背景：自1990年代至今，婚姻移民人數明顯增加。臺灣多數的婚姻移民婦女於婚後旋即懷孕。然而，這些移民婦女在懷孕的同時又必須經歷涵化的過程。對移民者而言，涵化包含兩個面向：適應宿主國文化和維持母國文化（即雙向涵化）。過去有關移民婦女的研究大多數著重在單向涵化（即適應宿主國文化），少有研究調查雙向涵化對孕產憂鬱的影響。
目的：針對臺灣新移民婦女發展雙向涵化量表和檢測其信效度，以及探討雙向涵化對孕產憂鬱的影響。
方法：本研究採前瞻性世代研究設計。收案對象為懷孕至少12週的婚姻移民婦女，從醫院、診所和健康中心收案共310人。自2013年3月至2015年12月，運用結構式問卷和採面訪、電訪、和郵寄或電子郵寄問卷等方式於第二孕期、第三孕期、產後一個月、產後三個月、產後六個月和產後一年進行資料收集。孕產憂鬱以愛丁堡產後憂鬱量表測量，孕期和產後的切點皆為10分以上。雙向涵化以自擬式的19題適應宿主國文化量表和19題維持母國文化量表測量，分數越高代表適應宿主國文化或維持母國文化程度越高；各量表皆被檢測其內容效度、建構效度和內在一致性。除了量表分數之外，兩者的分數皆可被分成高和低程度，並形成四個涵化類型（邊緣化、隔離、同化和整合）。社會支持包含三個次量表：情緒性、工具性和資訊性支持，各分數越高代表各支持程度越高。運用廣義估計方程式檢測雙向涵化和孕產憂鬱之間的關係。
結果：雙向涵化量表的專家效度和探索性因素分析結果顯示具有可接受的內容效度和建構效度。兩量表各有19題，包含4題語言使用、3題媒體使用、3題食物偏好和使用、3題文化傳統、2題社會互動和4題物品偏好和使用。適應宿主國文化量表和維持母國文化量表的內在一致性以Cronbach's alpha測定分別為0.88和0.83。自孕期到產後一年，宿主國文化的適應程度呈現下降的線性趨勢，但母國文化的維持程度呈現上升的線性趨勢。本研究參與者的憂鬱盛行率（切點：10分以上）在孕期和產後不同時間點分別為15.8%（第二孕期）、14.9%（第三孕期）、26.0%（產後一個月）、27.7%（產後三個月）、32.1%（產後六個月）和20.0%（產後一年）。憂鬱分數隨著時間呈現先上升後持平和緩降的二次方趨勢。廣義估計方程式顯示適應宿主國文化（β= –0.16；SE=0.05）、情緒性支持（β= –0.70；SE=0.24）和資訊性支持（β= –0.23；SE=0.06）隨著時間皆和孕產憂鬱呈現負相關。維持母國文化和孕產憂鬱的關係會隨著時間而不同。第二孕期到產後三個月，維持母國文化和孕產憂鬱隨著時間皆呈正相關（β=0.05；SE=0.02）；產後六個月到產後一年，其關係隨著時間皆呈負相關（β= –0.01；SE=0.02）。針對四組不同的涵化類型，邊緣化組、隔離組、同化組和整合組分別佔22.3%、24.5%、27.1%、26.1%。歸類為隔離組的憂鬱高於其他三組（邊緣化（β= –1.37；SE=0.66）、同化（β= –1.37；SE=0.62）和整合（β= –1.23；SE=0.62））。情緒性支持和孕產憂鬱的關係會隨著不同涵化組別而不同。相較於其他三組（邊緣化、同化和整合），隔離組的情緒性支持對孕產憂鬱更具有保護效果。
結論：新移民婦女的憂鬱率從孕期到產後一年皆高，並且產後的憂鬱傾向高於孕期。整體憂鬱趨勢的低點始於第二孕期，隨後快速上升直至產後三個月，接著於產後三個月到六個月間持平，最後在產後六個月到一年之間緩降。政策上應運用憂鬱篩檢於新移民的孕產期，尤其是在產後階段，並且應提供轉介服務和預防性介入以促進新移民的孕產健康。研究結果說明適應宿主國文化和維持母國文化在孕產期不是固定的，而是動態的/隨時間變動的。孕期到產後一年是劇烈的文化轉換之敏感期，未來的研究可以採用追蹤性研究測量孕產期的雙向涵化之動態趨勢。宿主國文化適應得好可以降低孕產憂鬱，但是母國文化的維持和孕產憂鬱之間的關係隨著時間不同而不同。母國文化維持得好會增加孕期到產後早期（產後三個月）的憂鬱，但會減少產後中期（產後六個月）到晚期（產後一年）的憂鬱。這說明對孕產期的新移民婦女而言，涵化不是單向的，而是雙向的。此外，孕期到產後三個月可能是歷經強勢宿主國文化洗禮和文化衝突的時期，而產後六個月到一年可視為產後轉換回正常生活的時期。當雙向涵化以四組涵化類型呈現時，較維持母國文化又較不適應宿主國文化的新移民婦女（隔離組）比其他三組（邊緣化、同化和整合）有較高的憂鬱傾向。為了降低孕產憂鬱，應針對具隔離傾向的移民婦女發展合適策略和提高其情緒性支持。另一方面，健康照護提供者應不只是要鼓勵新移民婦女適應宿主文化，而且要提供合適的資源和友善的外在環境讓新移民婦女有機會維持其母國文化。

Background: From 1990s to now, there have been an obviously increasing numbers of marriage-based immigrants in Taiwan. Most of those women become pregnant immediately after marriage. However, while being pregnant, those women have to deal with the process of acculturation when they immigrate to a new country. For immigrants, acculturation involves two dimensions, adaptation to host culture and maintenance of heritage culture. Most previous studies of immigrant mothers focused on uni-dimensional (i.e. the association between adaptation to host culture and perinatal depression), rather than the bi-dimensional acculturation. Few studies have investigated the effect of bi-dimensional acculturation on perinatal depression.
Objectives: The objective of this study was to develop and evaluate a new scale for measuring bi-dimensional acculturation among immigrant women in Taiwan and to examine the effect of bi-dimensional acculturation on depression during pregnancy and postpartum period for those women.
Method: This study employed a prospective cohort study design. Marriage-based immigrant women who were at least twelve weeks pregnant were recruited from hospitals, clinics and health centers (N=310). The data were collected by face-to-face or telephone interview, mail or e-mail, using structured questionnaire in the 2nd and 3rd trimester during pregnancy and at 1 month, 3 months, 6 months, and 1 year postpartum during the period from March 2013 to December 2015. Maternal depression was measured by Edinburgh Postnatal Depression Scale with a cutoff score of 10 during pregnancy and after delivery. Bi-dimensional acculturation was measured by two self-developed 19-item parallel scales, adaptation to host culture and maintenance of heritage culture, with higher score indicating higher level in each. Each scale was tested for content validity, construct validity, and internal consistency reliability. Besides the scale scores, the score for each of the two scales was divided into high and low level, which yielded a total of four acculturation types (marginalization, separation, assimilation, and integration). Social support was composed of three subscales (emotional, instrumental, and informational support) with higher score indicating higher level in each support. Generalized estimating equation (GEE) was used to examine the relationships between bi-dimensional acculturation and maternal depression, accounting for socio-demographic variables, obstetric variables, history of mental illness, immigration-related variables, marital satisfaction, and social support.
Results: Expert validity and exploratory factor analysis of bi-dimensional acculturation scale indicated the acceptable content validity and construct validity for data. Each scale contained 19 items, including 4 items on the “language use”, 3 items on the “media use”, 3 items on the “food preference and use”, 3 items on the “cultural heritage”, 2 items on the “social interaction”, and 4 items on the “goods preference and use”. The internal consistencies for adaptation to host culture was 0.88 and for maintenance of heritage culture was 0.83 as assessed by the Cronbach's alpha coefficient. Adaptation to host culture followed a downward linear trajectory, while maintenance of heritage culture followed an upward linear trajectory from pregnancy to one year postpartum. The prevalence of depression with a cut-off point of 10 among study participants was 15.8%, 14.9%, 26.0%, 27.7%, 32.1%, and 20.0% for the 2nd and 3rd trimester during pregnancy and at 1 month, 3 months, 6 months, and 1 year postpartum, respectively. Depression followed a quadratic trajectory. The GEE results showed that adaptation to host culture (β= –0.16, SE=0.05), emotional support (β= –0.70, SE=0.24) and informational support (β= –0.23, SE=0.06) negatively covaried with maternal depression over time. Maintenance of heritage culture interacted with time on maternal depression. Maintenance of heritage culture from the second trimester to 3 months postpartum positively covaried with maternal depression over time (β= 0.05, SE=0.02), whereas those from 6 months to 1 year postpartum negatively covaried with maternal depression over time (β= –0.01, SE=0.02). In terms of four acculturation types, the percentages were 22.3%, 24.5%, 27.1%, and 26.1% in the marginalization, separation, assimilation, and integration groups, respectively. The separation group had a higher level of depression than the other three groups (marginalization (β= –1.37, SE=0.66), assimilation (β= –1.37, SE=0.62), and integration (β= –1.23, SE=0.62)). Emotional support interacted with four-type acculturation on depression during pregnancy and postpartum period. In the separation group, emotional support had a more protective effect against maternal depression when compared to the other three groups (marginalization, assimilation, and integration).
Conclusions: The rates of depression were consistently high from pregnancy to one year postpartum, and depression was higher in the postpartum period than during pregnancy among immigrant women. The depression trajectory was lowest in the second trimester, increased sharply until 3 months postpartum, then flattened out between 3 and 6 months postpartum and gradually decreased between 6 months and 1 year postpartum. Screening for depressive symptoms during pregnancy and postpartum among immigrant women is therefore deemed necessary, especially in the postpartum period. Referral services and preventive intervention should be provided to improve their maternal health. The results demonstrated that adaptation to host culture and maintenance of heritage culture are not fixed, but dynamic/time-variant during pregnancy and postpartum period. The duration from pregnancy to one year postpartum was a sensitive period for acute cultural transformation. Future studies could adopt the follow-up study to assess dynamic bi-dimensional acculturation trends during pregnancy and postpartum. High adaptation to host culture could decrease depression from pregnancy to one year postpartum. However, the different relationships between maintenance of heritage culture and maternal depression were showed in different time. High maintenance of heritage culture could increase depression from pregnancy to early (3 months) postpartum period, but decrease depression from mid (6 months) to late (1 year) postpartum period. It suggested that acculturation was not a simple uni-dimension effect. Bi-dimensional acculturation was meaningful for pregnant and postpartum immigrant women. In addition, the duration from pregnancy to 3 months postpartum might be the period that processed strong cultural transformation in the host society and cultural conflicts between host and heritage cultures; and the duration from 6 months to 1 year postpartum might be viewed as the stage transferred from postpartum period to normal stage in lives. In terms of four acculturation types, immigrant women in the separation group (who were more likely to maintain the heritage culture, but less likely to adapt to the host culture) had higher depression symptoms than the other three groups (marginalization, assimilation, and integration). To decrease maternal depression, strategies should be developed to target immigrant women who had separation orientation and to increase their emotional support. On the other hand, healthcare providers should not only pay more attention to encourage their adaptation to host culture, but also provide applicable resources and friendly external environments to give them an opportunity to maintain their heritage culture.

Table of Contents
摘要………………………………………….…………………………………………i
Abstract………….……………………………………………………………………iv
Table of Contents……………………………………………………………………viii
List of Figures………………………………………………………………………....x
List of Tables………………………………………………………………………...xii
Chapter 1 Introduction………………………………………………………………...1
Chapter 2 Literature review…………………………………………………………..10
2.1 Overview of acculturation…………………10
2.2 Immigrant women’s depression during pregnancy and in the postpartum period…........21
2.3 Research on acculturation and depression during pregnancy and in the postpartum period………………26
2.4 Factors related to depression during pregnancy and in the postpartum period……………………………………………………………………………38
Chapter 3 Study objectives and study framework.………42
Chapter 4 Methods…………………………………………………...………………45
4.1 Study design…………………………………………………………………….45
4.2 Study participants....…………………………………….………………………45
4.3 Measurement……………………………………………………………………50
4.4 Data analysis……………………………………………………………………57
Chapter 5 Results……………………………………..……………….……………..59
5.1 The psychometric properties of the bi-dimensional acculturation scale………..59
5.2 The relationship between bi-dimensional acculturation and depression
trajectories during pregnancy and in the postpartum period...………………….70
5.3 Bi-dimensional acculturation and depression during pregnancy and in the
postpartum period: Testing Berry’s model of acculturation strategies using a longitudinal study………………………………88
Chapter 6 Discussion……………..…………………..……………….…………….106
6.1 The development and psychometric properties of the bi-dimensional acculturation scale…………106
6.2 The relationship between bi-dimensional acculturation and depression trajectories during pregnancy and in the postpartum period…………………..109
6.3 Bi-dimensional acculturation and depression during pregnancy and in the postpartum period: Testing Berry’s model of acculturation strategies using a longitudinal study……………………………………………………………...119
6.4 Strengths and limitations ……………………………………………………...126
Chapter 7 Conclusions……..………………………..………..……….……………129
Acknowledgments…………………………………………………………………..131
References…………………………………………………………………………..132
Appendices………………………………………………………………………….161
A. Approvals of the institutional review boards.........161
B. Questionnaires...........................165
C. Additional analyses……………………………………………………………..181
Curriculum Vitae……………………………………………………………………193

List of Figures
Figure 1.1. Uni-dimensional models of acculturation......10
Figure 1.2. Bi-dimensional models of acculturation……………11
Figure 2. Conceptual framework for perinatal depression and its determinants.........44
Figure 3. Flowchart of data collection waves………………………48
Figure 4. Time trends (mean) of the bi-dimensional acculturation from pregnancy to late postpartum…………………76
Figure 5. Time trends (mean) of the marital satisfaction, social support, and depression from the 2nd trimester to 1 year postpartum…………………...76
Figure 6. Time trends (equation) of the bi-dimensional acculturation from pregnancy to late postpartum………………79
Figure 7. Time trends (equation) of the marital satisfaction, social support, and depression from the 2nd trimester to 1 year postpartum…………………...79
Figure 8. Time trends (mean) of the bi-dimensional acculturation from pregnancy to late postpartum by Berry’s four acculturation categories……………..…..95
Figure 9. Time trends (mean) of depression from the 2nd trimester to 1 year postpartum by Berry’s four acculturation categories...……………………96
Figure 10. Time trends (equation) of the bi-dimensional acculturation from pregnancy to late postpartum by Berry’s four acculturation categories...……...……..99
Figure 11. Time trends (equation) of depression from the 2nd trimester to 1 year postpartum by Berry’s four acculturation categories...…………………..100
Figure 12. Time trends (mean) of the bi-dimensional acculturation from pregnancy to late postpartum (using imputed data)…………………………………….182
Figure 13. Time trends (mean) of the marital satisfaction, social support, and depression from the 2nd trimester to 1 year postpartum (using imputed data)…………………………182
Figure 14. Time trends (mean) of the bi-dimensional acculturation from pregnancy to late postpartum by Berry’s four acculturation categories (using imputed data)…………184
Figure 15. Time trends (mean) of depression from the 2nd trimester to 1 year postpartum by Berry’s four acculturation categories (using imputed data)……………186

List of Tables
Table 1. The scales of bi-dimensional acculturation.....20
Table 2. The rates of postpartum depression in Taiwan, China, Vietnam, Indonesia and Thailand......25
Table 3. Studies examining the association between acculturation and depression during pregnancy and in the postpartum period.....29
Table 4. The comparison between all immigrant women and immigrant women who participated at each time point…………………49
Table 5-1. Ratings on a 24-item acculturation scale (host country) by five experts…55
Table 5-2. Ratings on a 24-item acculturation scale (native country) by five experts.56
Table 6. Characteristics of the study participants……….60
Table 7-1. Item-total correlation coefficients of acculturation (host country)…….....63
Table 7-2. Item-total correlation coefficients of enculturation (native country)……..64
Table 8-1. Exploratory factor analysis for acculturation (host country)……………..65
Table 8-2. Exploratory factor analysis for enculturation (native country)…………...66
Table 9-1. Means and inter-correlations for six domains of acculturation…………..67
Table 9-2. Means and inter-correlations for six domains of enculturation…………..67
Table 10. Correlations of the bi-dimensional acculturation, immigration-related variables and depression during pregnancy…………69
Table 11. Sociodemographics, obstetric characteristics, and history of mental illness of the study participants......72
Table 12. Immigration-related characteristics of the study participants……………..74
Table 13. Means and standard deviations in the bi-dimensional acculturation, marital
satisfaction, social support, and depression during pregnancy and postpartum…………75
Table 14. Null model of trajectories from the 2nd trimester to 1 year postpartum…...78
Table 15. The correlation coefficients of depression with acculturation, marital
satisfaction and social support……………………………81
Table 16. GEE models for depression trajectory from the 2nd trimester to 1 year postpartum………………85
Table 17-1. GEE models for the interaction between bi-dimensional acculturation and time on depression……………86
Table 17-2. GEE models for the interaction between bi-dimensional acculturation and emotional support on depression…………………86
Table 17-3. GEE models for the interaction among bi-dimensional acculturation,emotional support and time on depression…………87
Table 18. Differences in Berry’s four acculturation categories by sociodemographics,
obstetric characteristics, and history of mental illness…………………….91
Table 19. Differences in the Berry’s four acculturation categories by acculturation-related characteristics………92
Table 20. Means and standard deviations for bi-dimensional acculturation by Berry’s four acculturation categories………93
Table 21. Means and standard deviations for depression by Berry’s four acculturation categories…………………94
Table 22. Null models of trajectories from the 2nd trimester to 1 year postpartum…..98
Table 23. GEE Models for depression trajectory…………103
Table 24. GEE Models for depression trajectory by Berry’s four acculturation categories…………105
Table 25. Means and standard deviations in the bi-dimensional acculturation, marital
satisfaction, social support, and depression during pregnancy and postpartum (imputed data)…………181
Table 26. Means and standard deviations for bi-dimensional acculturation by Berry’s four acculturation categories (imputed data)………………183
Table 27. Means and standard deviations for depression by Berry’s four acculturation categories (imputed data)………185
Table 28. GEE model for depression trajectory from the 2nd trimester to 1 year postpartum (at least two data points for each person)……187
Table 29-1. GEE models for the interaction between bi-dimensional acculturation and time on depression (at least two data points for each person)……………188
Table 29-2. GEE models for the interaction between bi-dimensional acculturation and emotional support on depression (at least two data points for each person)
…188
Table 29-3. GEE models for the interaction among bi-dimensional acculturation,emotional support and time on depression (at least two data points for each person)……189
Table 30. GEE Models for depression trajectory (at least two data points for each person)…………190
Table 31. GEE Models for depression trajectory by Berry’s four acculturation categories (at least two data points for each person)…………192

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