Older Immigrants Research Articles

Examining External and Internal Acculturative Factors: Cuban-Born Women’s Experience of Well-Being in the U.S.

Objective: This study investigates the influence of acculturative stress on the mental well-being of Cuban-born women and Latina immigrants, emphasizing their distinctive experiences. Methods: Utilizing data from the National Latino Asian American Study (NLAAS), a comprehensive nationwide mental health investigation among Latino and Asian Americans, this study examined 264 Cuban women (average age: 58) who migrated to the United States and live in south Florida. The study employed Family Stress Management (FSM) framework and Bekteshi et al.’s Contextual Influence on Acculturative Stress (CIAS) framework to scrutinize the interplay of contextual factors and individual characteristics impacting adolescents’ psychological distress. Results: The findings revealed several noteworthy associations. Higher levels of church attendance, challenges in visiting family overseas, and perceived racial discrimination correlated with elevated stress levels. Furthermore, the age at which individuals immigrated was positively linked to increased stress (b = 0.18; p = 0.04), indicating that older Cuban immigrants experienced greater psychological distress upon their arrival in the United States. Additionally, higher levels of conflict between family and cultural values, as well as intensified religious beliefs, were associated with elevated distress levels. Conclusion: This study underscores the intricate interplay of diverse contextual factors in shaping the mental health and well-being of Cuban-born women. The insights derived from this research have implications for the development of tailored interventions and support systems, aiming to address the unique needs of this population.

Public Benefits Use for Hispanic and non-Hispanic Older Immigrants in the United States

Public Benefits Use for Hispanic and non-Hispanic Older Immigrants in the United States

Factors Related to the Health Literacy of Older Immigrants in Korea

Factors Related to the Health Literacy of Older Immigrants in Korea

Perceptions of Older Immigrants About Health Care in the Host Countries: A Narrative Review

Older immigrants may have different needs regarding health and care services compared to other age groups. There are suggestions for adapting health services to the elderly and even immigrant elderly in order to provide equal service to everyone. There are studies indicating that with advancing age chronic diseases increase and functional capacity decreases, resulting in poorer physical and psychosocial health in immigrant elderly than in the general elderly population. It is stated that immigrants’ use of health services is lower than that of general population. Cultural and social factors influence health behaviors, opportunities, wishes and barriers for patients to access and use health and care services. Studies stated that elderly immigrants not knowing how to apply for health services, having language problems and being ineffective in communication with healthcare professionals, and experiencing lack of/insufficient social, community and family support, are lead to isolation and inadequate use of health services. In the narrative review, it is aimed to explore the existing research which was conducted on the experiences and perspectives of older immigrants, formal and informal caregivers and healthcare workers regarding health and care services and as well as interventions for better adaptation of health and care services among older immigrants.

FINANCIAL CAPABILITY AMONG OLDER ADULT IMMIGRANTS, A SYSTEMATIC REVIEW

Abstract The Financial Capability approach assesses individuals’ financial knowledge and behaviors within the context of opportunities in the environment. Scholars and practitioners have documented how immigration status can influence individuals’ access to and eligibility for financial products and services, due to federal, state, and community rules and norms. Those who lack immigration status (i.e., undocumented immigrants) often face additional financial hurdles. A separate line of research has shown how financial capability can influence retirement savings, yet this did not focus on immigration status. As such, this systematic review seeks to understand how variations in legal immigration status impact the financial capability and long-term financial wellbeing of older adult immigrants in the United States. The current review utilized standardized procedures and protocols to identify articles related to financial capability, immigration status, and retirement savings, resulting in an initial list of 3,599 articles. Three studies published before May 2023 were included in the final narrative synthesis due to their inclusion of immigrants over 55. Results demonstrate that financial capability studies of older adult immigrants that met eligibility criteria have centralized Asian individuals, particularly Chinese, Taiwanese, and Korean populations. Furthermore, studies indicate that increasing financial capability among older immigrants can strengthen their financial security, yet these studies focus less on the impact of immigration status. Programs, services, or products operating on the financial capability paradigm warrant continued research as older immigrants have unique attributes (e.g., language, culture) and require careful design, implementation, and evaluation of efforts seeking to target long-term financial wellbeing.

NEIGHBORHOOD AND DEPRESSION AMONG US CHINESE OLDER IMMIGRANTS: THE MEDIATION EFFECTS OF COPING

Abstract Studies have shown that neighborhood environment shapes older Americans’ aging experience and health. However, it remains largely unknown whether and how neighborhood environment influences the well-being of older Asian Immigrants. Guided by the neighborhood stress process model, this study aims to investigate (a) the associations between neighborhood environmental stressors and depression among Chinese older immigrants and (b) the potential mediation effects of intrapersonal (sense of mastery and sense of hopefulness) and interpersonal coping (social engagement) resources in such associations. This study analyzed data collected from 2,801 Chinese older immigrants in the greater Chicago area. Structural equation modeling with bootstrap resampling was used to fit path models on neighborhood environmental stressor, intra- and interpersonal coping resources, and depression. Findings showed that neighborhood social disintegration and physical disorder were associated with more depressive symptoms directly and indirectly via lower intra- and interpersonal coping resources. Specifically, older immigrants living in neighborhoods with greater social disintegration reported lower sense of mastery and social engagement, which in turn were associated with more depressive symptoms (partial mediation). Older immigrants living in neighborhoods with greater physical disorder reported lower sense of hopefulness and mastery, which subsequently were associated with more depressive symptoms (full mediation). The findings showed that neighborhood environmental stressors are risk factors for mental health of Chinese older immigrants, and coping resources may serve as pathways of the associations. The findings have implications for practice as they are helpful to inform the development of tailored psychosocial interventions to enhance coping resources in older immigrants.

EXPERIENCES OF SOCIAL ISOLATION BY MANDARIN AND PUNJABI-SPEAKING OLDER IMMIGRANTS LIVING IN CALGARY

Abstract Loneliness and social isolation have continued to be risk factors for the health and overall quality of life of older adults globally. The impact of loneliness on healthy ageing may even be more profound for older immigrants in Western countries like Canada, where there is a different language and culture from that of their home countries. As part of the Inclusive Communities for Older Immigrants (ICOI), which seeks to create knowledge about social isolation and improve social connectedness among older immigrants across Canada, we examined the experiences of social isolation amongst older Mandarin and Punjabi-speaking immigrants aged 60 years and over living in Calgary. Quantitative data was collected from 64 (33 Mandarin-speaking and 31 Punjabi-speaking) older adults in Calgary, Alberta. The data were cleaned and analysed using descriptive analysis with the aid of Statistical Packages for Social Sciences (SPSS), and findings showed that older immigrants conceptualised social isolation as limited participation in various community activities. Our results also showed that older immigrants perceived physical and mental health status, social conditions and environmental conditions as significant factors predisposing older immigrants to social isolation. The study, therefore, recommends designing interventions that will increase older immigrants’ participation in community activities considering their age, language, disabilities, health, and social conditions.

ORAL HEALTH AMONG FILIPINO OLDER ADULT IMMIGRANTS

Abstract Poor oral health has been associated with decreased quality of life, various non-communicable diseases, and a higher risk of mortality. There is also evidence that older immigrants and those who have been in the US for less than 5 years are more likely to have periodontitis, a serious gum disease and a common oral health condition. Despite this evidence, there is a paucity of studies investigating the influence of acculturation, immigration-related experiences, and resilience on oral health among older Filipino immigrants. To address this significant knowledge gap, a mixed methods study using a survey and focus group interviews was conducted among community-dwelling Filipino immigrants aged 60 years and older. This poster will present the results of the survey (N=103), which used a socio-demographic questionnaire, as well as valid and reliable instruments such as the Geriatric Oral Health Assessment Index, A Short Acculturation Scale for Filipino Americans, Everyday Discrimination Scale, and Connor-Davidson Resilience Scale. The results of the regression analysis revealed that the perception of discrimination and resilience were significantly associated with the perception of oral health among the participants surveyed [F(10,92) = 1.985, p < 0.05]; this regression model accounted for 18.6% of variance in the perception of oral health. The findings support the need for culturally sensitive interventions that could optimize oral health, including the utilization of dental care services for this underserved population.

HEALTH PROMOTION AS CATALYST: CHALLENGES AND COMPLEXITIES OF HEALTHCARE AMONG OLDER ASIAN IMMIGRANTS

Abstract Older adults are the most disadvantaged, vulnerable, and marginalized groups in the world. They often experience various challenges and complexities in navigating healthcare and other social care. Needless to say, these complexities are profound, especially, among older Asian immigrants in navigating healthcare and social care compared to other populations in the US. They often face various sociocultural challenges including structural barriers in search of proper healthcare and accessibility to care. The studies have shown older Asian immigrants are reluctant to seek or access needed care due to structural barriers poised against them. In addition, lack of cultural awareness and understanding by healthcare professionals further impedes accessing timely healthcare. Despite the complexities of healthcare navigation, health education and promotion play an important role as catalysts in disseminating health information relevant to healthcare and structural barriers to older Asian immigrants. Based on ecological framework, this presentation will showcase a holistic approach to health education intervention and promotion aimed to minimize complexities of healthcare navigation and structural barriers towards older Asian immigrants in the US.

IMMIGRANT EXPERIENCES AND CARE ARRANGEMENTS LATER IN LIFE: EVIDENCE FROM THE MARIEL BOATLIFT

Abstract The role of public policy in older immigrants’ use of and access to services has mainly been regarded with respect to its legal framework. However, the way public policies are framed and societies’ perceptions of immigrant groups can additionally influence immigrants’ experiences, with long-lasting effects on needs and services use later in life. Still, the importance of these mechanisms has rarely been analyzed. This study uses the Mariel boatlift in 1980 as a case study to assess the relationship between circumstances that surround an immigrants’ cohort and their care arrangement later in life. Cuban immigrants from the Mariel boatlift were perceived in a different way by the federal government and the general population than Cuban immigrants who arrived previously. Based on data from the American Community Survey (2008-2021), care arrangements of older Cubans who arrived in 1980, who are limited in daily activities, and who reside in the Miami area are compared to care arrangements of Cubans that immigrated before. Regression models are estimated and individual characteristics are accounted for. Compared to Cubans who arrived before 1980, Cubans of the Mariel boatlift are more likely to live in the community than in an institutional setting. However, among those living in the community, Cubans of the Mariel boatlift reveal a higher risk of living alone. The results suggest that Cubans of the Mariel boatlift are at higher risk for unmet needs. It is discussed how circumstances that surround immigrants’ cohort of arrival shape immigrants’ services needs and use.

HELP-SEEKING IN A FOREIGN COUNTRY: EXPERIENCES OF OLDER LATINO IMMIGRANTS NAVIGATING ASSISTANCE IN AMERICA

Abstract Access and utilization of assistance programs for older Latino immigrants focus on familismo or heavy reliance on family for help-seeking. The purpose of this paper is to document the different experiences of navigating services, including healthcare, for immigrants without family support. We also investigate the role of immigration status and age at migration on immigrants’ strategies for accessing and using social services. We conducted 141 in-depth interviews with immigrants 60 and over from Cuba, Dominican Republic, El Salvador, Mexico, Puerto Rico, and Venezuela. We used a grounded theory approach to code and analyze the data. Three themes shaped the variation we found in the strategies used by older Latino immigrants without family support: formal assistance rooted in state and local policies; age at migration and the resulting patterns of individual agency and resources, and variation by country of origin that captured legal statuses as well as social networks. Our study provides a deeper understanding of a hard-to-reach population’s access to and utilization of social services. It highlights the heterogeneity of Latino immigrants and elucidates differences from culture-based frameworks to understand Latino immigrants’ underutilization of social services later in life. We argue for a shift to perspectives that address how multiple structural dimensions intersect to impact older immigrants’ use of social services.

LEISURE ACTIVITIES, LIFE SATISFACTION, HAPPINESS, AND HEALTH PERCEPTION OF OLDER KOREAN IMMIGRANTS

Abstract The number of Korean immigrants in the United States has been increasing rapidly, with many facing psychological challenges due to cultural differences, limited resources, and language barriers. These challenges can lead to increased stress, which negatively affects mental health. However, research has shown that leisure activities can have positive effects on health outcomes, particularly for older adults. This study aimed to investigate the relationships among leisure activities, life satisfaction, happiness, and health perception in older Korean immigrants. Convenient sampling was used to recruit 51 Korean adults aged 50-85 from community centers and churches. Results showed that participation in leisure time physical activity (LTPA) predicted life satisfaction and happiness, with outdoor physical activity being positively associated with psychological well-being. Furthermore, education was significantly related to life satisfaction and health perception among those who engaged in LTPA. The findings suggest that LTPA may be linked to higher levels of happiness, life satisfaction, and health perception in older Korean immigrants. Therefore, offering recreational programs for Korean adults in the United States could potentially improve their overall well-being. By providing opportunities for older Korean immigrants to engage in leisure activities, such as outdoor physical activity, their mental and physical health may be positively impacted. These findings contribute to the growing body of research on the importance of leisure activities for older adults’ well-being and highlight the potential benefits of providing recreational programs for minority populations.

DEMYSTIFYING IMPACTS OF NEIGHBORHOOD ENVIRONMENT ON HEALTH OF OLDER CHINESE AMERICANS

Abstract Residential segregation is a key social determinant of health that disproportionately affects racial/ethnic minority and immigrant populations. The health impact of residential segregation and subjective neighborhood environment, however, is poorly understood among older Asian Americans. Findings from the limited existing studies on this topic exclusively relied on cross-sectional data and/or masked distinctive differences across Asian subgroups due to the usage of aggregated data. The purpose of this symposium is to provide a better understanding of health impacts of residential segregation and subjective neighborhood environment among older Chinese Americans, the largest Asian subgroup in the U.S. Findings presented in this symposium were from the Population Study of Chinese Elderly in Chicago (PINE) study, a longitudinal study of community-dwelling older Chinese immigrants living in greater Chicago. Session 1 describes key characteristics of neighborhood, sociodemographic, and health behaviors of older Chinese immigrants living in segregated neighborhoods. Session 2 moves beyond to determine unique and joint effects of residential segregation and neighborhood socioeconomic status on 8-year change in cognitive functioning. Session 3 focuses on mental health by investigating main and indirect effects of residential segregation on depression via social processes. Session 4 tests the interactive effects of social support with residential segregation on cognitive functioning and depression. Lastly, Session 5 demonstrates how subjective neighborhood environment, directly and indirectly, affects depression via coping. In sum, findings provide innovative and important evidence to facilitate a better understanding of health implications of living in segregated neighborhoods among older Chinese Americans.

IMPACTS OF ACCULTURATION ON HEALTH OF US OLDER CHINESE IMMIGRANTS

Abstract Acculturation from Asian- to Western-oriented values and cultural practices is a key aspect of social experience for many Asian Americans. The growing body of literature on this topic shows mixed findings on health impacts of acculturation and is largely relied on cross-sectional studies, preventing to draw definitive conclusions on the health impact of acculturation. The study aimed to examine long-term effects of acculturation on mental, physical, and cognitive health in U.S. older Chinese immigrants. Data were drawn from 2,811 participants (aged from 60 to 104 years) from the Population Study of Chinese Elderly in Chicago study. Acculturation was measured using a 12-item Acculturation Scale assessing language use, ethnic social relations, and media use. Health outcomes included depression assessed using the Patient Health Questionnaire-9, activities of daily living (ADL) assessed using the adapted Katz ADL Scale, and global cognition indexed by a composite score of episodic memory, working memory, executive function, and mental status. Results from latent growth curve models showed that high levels of acculturation were not associated with depression at baseline but predicted a faster decline in depression during the 6-year follow-up. Similarly, acculturation was not related to ADL at baseline but predicted a slower decline over time. Contrarily, acculturation was associated with better global cognition at baseline but was not related to long-term changes in cognition. These results suggest the long-term benefits of acculturation on mental and physical health among U.S. older Chinese immigrants. The health advantages related to acculturation, however, seem not to generalize to cognitive function.

NEIGHBORHOOD SEGREGATION AND CHARACTERISTICS OF OLDER CHINESE IMMIGRANTS LIVING IN GREATER CHICAGO

Abstract Neighborhoods profoundly influence health of older adults, with those living in more affluent neighborhoods tending to be happier and healthier. However, which neighborhoods to live, is shaped by pull and push factors, particularly among racial/ethnic minorities that disproportionally live in segregated neighborhoods characterized by social and economic deprivation. Residential segregation, however, is not well-examined among older Asian Americans. This study aimed to close this gap by investigating neighborhood, sociodemographic, and health behavior characteristics among older Chinese immigrants living in segregated neighborhoods. Data were drawn from 3,097 participants from Population Study of Chinese Elderly (PINE). Residential segregation was operationalized using Index of Concentrations at the Extremes (ICE), and the tertiles of ICE scores were used to categorize neighborhoods into four groups, ranging from neighborhoods extremely segregated toward Chinese speakers to segregated toward English-only speakers. Results showed that, compared to neighborhoods segregated toward English-only speakers, neighborhoods extremely segregated toward Chinese speakers had lower neighborhood socioeconomic status and cohesion but higher neighborhood disorder. Also, participants in neighborhoods segregated toward Chinese speakers were more likely to be unmarried but less likely to live alone, receive less education, and live in the U.S. longer. These participants also reported lower acculturation and racial discrimination, were more likely to smoke, and had lower adoption of preventive health practices than those living in neighborhoods segregated with English-only speakers. Findings highlight challenges and opportunities among older Chinese immigrants living in segregated neighborhoods and provide insights into existing mixed findings on health impacts of residential segregation among this understudied population.

SOCIAL NETWORKS: BUILDING RESOURCES FOR DIVERSE AGING FAMILIES

Abstract Social networks provide tangible resources for older adults and their families. Yet, their formation and characteristics may vary across diverse aging contexts. Friedman and colleagues examine multiple dimensions of caregivers’ networks using a nationally representative sample (N=2,176). Latent profile analysis identified three classes of caregiving networks: (1) Large, sparse networks with relatively few kin and only some people who assist with caregiving tasks for care recipients; (2) Moderately-sized, somewhat dense, kin-based networks; (3) Small, very dense family networks where caregiving is shared across network members, all of which uniquely influence caregiver well-being. Hu and colleagues evaluate measurement invariance of objective and subjective social isolation between US-born and foreign-born older adults using a regionally representative sample (N=611). Findings show indicators of social network structure and perceived relationship quality may be useful for examining social isolation among older immigrants. Ajrouch and colleagues show distinct dimensions of networks differentially influence older adult’s cognitive function. Larger networks and higher proportion of family are positively related while higher contact frequency is negatively related to cognitive function. Using data from the Detroit-based Social Relations Study, Webster and Chin show the extent of similarity in health-related behaviors between older adults and their closest social network members. Analysis of 247 dyads illustrate associations between multiple social network factors (homophily, structure, and relationship quality) and similarity in these behaviors. Together, these papers advance theoretical and methodological approaches to the ways in which social networks serve as a resource across diverse aging contexts.

SOCIAL NETWORKS AND COGNITIVE HEALTH IN RACIAL/ETHNIC CONTEXT

Abstract Social networks provide tangible resources for older adults and their families. Yet, their formation and characteristics may vary across diverse aging contexts. Friedman and colleagues examine multiple dimensions of caregivers’ networks using a nationally representative sample (N=2,176). Latent profile analysis identified three classes of caregiving networks: (1) Large, sparse networks with relatively few kin and only some people who assist with caregiving tasks for care recipients; (2) Moderately-sized, somewhat dense, kin-based networks; (3) Small, very dense family networks where caregiving is shared across network members, all of which uniquely influence caregiver well-being. Hu and colleagues evaluate measurement invariance of objective and subjective social isolation between US-born and foreign-born older adults using a regionally representative sample (N=611). Findings show indicators of social network structure and perceived relationship quality may be useful for examining social isolation among older immigrants. Ajrouch and colleagues show distinct dimensions of networks differentially influence older adult’s cognitive function. Larger networks and higher proportion of family are positively related while higher contact frequency is negatively related to cognitive function. Using data from the Detroit-based Social Relations Study, Webster and Chin show the extent of similarity in health-related behaviors between older adults and their closest social network members. Analysis of 247 dyads illustrate associations between multiple social network factors (homophily, structure, and relationship quality) and similarity in these behaviors. Together, these papers advance theoretical and methodological approaches to the ways in which social networks serve as a resource across diverse aging contexts.

EFFECTS OF COMPANION ROBOTS ON DEPRESSION AND SOCIAL ISOLATION AMONG KOREAN AMERICAN OLDER ADULTS

Abstract Objectives During the COVID-19, older immigrants in low resource areas who are already excluded from much of social life, had to distance themselves even further, deepening their social isolation. Lack of stimulation can be particularly detrimental, as it influences mood and increases loneliness. Selected for cost-effectiveness and interactive features, we introduced the Companion Robot (CR) system. Preliminary studies conducted in South Korea found statistically significant improvement in quality of sleep and cognition among low-income older patients living alone with multiple chronic conditions and cognitive impairment. Method. Thirty CRs were deployed to solo-living Korean American older adults. We followed up with them after 3 months. In this Stage 1A clinical trial, we tested feasibility, usability and acceptability of CRs, investigating which features of CRs will help improve health behaviors such as medication adherence and daily exercises. Robotic Social Attitude (RoSAS) are assessed with a generic 18-items questionnaire (Krägeloh et al., 2019). Results The primary clinical outcomes measured at pre-and post-intervention were medication adherence and reduction of depression, social isolation and disabilities. The user-friendly doll-shaped design of CRs helped participants feel comfortable interacting with the CR on their own. Exposure to individualized CR-delivered content, including quizzes for brain training and inspirational messages, combined with consistent interaction with CR appeared to be beneficial for cognitive function. Discussion Since very few participants had reported diagnosis of dementia, we need to screen for undetected dementia using the Modified Mini-Mental Status Exam. The next stage is to implement further cultural adaptation for the U.S. participants.

“THE ONLY WAY FOR US TO STAY SAFE IS TO HIDE”: THE EXPERIENCES OF OLDER CHINESE IMMIGRANTS DURING COVID-19 IN NYC

Abstract The COVID-19 pandemic disproportionately affected older adults, who were at heightened risk for COVID-19 morbidity and mortality, as well as social isolation. Challenges to accessing health information and vaccine resources were amplified among older immigrants due to language barriers, lack of established social networks, and experiences of systemic discrimination. Considering the surge of anti-Asian violence across the country and the high-profile violent incidents targeting Asian older adults, our analysis focuses on the lived experiences of older Chinese immigrants during the pandemic in New York City (NYC). To describe the support needed during the pandemic to inform service delivery, we conducted in-depth interviews with 9 low-income Chinese adults over 65 about their experiences in coping with COVID-19. Interviews were transcribed and subjected to inductive thematic analysis. Results show that driven by the pro-vaccination and science norms in China, participants shared an overall positive attitude towards vaccines and exhibited extraordinary resilience to COVID-misinformation. However, COVID-19 and anti-Asian violence amplified each other. Fear of contracting COVID-19 due to perceived age-related vulnerability and fear of anti-Asian violence were prevalent, leading to self-protective withdrawal and deferred health care. Many expressed concerns about traveling to public places alone. Deeply frustrated with the government’s role in controlling violent crimes, some participants decided to stay home indefinitely to evade trouble. Mechanisms to draw out people who have socially withdrawn are needed. Senior service providers in NYC should initiate discussions about perceived safety and implement peer buddy systems to enhance post-pandemic quality of life for Asian older adults.

RESIDENTIAL SEGREGATION AND DEPRESSIVE SYMPTOMS IN OLDER CHINESE IMMIGRANTS: MEDIATING ROLE OF SOCIAL PROCESSES

Abstract Older Chinese immigrants are particularly at risk for depression due to acculturative stress and language barriers. Residential segregation with respect to language use may play an important role in mental health of historically marginalized immigrant populations. Previous research provided mixed evidence about the segregation effect among older Latino and Asian immigrants. Guided by a model of social processes, we examined the direct and indirect effects of residential segregation on depressive symptoms via multiple mechanisms of acculturation, discrimination, social network, social support, social strain, and social engagement. Four waves of depressive symptoms were assessed in the Population Study of Chinese Elderly (2011-2019, N=1,970), and linked to the 2010-2014 American Community Survey estimates of neighborhood context. Residential segregation was measured by the Index of Concentrations at the Extremes that simultaneously assesses Chinese and English language use within a given census tract. Latent growth curve models with adjusted cluster robust standard errors were estimated after controlling for individual-level factors. Residents of segregated Chinese-speaking neighborhoods had fewer baseline depressive symptoms but a slower decline rate than those living in segregated toward English-only speaking neighborhoods. Racial discrimination, social strain, and social engagement partially mediated the association between segregation and initial level; social strain and social engagement also partially mediated the association with decline in depressive symptoms. This study demonstrates the importance of residential segregation and social processes in shaping mental well-being among older Chinese immigrants and suggests potential mechanisms to alleviate mental health risks.