scaled variables (i.e., discrimination, social support), we assessed McDonald’s omega, and deemed an omega of > 0.70 to be acceptable (29). We used ANOVA tests to examine associations between CES-D-10 scores and categorical variables and linear regression to compare CES-D-10 scores with continuous variables (age, time living in the U.S). Statistical significance was considered at the p<0.05 level. Data analysis was done using R version 4.1.2.
(30).