How do psychosocial determinants in migrant women in the Netherlands differ from these among their counterparts in their country of origin? A cross-sectional study

Smoking remains one of the major causes of cardiovascular diseases and several types of cancer. Seen as a direct health consequence of smoking, these diseases (and others) can be avoided by preventing people from smoking [1]. In Western countries, anti-smoking activities and smoking cessation programs have proved to be a valuable contribution to considerably decreasing the prevalence of smoking [2]. However, the increase in migration of non-Western populations into Western countries poses new challenges in the planning and development of smoking prevention programs [3].

In migrant populations, a multitude of determinants underlie smoking behaviour. These include broader contextual issues, socioeconomic inequalities compared to host populations, psychosocial aspects such as stress, hardship and discrimination, all of which are known to contribute to health inequalities. Finally, socio-cultural factors governing attitudes towards smoking and the process of acculturation to a 'Western' environment are also relevant [4‐9]. These processes and their interaction often imply a change in smoking behaviour after migration. As far as smoking in female migrants is concerned, coming from an environment where smoking rates are low and migrating to an environment where smoking is more common, it often imply an increase in smoking [6, 10‐13]. In the Netherlands this seems to take place in female migrants from Surinam, a former Dutch colony. People from Surinam (who consist mainly of people with a South Asian or African background) comprise the second largest migrant population in the Netherlands and there are indications that the smoking prevalence is higher in the Netherlands compared to the country of origin [3, 14].

In order to develop interventions for preventing an increase in smoking among migrant women, insight into the underlying determinants is needed. This includes insight into changes in proximal factors such as psychosocial determinants: attitudes towards smoking, social influences regarding smoking and self-efficacy [15, 16]. At present there is limited information on these underlying determinants and how they change with migration, hampering the development of appropriate interventions for migrant women. For example, when women appeared to have a more positive attitude towards smoking after migration, interventions might be targeted to prevent this change in attitude from taking place.

In our study we had the opportunity to compare the determinants of smoking of Surinamese women in Surinam with Surinamese women in the host country, the Netherlands. Our aim was to gain insight into the differences in psychosocial determinants of Surinamese women in the Netherlands compared to those in the country of origin.

This study aims to provide more insight into the psychosocial determinants of smoking among Surinamese migrant women in the Netherlands and Surinamese women in Surinam. Of the female Surinamese smokers, those in the Netherlands were three times more likely to perceive emotional and cognitive advantages of smoking than those in Suriname. These women also perceived a positive norm of their partner and among friends regarding smoking more frequently.

As far as we know this is the first study in which the differences between the underlying psychosocial determinants between migrants and their counterparts in the country of origin have been explored. Other studies that have focused on psychosocial determinants in the context of migration, look at the changes by assessing the associations of acculturation with health related behaviour and its determinants of immigrants in the host country, but did not compare these data with any data on people in the country of origin [23‐25].

Some limitations of this study need to be considered before discussing the results. Firstly, due to the cross-sectional design we are not sure whether migrant women changed their smoking behaviour after migration. It is possible that the women who migrated differ regarding smoking behaviour and beliefs about smoking from those who stayed in Suriname. However, a previous study suggests that Surinamese women in the Netherlands are in an earlier stage of the tobacco epidemic than the ethnic Dutch women [3]. This might be an indication that the smoking pattern in Surinam will be in a previous stage as well, implying lower smoking rates. Nevertheless, longitudinal studies among recently migrated people should test whether the differences we have found are really the results of migration.

Secondly, we were not able to include non-smoking women in Suriname in our study, which implies that we cannot be sure that the determinants account for the differences in smoking prevalence in Surinamese women in both countries. However, as many studies have shown that these determinants are important predictors of behavioural change, our study seems to hold strong indications that the differences in determinants might contribute to the differences in smoking behaviour.

Despite these limitations, our study found interesting results regarding the psychosocial determinants of smoking among female Surinamese migrants. As expected we found a higher prevalence of smoking in female Surinamese migrants in the Netherlands compared to those in the country of origin. The relatively positive attitudes and norms are in line with the differences in the prevalence. Explanations for these results can be found in the different place where the women live.

In Western countries, smoking is culturally less restricted for women than in non-Western countries such as Suriname. In contrast to smoking in Suriname, in the Netherlands smoking is not regarded as shameful for women and they can smoke where they want. This seems to be reflected in the higher percentage of smokers among Surinamese women in the Netherlands. However, there is also more anti-smoking prevention available in Western countries, which might prevent a positive attitude among these women [26]. Though, Surinamese women in the Netherlands might be less convinced about the negative consequences of smoking than their counterparts in Surinam. This may indicate that these prevention activities do not adequately reach the Surinamese population.

However, when we compare results of a study among Dutch students with those of the Surinamese women, we have found that the percentage of Dutch students that were aware of negative consequences of smoking for heart disease was similar with or even lower than the percentage we have found (71.2% vs. 77.9% in our study) [27]. This may indicate that, despite all prevention activities, the attitude of the general population is relatively positive, and that the attitude of the Surinamese women in the Netherlands seems to converge to this attitude.

Regarding the subjective norm of family and the number of family members who smoke we have found no differences between the women in both countries. This might indicate that the norms among the family did not change after migration. It may be that, due to migration, family ties are loosening and that as a result norms in the family have less influence on smoking behaviour. The increase in smoking may be more associated with the increase of friends who smoke and a positive subjective norm towards smoking among friends and the partner in combination with a positive attitude towards smoking. As a result Surinamese women in the Netherlands are more exposed to a proximal pro-smoking social environment compared to the women in Surinam.

The differences observed should be understood in the broader context of the changes that people experience after migration and which are also known to contribute to health inequalities. These include cultural changes, changes in socio-economic position, social position and perceived discrimination [8]. With regard to smoking behaviour, previous research shows for example that socio-economic position is an important factor in relation to migration and smoking behaviour. As the Surinamese migrant women have a relatively low socio-economic position they more frequently live in disadvantaged neighbourhoods where smoking norms are more positive [3, 8, 9, 28]. Also, their relative disadvantaged position may be related to a lower access of health care and (smoking) prevention programs [29].

With regard to other contextual factors, the results of our study will be best generalisable to other migrant women who have a similar background. Regarding the Surinamese population, their colonial background, a fluency of the Dutch language and a lower socio-economic position than the ethnic Dutch are important contextual characteristics. Hence, our results may be most generalisable to migrant female groups with a colonial background from other countries, such as South Asians in the UK. However, as we see also increases in smoking behaviour among other migrant populations, similar changes might be present in other migrant groups as well.

The results of this study indicate that anti-smoking interventions for migrant women should focus on the negative consequences of smoking and the prevention of a positive norm towards smoking - for example, by developing culturally targeted interventions using role modelling [30]. These interventions should be developed for other female migrants from non-Western countries as well as we see a similar increase in smoking prevalence either following migration, or as integration increases.

In conclusion, the results of this study suggest that migrant women are more positive towards smoking and perceived a more positive norm towards smoking when compared with women in the country of origin. Interventions targeted at the psychosocial determinants regarding smoking for newly migrated women, in particular the consequences of smoking and the norm towards smoking might help to prevent an increase in smoking in those populations.

In 1975, almost half the population of the former Dutch colony Surinam migrated to the Netherlands. Approximately 80% of these Surinamese immigrants in the Netherlands are Hindustani ('South Asian', originally from the Indian sub-continent) or African (mixed African, Indian and European, but predominantly of African origin). Other ethnicities include Chinese and Javanese.