Impact of Rural-Urban Immigration on Substance Use in a Sample of Turkish Youth

Hatice Burakgazi Yilmaz; Parna Prajapati; Alicanz Dalkilic; Ali Unlu; Mariam Rahmani; Andres Pumariega

doi:10.4103/wsp.wsp_16_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 4 | Issue : 2 | Page : 132-138

Impact of Rural-Urban Immigration on Substance Use in a Sample of Turkish Youth

Hatice Burakgazi Yilmaz¹, Parna Prajapati², Alicanz Dalkilic¹, Ali Unlu³, Mariam Rahmani⁴, Andres Pumariega⁴
¹ Department of Psychiatry, Cooper Medical School of Rowan University, Camden, New Jersey, USA
² Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
³ Drugs and Addictions Unit, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
⁴ Department of Psychiatry, University of Florida, Gainesville, Florida, USA

Date of Submission	27-Jun-2022
Date of Decision	29-Jun-2022
Date of Acceptance	30-Jun-2022
Date of Web Publication	22-Aug-2022

Correspondence Address:
Dr. Hatice Burakgazi Yilmaz
900 North Kings Hwy, Suite 206, Cherry Hill, New Jersey 08034
USA

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_16_22

Abstract

Objectives: This study examines the data from a large survey of youth in metropolitan Istanbul to examine the generation status in rural-urban immigration and its relationship of substance use/alcohol use in a high school (HS) setting. Methods: The study data were collected by the Istanbul Department of Education on 31,604 HS students which were a survey of 66 questions administered in the school setting. Immigration statuses of the students and their parents were categorized, and it was compared with the type of substance use. Odds ratios were calculated by using the participants from rural area as the reference category. Results: A total of 31,272 participants, 14,477 (46.6%) male and 16,581 (53.4%) females between the ages of 13 and 21 years constituted the final sample size for this study. Out of the total number of participants included in analyses (24,974), 18% had all family members from Istanbul, 16% had at least one family member from outside of Istanbul, 44% had majority of family members from outside of Istanbul, and 21% were from outside of Istanbul. About 15% of participants from Istanbul reported using tobacco, whereas those from outside of the city reported about 12%. Twenty-seven percent of participants from Istanbul reported using alcohol as compared to 18% in participants from outside of Istanbul. The combined category usage (alcohol and any substance use) was found in 33.7% in participants from Istanbul and 24% in participants from outside of the city. Conclusion: Rural background may play a protective role in substance and alcohol use in Turkish adolescents and young adults. In Istanbul, nonimmigrant individuals are more likely to use any type of illicit substance, or combination of illicit substances and alcohol as compared to immigrant individuals.

Keywords: Istanbul, rural-urban immigration, substance use, Turkish youth

How to cite this article:
Burakgazi Yilmaz H, Prajapati P, Dalkilic A, Unlu A, Rahmani M, Pumariega A. Impact of Rural-Urban Immigration on Substance Use in a Sample of Turkish Youth. World Soc Psychiatry 2022;4:132-8

How to cite this URL:
Burakgazi Yilmaz H, Prajapati P, Dalkilic A, Unlu A, Rahmani M, Pumariega A. Impact of Rural-Urban Immigration on Substance Use in a Sample of Turkish Youth. World Soc Psychiatry [serial online] 2022 [cited 2023 May 31];4:132-8. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/2/132/354174

Introduction

The world's demographics have been shifted largely from rural to urban migration due to cross-national migration. According to World bank,^[1] 55% of the world's population live in cities. By 2050, the urban population more likely double its current size, and nearly 7 of 10 people in the world will live in cities. In North America, a significant number of people migrate at least once and many people change their residence multiple times in their lifetime.^[2] In Turkey, rural to urban immigration started in the 1950s with the increase of industrial opportunities in larger cities, especially Istanbul. Istanbul is the most important city in Turkey in terms of fast-growing economy and its unique geography. Istanbul connects Asia and Europe via the Bosporus Bridge and is the cultural, economic, and touristic center in Turkey.^[3] Istanbul attracts suburban population due to economic, social, environmental, and cultural reasons. In 2000, it received 22.4% of the rural-urban immigration in Turkey.^[4]

Immigration's impact on social and economic growth has an important secondary impact on society. Commenting on rural-urban immigration in Turkey, Guresci^[5] indicated that, although such immigration has had positive economic contribution by increasing the work force, it also has also increased the risk of violence, theft, and cultural and adaptation difficulties. Urbanization may also increase the risk of mental health problems, including depression, anxiety, and substance use.^[6]

A few studies have that investigated the impact of rural to urban migration on individual's mental health have shown conflicting results. Maggi et al.^[2] conducted a case − control study to assess the link of migration pattern to mental health diagnosis among 8502 individuals in Canada who grew up in rural or urban communities or migrated between communities. This study concluded that rural environment played a protective role against the development of depression, adjustment reaction, and acute reaction stress. However, they did not find any relationship between migration and other disorders, such as substance use, alcohol use, neurotic disorder or personality disorder. Jirapramukpitak et al.^[7] designed a population-based cross-sectional survey of 1052 adolescents and young adults in Thailand. They examined the prevalence of illicit substance use and harmful drinking and their association between their immigration statuses. This study found that there was no association between rural-urban immigration and illicit substance use. On the other hand, harmful drinking was associated with being late migrants, who moved to Greater Bangkok at the age of 15 or older. In contrast, Lin et al.^[8] studied a cross-sectional sample of 2153 individuals aged 18–30 years and found elevated incidents of alcohol intoxication and risky sexual behaviors among Chinese rural-to-urban migrants compared to the general Chinese population.

Most of immigration studies have focused on adults undergoing international immigration and its effects on mental health and addiction. These studies suggest that adaptation of second-generation immigrants is related to the acculturation stress, family adaptation, financial and cultural barriers, and access to community resources. Johnson et al.^[9] examined data from the U.S. National Health Interview Survey the self-reported substance use behaviors of approximately 21,000 adults aged 18–44, which represents one of the largest migration streams in the past one hundred years. They found that immigrants to the U.S. in the late twentieth century were less likely to use alcohol and other substances than native born citizens. On the other hand, after long-term exposure and assimilation to the American culture, their substance use and alcohol use patterns were similar to the native-born citizens. The increase of substance use was not thought to be related to acculturative stress. Borges et al.^[10] in a cross-national study on Mexico-US migration and its relationship to substance use and substance use disorders, found that current Mexican immigrants in the US do not have a higher risk of alcohol use or alcohol use disorder compared to Mexicans living in Mexico. On the other hand, they do have higher risk of substance use and substance use disorders. Second generation immigrants and returning immigrants have increased risk of alcohol use, substance use and alcohol, and substance use disorders. Zemore^[11] reviewed 32 articles about acculturation and alcohol use among Latinos in the US and found a relation between higher acculturation and heavier drinking outcomes among women.

Some studies have focused on immigrant adolescent populations in the US, particularly emigrating from Latin America. Swanson et al.^[12] conducted a study of depressive symptoms, illicit substance use, and suicidality among 4157 adolescents attending schools in six border cities in the lower Rio Grande Valley in Texas and in neighboring Tamaulipas, Mexico. They found that 21% of adolescents in Texas reported substance use in the past month, whereas 4.95% of Mexican youth reported substance use. Participants with the most recent ties to Mexico were less likely to use substances compared to the participants with the greatest exposure to life in the US. In a further analysis of this study, Pumariega et al.^[13] also found that generational status (higher with US second generation), culturally determined practices, and depression all contributed toward higher risk for substance use in US-Mexico border youth. In another study, Pumariega et al.^[14] examined the relationship between illegal substance use, acculturation, family relationship, and depression in 66 Latino youth aged 12–19 in Northeast Tennessee. In this study, 53% of the youth reported substance use at some time their life, significantly more than youth along the US-Mexico border. Among the respondents, 73% were born in Mexico and 20% of them were born in the US, which may indicate that adapting to a new culture and acculturation stress may contribute to a higher risk for the use of substances.

Blake et al.^[15] conducted a study among 2635 immigrant Massachusetts participants in 8^th through 10^th grades who moved to US <6 years previously and compared them to nonimmigrants (youths living in the US always or for more than 6 years). Immigrant youths tend to use less marijuana and alcohol compare to the others. On the other hand, they reported more peer pressure and less parental control. Torres Stone and Meyler^[16] found that, although immigrant youth have unique stressors which may increase the risk of alcohol use, cultural expectations (especially for girls) may be a protective factor against substance use for US Latino youth.

In summary, there is some data on rural to urban immigration and international immigration that is suggestive of a relationship between immigration (both international and rural-urban) and substance use by youth. Since both involve significant cultural adaptation, it is not surprising how culture and acculturation interact with adolescent development. We have recently had the opportunity to examine the data from a large survey of youth in metropolitan Istanbul that included information on rural-urban immigration along with substance use and mental health variables. To the best of our knowledge, our study is the first study in the literature that examines generation status in rural-urban immigration and its relationship of substance use/alcohol use in a high school (HS) setting in Turkish youth.

Methods

The study population

The participants in this survey study were 31,604 HS students, representing 20% of the total HS student population of the city of Istanbul in 2010. Out of 39 provinces of Istanbul, 28 (inner cities) were selected for sampling. The schools were divided into three categories in each province as regular, vocational, and Anatolian HS based on the regulations of the Ministry of Education and each school type had a special structure, focus, and curriculum.

Data sampling and distribution

In 2010 there were 232 regular, 242 vocational, and 88 Anatolian HS's with a total of 562 schools in Istanbul. In each category, the schools were listed alphabetically and every third school was selected from the list starting from A. The sampling design included 65 Regular, 62 Vocational and 27 Anatolian HS's into the study with the total of 154 h's. The sample represents approximately 20% of the total school population. In general students in three types of HS represent a continuum of socioeconomic status (SES) backgrounds, as the Anatolian HS's are more college preparatory and accessed by higher SES populations via entrance examination, the Regular HS have more students from the middle class, and the vocational HS's are preferred by students from lower SES, as their curriculum includes vocational skill training, as well. The survey sample consisted of youth between the ages of 14 and 19 in the city of Istanbul. The systematic sampling was used to select the allocated sample of classrooms. Every third classroom from each grade was included in the sampling. As the schools and classes were selected by stratified sampling method, the sample is representative of schools in their districts and the city of Istanbul. Ninth graders represent the largest student group, and student numbers decrease toward the higher grades among total number of students and in our sample [Figure 1].

Figure 1: Sampling and sample size

Click here to view

Survey instrument

The survey instrument used in the study was a combination of the European School Survey Project on Alcohol and Other Drugs by Hibell et al.^[17] and Youth in Europe Survey by Kristjansson.^[18] Both of these surveys were translated into Turkish and used in research previously Ogel et al.,^[19] Ogel et al.,^[20] and Altuner et al.^[21] A total of 27 items were used from these surveys. The total students surveyed were 31,604 but a “trick” substance named “relevin” was included in the questionnaire, and the responses from students who endorsed its use were removed from the analysis as their responses were deemed not credible. They consisted 1.05% (332) of the sample, pointing to an acceptable face validity ratio. The final sample size was 31,272 which consisted of 14,477 (46.6%) male and 16,581 (53.4%) female students.

Method of collection

Trained counselors and teachers who were assigned as pollsters distributed the survey, and its completion was anonymous and based on self-report, with full right of refusal. To improve validity, classroom teachers were not allowed to be present during the survey period. To maximize confidentiality, students were provided anonymous optical forms, and the booklets were collected in closed unmarked envelopes, with computers compiling responses. Data were entered into electronic spreadsheets and analyzed using SPSS Inc. Released 2007. SPSS for Windows, Verson 16, SPSS, Inc., Chicago, Illinois, US. Participants who answered at least one question were included in the data analysis and missing values were eliminated on a case by case basis.

The primary variable used in the study was obtained from the immigration statuses of the student, student's mother, and student's father. A single immigration independent variable for the analyses was calculated by adding the responses from above three variables, providing a scale ranging from 3 to 6 wherein 3 represents that all family members (participants and parents) were from Istanbul (category-1), 4 represents that “at least 1 family member (student, mother or father) was from outside of Istanbul” (category-2), 5 represents that “at least 2 (student, mother or father) were from outside of Istanbul” (category-3), and 6 represents 'all (student and parents) were from outside of Istanbul (category-4).

In order to calculate dependent variable of substance use, the information provided by the participants were categorized into “yes” and “no” for substances: Alcohol, amphetamines, homemade brews, cannabis, cocaine, ecstasy, inhalants, lysergic acid diethylamide (LSD), mushrooms, sleep pills, steroids, and tobacco. In order to calculate student using at least one substance, responses to all the individual substance use were added to give one combined variable. Alcohol use by the participants was added to this variable to obtain combined use of substances and alcohol.

Human subjects/institutional review board review

The survey was conducted according to the procedures of Nuremberg Code and Declaration of Helsinki with permission from the Governance of Istanbul during the period of May to June 2010. The Institutional Review Board of Cooper University Medical Center and the Ethics Committee of the Security Sciences Institute of the Turkish Police Academy both approved the use of the dataset for research purposes.

Statistical analysis

Data are tabulated as number (percent) for the dependent variables (substances used) and independent variable (immigration status). Binary logistic regression was used to analyze the regression models between the dependent variables (substances used) and independent variable (immigration status). Categorical covariates for independent variable were calculated with the reference category as “student and parents from outside of Istanbul.” Level of significance was kept at P < 0.05. Odds ratios were calculated with 95% confidence intervals to measure the effect size on each of the dependent variable.

Results

The final sample consisted of 31,272 participants between the ages of 13 and 21 with 14,477 (46.6%) male and 16,581 (53.4%) female participants. The immigration status variable consisted of 24,974 survey responses out of which 18% had all family members from Istanbul (category 1), 16% had at least one family member from outside of Istanbul (category 2), 44% had majority of family members from outside of Istanbul (category 3), and 21% were from outside of Istanbul (category 4). For entire analyses, category 4, in which participants who were born outside of Istanbul and whose parents were also born outside of Istanbul, was kept as the reference category for comparison.

[Table 1] represents the number (percent) of substance use and immigration status of the participants. The second column in the table represents the total number of participants who reported using substances, whereas columns 4 through 7 indicate substance use per immigration status. About 15% of participants from Istanbul reported using tobacco whereas those from outside of the city reported about 12%. There was no noticeable difference in usage of sleeping pills, amphetamines, LSD, ecstasy, cocaine, mushroom, inhalants, steroids, and homemade brews. While alcohol use among the participants from Istanbul was 27% as compared to 18% in participants those from outside of Istanbul, the combined category usage (alcohol and any substance use) in these groups were found to be 33.7% and 24% respectively.

Table 1: Total number (n) and percent (%) use of substances based on the immigration status of the participants

Click here to view

[Table 2] represents the odds ratios for each substance under study as compared to the default category-4 which is “all family members from outside of Istanbul.” For all the substances including alcohol, immigration appeared to be protective against any substance or alcohol use. In other words, odds of using substances and alcohol among immigrant participants who migrated to Istanbul with their parents who were also from outside of Istanbul, was low as compared to student in category-1 (student and family from Istanbul). For alcohol, homemade brews, tobacco, and sleeping pills this association was statistically significant with a discernible descending pattern of odds ratios. While the association for other substances was not found to be statistically significant, the descending pattern in odds ratio was clearly noticeable. The participants from Istanbul were at increased odds of using ecstasy, inhalants, and steroid as compared to immigrant participants. The odds of using various substances in nonimmigrant individuals were found to be: Alcohol use (1.7), homemade brews (1.66), amphetamines (1.4), ecstasy (1.51) sleeping pills (1.23), steroid (1.31), tobacco (1.26) and inhalants (1.33) as compared to immigrant participants. Overall, nonimmigrant individuals are more likely to use any type of illicit substance, or combination of illicit substances and alcohol as compared to immigrant individuals.

Table 2: substance use and respective odds ratios comparing the immigration status with default Category.4 (gAlloutside of Istanbulh)

Click here to view

Discussion

Our study's findings suggest that substance use is negatively correlated with more recent immigration status. In order to understand the possible reasons, we should explore in more depth the family structure of immigrant families and families from Istanbul. Turkish culture and Islamic values prohibit the use of alcohol or other substances. Immigrant families tend to be more traditional compared to families from Istanbul, which may play a protective role for immigrant families.

Adaptation to inner city culture and possible peer pressure may increase the risk of substance and alcohol use. Immigrant parents may have difficulties adapting to the host culture and may not be aware of the possible dangers and availability of substances for their youth. Therefore, parents need to be educated and encouraged to be more involved with their children, while immigrant participants should be educated and be taught skills to cope with peer pressure, especially around substance use. Mental health care providers and school counselors need to evaluate the level of rural-urban acculturation of youth they serve and their parents. Youth tend to adopt new cultural norms and language more rapidly than adults because youths are cognitively more flexible than adults.^[22],[23] In contrast, adaptation to a new culture is challenging for adults because they have established personal, cultural and ethnic identities, are less educated, and may have difficulty learning a new language as well.^[24] The adaptation differences to a new culture, including urban cultures, may cause generational family distancing and intergenerational conflicts which can lead to increased risk for youth substance use and conduct problems.^[25],[26]

Conclusions

Based on cross-cultural research, the best outcome for immigrant youth is to develop a bicultural identity, which indicates that immigrant youth remain rooted in their culture of origin, whereas they have the necessary skills and knowledge to adapt and navigate to the mainstream culture.^[22],[23] Educators and mental health providers should promote the importance of bicultural identity formation in youth and include the family members in their assessments and treatment planning. They should also support families to develop appropriate behavioral management skills consistent with their cultural values and beliefs. School-based substance use prevention programs addressing these issues should be considered in schools with high numbers of rural-urban immigrants.

The findings of our study must be interpreted with caution because of the reliability and validity of self-reported data. The data relies on student's willingness to self-disclose. Although classroom teachers were not present during the administration of the survey, it is possible that the respondent's under-reported substance use fearing possible punitive consequences, especially in school settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Urban Development Overview. Available from: https://www.worldbank.org/en/topic/urbandevelopment/overview. [Last accessed on 2022 Jun 13].
2.	Maggi S, Ostry A, Callaghan K, Hershler R, Chen L, D'Angiulli A, et al. Rural-urban migration patterns and mental health diagnoses of adolescents and young adults in British Columbia, Canada: A case-control study. Child Adolesc Psychiatry Ment Health 2010;4:13.
3.	Burakgazi Yilmaz H, Dalkilic A, Al-Mateen C, Sood A, Pumariega A. Culturally informed care of the Turkish-American child, adolescent and family. Adolesc Psychiatry 2013;3:39-45.
4.	Ozdemir H. A General Evaluation over Internal Migration in Turkey. Akad Bakis Derg 2012;30:1-18.
5.	Guresci E. The migration to city from village in Turkey and some thoughts on the issue. Sosyo Economi 2011;11:125-35.
6.	Harpham T. Urbanization and mental health in developing countries: A research role for social scientists, public health professionals and social psychiatrists. Soc Sci Med 1994;39:233-45.
7.	Jirapramukpitak T, Prince M, Harpham T. Rural-urban migration, illicit drug use and hazardous/harmful drinking in the young Thai population. Addiction 2008;103:91-100.
8.	Lin D, Li X, Yang H, Fang X, Stanton B, Chen X, et al. Alcohol intoxication and sexual risk behaviors among rural-to-urban migrants in China. Drug Alcohol Depend 2005;79:103-12.
9.	Johnson TP, VanGeest JB, Cho YI. Migration and substance use: Evidence from the US national health interview survey. Subst Use Misuse 2002;37:941-72.
10.	Borges G, Breslau J, Orozco R, Tancredi DJ, Anderson H, Aguilar-Gaxiola S, et al. A cross-national study on Mexico-US migration, substance use and substance use disorders. Drug Alcohol Depend 2011;117:16-23.
11.	Zemore SE. Acculturation and alcohol among Latino adults in the United States: A comprehensive review. Alcohol Clin Exp Res 2007;31:1968-90.
12.	Swanson JW, Linskey AO, Quintero-Salinas R, Pumariega AJ, Holzer CE 3^rd. A binational school survey of depressive symptoms, drug use, and suicidal ideation. J Am Acad Child Adolesc Psychiatry 1992;31:669-78.
13.	Pumariega A, Swanson J, Holzer C, Linskey A, Quintero-Salinas R. Cultural context and substance use in Hispanic adolescents. J Child Fam Stud 1992;1:75-92.
14.	Pumariega A, Millsaps U, Rodriguez L, Moser M, Pumariega J. Substance use in immigrant Latino youth in Appalachia. Addict Disord Their Treat 2007;6:157-65.
15.	Blake SM, Ledsky R, Goodenow C, O'Donnell L. Recency of immigration, substance use, and sexual behavior among Massachusetts adolescents. Am J Public Health 2001;91:794-8.
16.	Torres Stone RA, Meyler D. Identifying potential risk and protective factors among non-metropolitan Latino youth: Cultural implications for substance use research. J Immigr Minor Health 2007;9:95-107.
17.	Hibell B, Guttormsson U, Ahlström S, Balakireva O, Bjarnason T, Kokkevi A, Kraus L, et al. The 2011 ESPAD Report: Substance Use Among Students in 36 European Countries. Stockholm: The Swedish Council for Information on Alcohol and Other Drugs (CAN); http://www.espad.org/Uploads/ESPAD_reports/2011/. Published 2012.
18.	Kristjansson AL. Concepts and Measures in the 2006 and 2008 Youth in Europe Survey. Reykjavik: Icelandic Centre for Social Research and Analysis; 2008.
19.	Ogel K, Tamar D, Evren C, Cakmak D. Prevalence of substance use among high school students in Istanbul. J Clin Psychiatry 2000;3:242-5.
20.	Ogel K, Corapçioğlu A, Sir A, Tamar M, Tot S, Doğan O, et al. Tobacco, alcohol and substance use prevalence among elementary and secondary school students in nine cities of Turkey. Turk Psikiyatri Derg 2004;15:112-8.
21.	Altuner D, Engin N, Gurer C, Akyay I, Akgul A. Substance use and crime: The results of a survey research. J Med Investig 2009;7:87-94.
22.	Rothe EM, Tzuang D, Pumariega AJ. Acculturation, development, and adaptation. Child Adolesc Psychiatr Clin N Am 2010;19:681-96.
23.	Pumariega AJ, Rothe E, Mian A, Carlisle L, Toppelberg C, Harris T, et al. Practice parameter for cultural competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry 2013;52:1101-15.
24.	Pumariega AJ, Rothe E. Leaving no children or families outside: The challenges of immigration. Am J Orthopsychiatry 2010;80:505-15.
25.	Szapocznik J, Rio A, Murray E, Cohen R, Scopetta M, Rivas-Vazquez A, et al. Structural family versus psychodynamic child therapy for problematic Hispanic boys. J Consult Clin Psychol 1989;57:571-8.
26.	Portes A, Rumbaut R. Immigrant America: A Portrait. 2^nd ed. Berkeley: University of California Press; 1996.