The Relationship between Ethnic Identity and Depression, Anxiety, and Stress Symptoms in University Students in Iran

Relationship Abstract Ethnic identity, as a component of one’s individual identity, refers to the commitment to a cultural group and engagement in its practices. A healthy ethnic identity development should contribute to wellbeing. The aim of the present study is to investigate the strength of association between ethnic identity and depression, anxiety, and stress in Iranian university students. A total of 184 students from three Iranian universities filled in the Multigroup Ethnic Identity Measure (MEIM) and the Depression, Anxiety and Stress Scale (DASS-42). Ethnic identity correlates significantly and negatively with depression, anxiety, and stress. The sense of belonging to the ethnic groups shows the strongest and most significant corre lations with depression, anxiety, and stress. This result is compared to the findings of studies with other ethnic groups. It seems that the strength of correlation between ethnic identity and mental problems is higher in Iranians than in European Americans or Europeans, which might be due to the differing role of ethnic identity for mental health in different ethnic groups.


Introduction
Ethnic identity can be conceptualized as a component of one's individual identity and refers to "commitment to a cultural group and engagement in its cultural practices (e.g., culture, religion), irrespective of racial ascriptions" [1]. The development of ethnic identity is embedded in one's individual identity development, but at the same time influenced by the socialization processes within the ethnic group that the individual belongs to. Current models of ethnic identity, such as Phinney's [2] three-stage model of ethnic identity development, are grounded in the work of Erikson [3] and Marcia [4]. Erikson [3] describes the development of one's identity as a lifelong process, beginning in childhood, with a peak in adolescence and early adulthood, but continuing until late adulthood. Marcia [4] described processes of identity development, namely exploration of identity issues and commitment to significant and related identity domains.
Building on these more general identity development models, Phinney [5] describes three stages of ethnic identity development. First, commitment and attachment, i.e., the extent of an individual's sense of belonging to his or her group; second, exploration, i.e., engaging in activities that increase knowledge and experiences of one's ethnicity; and third, achieved ethnic identity, i.e., having a clear sense of group membership and what one's ethnicity means to the individual. Related to these stages, Phinney [5] describes three dimensions of ethnic identity that are common across ethnic groups, namely affirmation and belonging, ethnic identity achievement, and ethnic behaviors. Following this multidimensional model, he developed the Multigroup Ethnic Identity Measure (MEIM) which is one of the most often used measures of ethnic identity [1,6].

Depression:
Since psychopathological syndromes such as depression and anxiety are inversely associated with wellbeing, ethnic identity correlates negatively with depression in North-American multicultural samples [8,18], in North-American people of color [10], in Latino Americans [19], and in African Americans [20][21][22].
Anxiety: As with depression, ethnic identity correlates negatively with anxiety symptoms in African Americans [22]. A systematic review on this topic concluded that there is relatively much research with samples of African and Latino Americans, but a dearth of research with Asians and Asian Americans [23]. We want to add that there is almost no research on the association of ethnic identity and mental health in Muslim countries such as Iran. To the best of our knowledge, there is only one published article on this association, however, it is only published in the Farsi language. Alijani [24] found that a positive religious identity is associated with lower symptoms of depression and anxiety. Therefore, the association of ethnic identity and mental health in Iran should receive more attention.

Aim of the present study
The aim of the present study is to investigate the strength of association between ethnic identity and depression, anxiety, and stress in Iranian university students.

Participants
Inclusion and exclusion criteria: The participants of this study consisted of university students in the South-West of Iran. They were recruited from the Islamic Azad Universities of Gachsaran, Noorabad, Mamasani, University of Educational Sciences, and the Art University of Shiraz. Overall, the sample included 184 participants with a mean age of 21.89 years (SD 0.29). They were included in the study after they had given their consent to participate. Some of the participants lived in urban surroundings, some in a rural area. All of them were Persians and Muslims.

Informed consent
The objectives and goals and detailed information about the assessment were explained to the participants. Written informed consent was obtained from all participants prior to inclusion. The study protocol was approved by the ethics committee of the Islamic Azad University of Gachsaran, Iran.

Multigroup Ethnic Identity Measure (MEIM)
The Multigroup Ethnic Identity Measure (MEIM) was designed by Phinney [5]. The aim of the questionnaire was to measure three components of ethnic identity that are common across ethnic groups, namely affirmation and belonging (five items), ethnic identity achievement (seven items), and ethnic behaviors (two items). It consists of 14 questions with a Likert scale ranging from 1 to 4. Some items are reversely coded. A sample item for affirmation and belonging is "I have a strong sense of belonging to my own ethnic group"; for ethnic identity achievement "I have a clear sense of my ethnic background and what it means for me"; for ethnic behaviors "I participate in cultural practices of my own group, such as special food, music, or customs". Cronbach's alpha was 0.80 for the total scale, 0.83 for affirmation/belonging, and 0.57 for ethnic identity achievement in the present sample. Validity has been shown, e.g., by a moderate and positive correlation with self-esteem [5].

Depression, anxiety and stress scale (DASS-42)
The DASS-42 is a 42-item self-report inventory that assesses symptoms of depression, anxiety and stress in the previous seven days [25]. The depression subscale includes items evaluating symptoms such as anhedonia, feelings of sadness, worthlessness, hopelessness, and lack of energy. The anxiety subscale includes items evaluating physiological arousal, phobias, and situational anxiety. The stress subscale includes items evaluating symptoms such as difficulty in achieving relaxation, state of nervous tension, agitation, overreaction to situations, irritability, and restlessness. Each item is rated from 0 to 3 according to severity or frequency of the symptom. Each subscale has 14 items, and a participant's score in each subscale is obtained by the sum of all items related to a subscale. The DASS-42 has been shown to have good psychometric properties in psychiatric and non-psychiatric populations in various countries, and the three-factor structure has also been approved. We used the Persian (Farsi) translation of the DASS-42 [26]. Cronbach's alpha was 0.94 for depression, 0.8 for anxiety and 0.91 for stress in the present sample.

Statistical analysis
All statistical analyses were performed using the SPSS software, version 26 (SPSS Inc., Chicago, Illinois). The descriptive statistics section describes the data in terms of mean, standard deviation, minimum and maximum. Pearson correlations between the variables were calculated to assess their associations.

Result
Mean ethnic identity total score is M = 2.78 (SD = .46), which is, on a Likert scale from 1 to 4, a moderately high value. Mean values for the ethnic identity subscales as well as those for depression, anxiety, and stress are presented in Table 1. The correlations of ethnic identity with depression, anxiety, and stress are presented in Table 2. Ethnic identity total score correlates negatively with all psychopathological variables with a moderate effect size. The

Discussion
In a sample of university students in Iran, we found negative correlations of ethnic identity with depression, anxiety, and stress that were statistically significant or even highly significant. The affirmation/belonging subscale shows the strongest and most significant correlations with depression, anxiety, and stress.

Comparison with other studies on the association of ethnic identity with mental health
The MEIM score of M = 2.78 (SD = .46) is similar to that obtained in the study by Taghizadeh [27] with M= 2.98 (SD = .61) in male students and M = 2.82 (SD = .59) in female students in Iran. The DASS is usually used in its 21-item version in Iran, therefore we compare our results of the DASS-42 with a Turkish sample of university students. The scores in our sample were similar to those in the study of Demirbatir [28]: for depression M = 11.05 (10.07) vs. 12.24 (SD = 9.52), for anxiety M = 8.05 (6.33) vs. 11.67 (SD = 8.74), and for stress M = 17.12 (9.31) vs. 16.86 (SD = 9.38). The correlation between ethnic identity (MEIM total score) and psychopathological variables found in the present study were moderate, between r=-.22 for depression and r = -.29 for anxiety. With regard to depression, Williams et al. [22] found a correlation between MEIM total score and depression of r = -.27 (p< .01) in African Americans and r = .04 (p not significant) in European Americans, and Roberts et al. (8) of r = -.09 (p not significant) in a North-American multicultural sample. With regard to anxiety, Williams et al. [22] found a correlation between MEIM total score and anxiety of r = -.35 (p < .01) in African Americans and r = -.09 (p not significant) in European Americans. This comparison shows that the strength of association between ethnic identity and mental health problems differs between ethnic groups. This might be explained by the differing role of ethnic identity for mental health in different ethnic groups. Ethnic identity might not be as important in European Americans and Europeans, and, thus, mental health might depend more on other variables such as satisfaction with personal goals (in contrast to goals of the ethnic group). On the contrary, ethnic identity might be of higher importance for Iranians or African Americans and, thus, contributes more strongly to mental health. As Williams et al. [22] put it, "our findings support assertions that ethnic identity is less salient to European Americans" [29].

Limitations
There are some limitations to this study that should be considered in the interpretation of the results. First, this is a Copyright © Forstmeier S PPRS.000602. 5(1).2021 cross-sectional study, thus, no causal inferences on the association between ethnic identity and mental health can be made. Second, we used no other variables possibly influencing mental health or moderating this association. Further variables would be very interesting to explain this association and its mechanisms. Future studies should address the role that other variables may have in this association in a longitudinal study. Third, only the presence of depression, anxiety, and stress was investigated. Measures of positive wellbeing as well as psychiatric diagnoses have not been applied. Finally, the sample consists of university students, but not other young adults with a different working career, and no other age groups in Iran. Therefore, we cannot generalize our results to other Iranian or Muslim populations.

Practical consequences for treatment
Based on our finding that ethnic identity is negatively associated with depression, anxiety, and stress, the treatment of these psychopathological syndromes should take ethnic and cultural themes into account. It has been suggested that tailoring the treatment to the patient's values improves its efficacy [30]. Furthermore, in a Muslim country like Iran, ethnic and religious values might be associated. It is known that religious patients usually want to discuss spiritual issues in psychotherapy [31]. Therefore, psychotherapists should be sensitive to the patient's preferences regarding ethnic (e.g., discrimination experiences) and spiritual issues and also to the inclusion of interventions that may be in conflict with the patient's beliefs.
A study in the Netherlands studied asylum seekers' needs and expectations concerning psychotherapy in order to develop a culturally sensitive psychosocial intervention [32]. The participants in this study originated from Iran and other Middle Eastern countries. They understood their mental health problems mainly in association with post-migration stressors and not with past traumatic experiences. In addition, they hesitated to talk about their problems because of shame and the fear of negative stigma. The question arises as to how important the patient's concealment of aspects of their cultural identity is for the success of psychotherapy. In a multicultural American student sample, Drinane et al. [33] found that withholding cultural information while engaging with the therapist in a session correlates negatively and moderately (r = -.44) with the patient's improvement in therapy. Thus, concealing and incorporating aspects of ethnic and cultural identity is important for the efficacy of mental health treatments.