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Effects of chronic ethnic discrimination in the daily life of Turkish immigrants living in Austria: study protocol of a 30-day ambulatory assessment study

Introduction Chronic ethnic discrimination is associated with negative mental and physical health outcomes in ethnic minority groups. It is assumed that suffering from repeated discriminatory events leads, over time, to psychological consequences such as higher perceived stress, higher negative affect and lower positive affect. Higher stress reactivity to non-discriminatory stressors, such as daily hassles, as well as anticipation and avoidance behaviour regarding discriminatory events, may further contribute to the overall burden for affected individuals. Studies investigating chronic ethnic discrimination and its psychological consequences in the daily lives of affected persons are lacking. Here, we present a study protocol to investigate the impact of chronic ethnic discrimination and acute discriminatory events in the daily lives of Turkish immigrants living in Austria, using an ambulatory assessment design. The feasibility of our study design was tested and confirmed in a pilot study (n=10). Methods and analysis Ninety male Turkish immigrants will complete daily questionnaires for 30 days. Participants will indicate stress, perceived discrimination, negative and positive affect, daily hassles, anticipation and avoidance behaviour, as well as rumination with regard to discriminatory events on a daily basis. Furthermore, they will use preprogrammed iPods to assess acute discriminatory events in real time. Our hypotheses will be tested using multilevel analyses. Ethics and dissemination This study has been approved by the institutional review board of the University of Vienna (reference number 00358). Results will be presented at conferences and submitted for publication in a peer-reviewed journal.


Discriminatory Events 54
The reporting, classification, and assessment of perceived stress and discrimination 55 of the discriminatory events was conducted-via a preprogrammed iPod touch-as reported 56 in the study protocol. 57

Daily Diary 58
The daily diary assessment was identical to the assessment described in the main 59 study, yet the pilot study only included the outcomes daily perceived stress, daily perceived 60 discrimination, and daily affect-assessed with the Positive and Negative Affect Schedule 61 (PANAS; Watson, Clark, & Tellegen, 1988). Within-person Cronbach's alpha was .78 for 62 perceived stress, .95 for perceived discrimination, .99 for positive affect, and .98 for negative 63 affect in this study. 64

Data Analysis 65
Repeated data entries at level 1 (i.e., stress, discrimination, and affect) were nested 66 in participants (level 2). Descriptive statistics of baseline variables and discriminatory events 67 are presented. Analyses were conducted in R 3.6.1 (R Core Team, 2019). To probe the effect 68 of acute discriminatory events on perceived stress, perceived discrimination, and affect over 69 the 30 days, hierarchical linear models were conducted with the package lm4 (Bates, Mächler, 70 Bolker, & Walker, 2015). p-values of the hierarchical linear models were supplied by the 71 package lmerTest (Kuznetsova, Brockhoff, & Christensen, 2017). Intraclass correlations (i.e., 72 the proportion of variance in the outcomes accounted for by the nesting in participants) were 73 .10 for perceived stress, .56 for perceived discrimination, .50 for positive affect, and .38 for 74 negative affect. Therefore, two separate random intercept models were analyzed: models with 75 a time-varying predictor event coded as 0/1 (acute discriminatory event occurred: no/yes) for 76 the effect of acute discriminatory events on each of the daily diary variables on the same day; 77 and models with a time-varying predictor event -1 coded as 0/1 (acute discriminatory event 78 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

Occurrence and Description of Acute Discriminatory Events 97
Six acute discriminatory events were reported by six participants over the course of 98 the 30-day assessment. Four of the six events were categorized as 'being treated worse' and 99 two were reported via the category 'other'; these were described as 1) being approached in 100 English because the other person assumed no command of German, and 2) a neighbor 101 behaving in a nervous way around them. The median of the number of perpetrating persons 102 was 1 (M = 1.5, SD = 0.84, range: 1-3). Perpetrating persons were the police and service 103 personnel (one event each), and all but one person-a janitor-were unfamiliar to the 104 participants. Two events occurred while dealing with government agencies; the options during 105 work and leisure time were each reported once. The remaining two events were categorized as 106 'other', as they occurred in the elevator of their home apartment building and at school. 107 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

Results of the Daily Diary Assessment 111
Ninety-four percent of all daily assessments were completed, and participants 112 completed the assessment, on average, for 28.1 days (SD = 2.8). The results of our 113 hierarchical linear models revealed that perceived discrimination was rated higher when acute 114 discriminatory events had occurred on the same day, compared to days when it had not (b = 115 2.47, p < .001). Furthermore, discriminatory events were associated with more negative affect 116 (b = 0.43, p = .033), but did not have an impact on positive affect (b = -0.28, p = .250) and 117 perceived stress (b = 0.79, p = .079). Our time-lagged analyses showed no prolonged effect of 118 discriminatory events on one day on perceived stress, perceived discrimination, positive 119 affect, and negative affect on the following day (all ps > .376). 120 121 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

Secondary Variables of the Study Protocol 122
Here, we provide information about secondary variables that will be used in the 123 proposed study described in the study protocol. Secondary variables may serve as outcome, 124 control, moderator and/or mediator variables in exploratory as well as secondary analyses. A 125 complete list of all study variables (including secondary measures) can be found in 126 Supplementary Table 2. 127

Perceived Discrimination 128
In addition to the EDS (see Procedure of the study protocol), the BIAS-Treatment 129 Scale (BIAS-TS; Sibley, 2011) will be used to assess different forms of ethnic discrimination. 130 This is based on the BIAS map (Cuddy, Fiske, & Glick, 2007) and detects four different kinds 131 of harmful and facilitatory behavior that individuals may encounter: active harm (i.e., 132 intention to hurt), passive harm (ignorance, undermining the social value), active facilitation 133 (benefiting a group), and passive facilitation (instrumental collaboration to pursue one's own 134 aims). Active and passive harm are assumed to have negative consequences for the group 135 member (Fiske, 2018;Fiske, Cuddy, Glick, & Xu, 2002).We will apply a short form (Sibley, 136 2011) with three items for each scale, and items will be rated on a 7-point scale (1 = have 137 never experienced this, 7 = often experience this). 138

Depressive Symptoms 139
In addition to the screening (see Procedure of the study protocol), in which we will 140 assess mental health in a categorical way as an exclusion criterion, we aim to assess 141 depressive and somatoform symptoms dimensionally. The depression module (PHQ-9) of the 142 Patient Health Questionnaire (Löwe et al., 2002) will be used to examine depressive 143 symptoms. The nine items cover impairment in the last two weeks in close correspondence 144 with the diagnostic criteria of the DSM-IV for depressive disorders (APA, 2000). Items will 145 be presented on a 4-point Likert-type scale (0-not at all, 1-several days, 2-more than half the 146 days, and 3-nearly every day) and refer to the last two weeks. 147 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

Somatoform Symptoms 160
To assess somatoform symptoms, we will use the somatoform module (PHQ-15) of 161 the PHQ (Löwe et al., 2002). The module assesses 15 common physical complaints referring 162 to the last four weeks (e.g., stomach and back pain; pain in arms, legs, or joints; pain or 163 problems during sexual intercourse). As our sample will consist only of male participants, the 164 item "menstrual cramps or other problems with your periods" will be excluded. Items will be 165 answered on a Likert-type scale (0-not at all, 1-bothered a little, and 2-bothered a lot). The 166 scores can be summarized, with higher values indicating a higher level of somatic symptom 167 severity. 168

Perceived Stress 169
The Perceived Stress Scale (PSS; Cohen et al., 1983) will be used to measure 170 perceived stress. We will use a short scale with ten items (Cohen & Williamson, 1988) and 171 participants will be asked to report how often they have felt a certain way (e.g., "In the last 172 month, how often have you felt that you were unable to control the important things in your 173 life?"). Items will be rated on a 5-point Likert-type scale (0 = never, 4 = very often), with 174 higher scores indicating a higher level of perceived stress. 175

Chronic Stress 176
Chronic stress within the last three months will be measured by the 12-item

Stress Reactivity 182
Reactivity to potentially stressful situations will be assessed using the 29-item 183 Stress Reactivity Scale (SRS;Schulz et al., 2005). The SRS defines stress reactivity as a 184 person's disposition to respond to stressors with immediate, intense, and long-lasting stress 185 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) options. Example items are "If I have little time for my work", with the response options: "1 = 187 I mostly stay calm; 2 = I mostly get uneasy; 3 = I mostly get quite hectic", and "When I have 188 to speak in front of other people", with the response options: "1 = I am mostly very nervous; 2 189 = I am mostly slightly nervous; 3 = I generally keep my balance". 190

Discrimination-Specific Coping 191
Coping strategies may be protective resources-e.g., religious coping (Szymanski 192 & Obiri, 2010) and problem-focused coping (West, Donovan, & Roemer, 2009;Williams et 193 al., 1997) and 14 scales. In our study, we will use twelve scales (24 items) and omit the scales 202 Emotional Support and Instrumental Support, as they are measured with the Berlin Social 203 Support Scales (see below). All items of the Brief COPE are rated on a 5-point scale (1 = 204 never, 5 = always). We reformulated the instructions to measure coping specifically after 205 perceived experiences of ethnic discrimination, i.e., discrimination-specific individual coping 206 (c.f., Brown, Phillips, Abdullah, Vinson, & Robertson, 2010;Plummer & Slane, 1996). 207 Typical items of the Brief COPE are "I've been refusing to believe that it has happened" and 208 "I've been using alcohol or other drugs to make myself feel better.".

Social Support 212
Perceived social support has been found to be particularly beneficial to 213 psychological adjustment and well-being in ethnic minority groups (Ajrouch, Reisine, Lim, 214 Sohn, & Ismail, 2010;Noh & Kaspar, 2003;Vega, Kolody, Valle, & Weir, 1991), and access 215 to a supportive social network may be crucial in terms of adaptation to and reduction of stress 216 caused by ethnic discrimination (Schmitt, Postmes, Branscombe, & Garcia, 2014). 217 Social support will be assessed with the Berlin Social Support Scales (BSSS; 218 Schulz & Schwarzer, 2003). The BSSS contains 33 items and five scales. For this study, only 219 the 8-item subscale perceived social support will be used. For all items, we have specifically 220 reformulated the instructions to refer to ethnic discrimination, similar to the instructions of the 221 Brief COPE. Example items are "When I feel sad, there are people who cheer me up" and 222 "When I am worried, somebody is there to help me". The items will be rated on a 4-point 223 Likert-type scale (0 = completely agree, 3 = completely disagree). 224

In-group Identification 225
In-group identification has been postulated as a factor that potentially influences the 226 association between ethnic discrimination and health (Mewes, Asbrock, & Laskawi, 2015). 227 According to the social identity theory (Cameron, 2004), in-group identification is an 228 important part of an individual's self-concept. A high level of in-group identification, which 229 translates into high levels of affective (i.e., perceived pride) or cognitive (i.e., perceived 230 importance) connections to one's in-group, may provide people with the resources to 231 counteract the harm caused by discrimination (Brondolo et al., 2009;Jetten, Haslam, Cruwys, 232 & Branscombe, 2017). 233 In-group identification will be assessed with the 12-item Social Identity Scale 234 (Cameron, 2004). This scale measures social identity on the basis of its three components: 235 cognitive centrality (the importance of the group for one's self-concept), in-group affect 236 (positive or negative affect associated with being a group member), and in-group ties 237 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)  [Turks].". Items will be rated on a 6-point Likert-type scale (1 = strongly 240 disagree, 6 = strongly agree). 241

Acculturation 242
Acculturation describes psychological processes that occur when individuals of 243 minority groups come into first-hand contact with individuals of the cultural majority (J. W. 244 Berry & Sam, 1997;Oppedal, Røysamb, & Heyerdahl, 2005). The degree of acculturation is 245 typically equated with language acquisition, general culture acquisition, and integration into 246 the host society (Rudmin, 2009). Importantly, in the context of perceived ethnic 247 discrimination, an adoptive degree of acculturation is assumed to be a protective and 248 amplifying resource for affected individuals (e.g., Noh & Kaspar, 2003). 249 Acculturation will be measured with the 15-item Frankfurt Acculturation Scale 250 (FRAKK; Bongard et al., 2002). The FRAKK assesses the degree to which a person is 251 oriented towards the host culture via statements revolving around language and media use as 252 well as their degree of connectivity in social networks (example items: "I use [Turkish] mass 253 media (TV, press, magazines, etc.)" or "I follow political developments in [Austria]."). Items 254 are rated on a 7-point Likert-type scale (0 = never, 6 = always). 255

Emotion Regulation 256
Emotion regulation will be assessed using the 10-item Emotion Regulation 257 Questionnaire (ERQ; Gross & John, 2003). The ERQ measures emotion regulation on the two 258 subscales suppression (i.e., inhibition of emotion-expressive behavior) and reappraisal (i.e., 259 cognitive change of the emotion-eliciting situation to change its impact). The German version 260 (Abler & Kessler, 2009) will be used in the current study. Example items are "I control my 261 emotions by not expressing them" (suppression) and "When I want to feel more positive 262 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) are presented on a 7-point Likert-type scale (1 = completely disagree, 7 = completely agree). 264

Resilience 265
Resilience will be assessed with the 11-item Resilience Scale (RS-11;Schumacher, 266 Leppert, Gunzelmann, Strauß, & Brähler, 2005), which is a short form of the original 267 Resilience Scale with 25 items (Wagnild & Young, 1993). Resilience potentially moderates 268 the negative effects of stress and promotes adaptation. Example items of the RS-11 are 269 "When I make plans, I follow through with them" and "I can usually look at a situation in a 270 number of ways". Items are rated on a 7-point Likert-type scale (1 = disagree, 7 = agree). 271

Personality Traits 272
We will measure the Big Five personality traits (neuroticism, extraversion, 273 openness to experience, agreeableness, and conscientiousness) with the Big Five Inventory 10 274