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Research Paper Rubric

Student Name: _________________________________________ Date: ___________________

Items
Beginning
(1 Point)

Accomplished
(3 Points)

Exemplary
(4 Points)

Format Paper does not follow the research project
guidelines for length, spacing, or format.

Paper is 5-7 pages, double-spaced, with APA
format for the cover page and citations.
However, there are a few formatting issues
present.

Paper is 5-7 pages, double-spaced, with APA
format for the cover page and citations. There
are minimal or no formatting issues present.

Introduction Paper does not have a clearly-identifiable thesis
or hypothesis in the introduction.

Paper has a somewhat identifiable thesis or
hypothesis in the introduction.

Paper has a clearly identifiable thesis or
hypothesis in the introduction.

Methods Paper does not describe the methods taken to
obtain information cited.

Paper makes general statements about
methods taken without identifying specific
topics, databases, or questions that guiding
obtaining the information cited.

Paper clearly identifies methods taken by
specific references to databases, research
questions, or topics of interest that guided
obtainment of information cited.

Results Paper does not tie results to the thesis,
hypothesis, or larger questions posed in the
introduction.

Paper attempts to link results back to the
thesis, hypothesis, or larger questions posed in
the introduction.

Paper clearly identifies 3-5 results and links
them to the thesis, hypothesis, or larger
question posed in the introduction.

Conclusion Paper does not recount 3-5 results and does
not summarize what the findings might mean.
Paper does not tie the findings to readings,
class lectures, or class discussions.

Paper recounts 3-5 results but is unable to
summarize and link the findings to readings,
class lectures, or class discussions. Paper
makes recommendations for future research or
services.

Paper recounts 3-5 results and summarizes
what they might mean as related to readings,
class lectures, or class discussions. Paper also
makes recommendations for future research or
services.

Research Paper Rubric

AA S 591.01

Baldeep Pabla, LCSW

Research Paper Guidelines

Purpose: This project provides an opportunity for students to develop and/or refine their skills at

researching, collecting, and analyzing primarily data. The project also provides an opportunity

for students to critically assess previous studies in the areas they have chosen for their research

topic to either test out existing information or further a particular question that was lacking from

your literature review.

Each student is expected to undertake and complete a research project that will advance their

own knowledge and skill in some aspects of Asians in an American community.

The Research Paper should be 5-7 double-spaced pages in length, not counting a required APA-

style cover page, in-text citations, and a works cited page. The paper is going to be graded based

on four main sections: Introduction, Method, Results and Conclusion.

In the introduction section, students are required to give an overview of their topic through their

library research. Your task here is to provide me with information about your topic. What have

people written in relation to your topic? If your topic is not directly addressed in your library

research, you should look at a related topic to help you understand and/or put your topic in

context to this class. It is very important that you make a clear thesis statement or hypothesis of

your research project.

In the method section, students are expected to state the method they have chosen to gather their

data – including rationale for topic of interest and what the process was for obtaining specific

information, articles, and narrowing down results for their topic. What kind of databases,

research methods, experiments, or studies did the student come across when narrowing their

search?

In the results/discussion section, students are required to summarize their findings in some

logical manner, either by theme or major concepts you discovered from your literature review.

After you present your findings, students are expected to discuss and make some assessment of

their findings. Students should give some explanation to why they think their findings came out

the way it did using concepts presented in readings, class lectures, or class discussions.

In the conclusion section, you are required to summarize your key findings (approximately 3-5

findings). Then, you should discuss the significance and or contributions of your topic to Asian

American community health. Lastly, you will provide some recommendations to future research.

Runninghead: ASIAN AMERICANS AND MENTAL HEALTH 1

Asian Americans and Mental Health Related Disorders

Student Name

San Francisco State University

Asian-American Population and Mental Health Related Disorders

ASIAN AMERICANS AND MENTAL HEALTH 2

Asian-American Population and Mental Health Related Disorders

When immigrants arrived to the United States, their purpose was to seek a better life for

their families and loved ones. For those born in America, different struggles arise that may not be

a big deal to those who came here from a different country. To many Asian Americans, sadness

and mental health are the least of their problems, as providing for their families and having

financial stability are held at a higher priority. Most Asian immigrants started their own families

here in America where their children grew up with a different environment, thus teaching them

western values. Adapting to the American way of life is already difficult enough for many

immigrants who come to the United States, especially being introduced to a new western culture

they are unfamiliar with. This is a hardship many Asian Americans face in America, which can

cause a significant negative effect to their mental health. Many factors play into mental health in

Asian Americans such as; disparities in health care, social stigma, and acculturation which could

lead to rejection and mental health problems.

There is discerned interpersonal discrimination while seeking healthcare services

corresponding with poor and physical health, especially amongst Asian Americans. Ranjita

Misra, a researcher for the department of Social and Behavioral Sciences at West Virginia

University, did a study that correlates reported interpersonal discrimination when seeking health

care among a large subgroup of Asian Indians, which is the third largest Asian American

subgroup in the United States. A cross-sectional survey of 1824 participants took place in the

study, specifically those from populations in six states with higher concentrations of Asian

Indians. Perceived interpersonal discrimination when seeking health care was reported by a

relatively small proportion of the population (7.2%). However, Asian Indians who reported poor

self-rated health were approximately twice as likely to perceived discrimination when seeking

ASIAN AMERICANS AND MENTAL HEALTH 3

care as compared to those in good or excellent health status (Ranjita, 2016). The results of this

study shows that Asian Indians experience these interpersonal discrimination acts when seeking

health care services, which shows the lack of help given to them when it comes to their mental

health and well-being.

Another reason why many Asian Americans do not seek health care is because there is a

social stigma which is due to their cultural and social beliefs. “A mental health problem is

considered a sign of weakness in traditional Asian cultures, and families do not want to be

stigmatized” (Kim, Atkinson, & Umemoto, 2001). Astraea Augsberger, a researcher at the

Boston University School of Social Work, reported a study of significantly high prevalence of

depression, suicidal ideation and suicide attempts amongst Asian American women who are

children of immigrants. A 5-year mixed methods study examined the differential proportion of

mental health utilization amongst a survey of 701 Asian-American women participants based on

their mental health risk profile determined by current moderate to severe depression symptoms

and lifetime history of suicidality. Results showed that 43% of women reported that they either

suffered from current moderate to severe depression symptoms or lifetime history of suicidal

ideation or suicidal attempts (Augsberger, 2015). Although the high-risk group demonstrated

statistically significant higher mental health utilization compared to the low and medium risk

groups, more than 60% of the high-risk group did not access any mental health care due to the

social stigma of mental health. Also, because mental health is so stigmatized amongst the Asian

American population, many try to solve problems on their own by seeking help from relatives,

spiritual leaders, or traditional healers. Yijie Wang and Su Yeong Kim, journalists for the

Department of Human Development and Family Sciences at University of Texas, conducted a

study on 24 years old old Chinese women name Ting who suffered severe move swings since

ASIAN AMERICANS AND MENTAL HEALTH 4

college and was diagnosed with bipolar disorder. Wang and Kim states that, “Ting’s family did

not seek professional help until after Ting had already been suffering from bipolar disorder for

several years. Even after Ting was diagnosed with a mood disorder, they preferred traditional

Chinese treatment over medication (Wang and Kim, 2013).” Asian cultures tend to hold a

holistic view of mind–body relationships, which may explain why Asian Americans with mental

health problems are likely to report somatic symptoms and prefer traditional treatments that

target both mind and body (Chun, Enomoto, & Sue, 1996). In conclusion, this showed that

mental health is extremely stigmatized in Asian cultures that most Asian families would rather

seek help from relatives, spiritual leaders or traditional healers than seeking professional health

at mental health clinics.

Moving to America, Asian American immigrants are introduced to a new way of living

that is very distinct from their own culture, beliefs, and values, which can have a degrading

effect on their mental health. This problem revolves around the idea of acculturation, which is

defined as a person or group from one culture comes to adopt practices and values of another

culture, while still retaining their own distinct culture (Cole, 2017). For example, Asian

Americans adapting into western culture, norms, and values would be an example of

acculturation. Another term for Asian Americans adjusting to a new culture is also called

“assimilation,” which means the process through which immigrants, their children, and their

children’s children gradually lose their culture of origin and become an indistinguishable part of

the mainstream society (Wang and Kim, 2013). John W. Berry, a Professor of Psychology at

Queen’s University, proposed two different acculturation strategies: integration and assimilation.

Asian immigrants who choose the strategy of assimilation are oriented towards the western

culture rather than towards their heritage culture. Immigrants who choose the strategy of

ASIAN AMERICANS AND MENTAL HEALTH 5

integration are highly oriented towards both western culture and their heritage culture. In results,

amongst the two acculturation strategies, integration represents the most effective strategy in

having mutual acceptance between two different cultures, versus, assimilation which has the

lowest mutual acceptance of losing their culture of origin for a mainstream culture. Another

study was conducted by David Takauchi, a Professor and Journalist at the Chinese American

Psychiatric Epidemiological (CAPES), where he took a large-scale sample of 1,747 Chinese

Americans between the ages of 18 and 65. He found that among highly acculturated individuals,

older women were twice as likely as men to experience depression compared to less acculturated

individuals. Takeuchi also states that “U.S.-born Asian American women experienced higher

rates of lifetime depression and anxiety disorders than did foreign-born Asian American women,

and that Asian American men who were more fluent in English experienced lower rates of

depression and anxiety disorders during both a particular 12-month period and over the course of

their life (Takeuchi, 2007). In results, these research findings indicate possible gender and

generational differences in the relationship between acculturation and psychological well-being

showing acculturation being a risk factor for significant levels of depression.

In conclusion, Asian-Americans have a difficult time addressing mental health due to the

perspective of past generations. Older generations of Asians that originate from Asian countries

have always perceived mental illnesses as an impractical problem or a deficiency. There are

disparities in mental health amongst Asian Americans unlike other races in this country. For

example, Indians that live in America face a type of prejudice when pursuing health care

services, which ultimately can affect their mental health. Also, the beliefs of different

generations of Asians can affect their mental health as well due to the stigma connected to

mental health. Older generations of Asians see mental health as a weakness or sort of a “fake

ASIAN AMERICANS AND MENTAL HEALTH 6

problem” because of the many hardships they had to endure in their life. Most families would

rather put their trust in a family member, a healer, or a religious leader when it comes to seeking

healthcare, over a mental health hospital. Moving to America also plays a role in this

indifference between generations on how mental health is noted. The acculturation and change

that families must accustom to once moving into this country for the first time can startle the

social norms that they are familiar to. Parents and past generations have already been taught a

lifestyle and way of life from their origin country, which ultimately causes different perspectives

on certain topics such as mental health. Today in America, a new lifestyle and culture is

introduced to Asian Americans that can shift their values and mental health as it is vastly

different from their parent’s point of view. Asian Americans learn to adapt to the environment of

this country and grow up conforming to the social norms of normal American children and teens.

ASIAN AMERICANS AND MENTAL HEALTH 7

Work Cited

Augsberger, A., Yeung, A., Dougher, M., & Hahm, H. C. (2015). Factors influencing the

underutilization of mental health services among Asian American women with a history

of depression and suicide. BMC Health Services Research, 15(1), 542.

Misra, R., & Hunte, H. (2016). Perceived discrimination and health outcomes among Asian

Indians in the United States. BMC Health Services Research, 16(1), 567.

Berry, J. W. (1980). Social and cultural change. In H. C. Triandis & R. Brislin (Eds.), Handbook

of cross-cultural psychology (Social psychology, Vol. 5, pp. 211– 279). Boston: Allyn &

Bacon.

Takeuchi, D. T., Chun, C.-A., Gong, F., & Shen, H. (2002). Cultural expressions of distress.

Health, 6 , 221–236.

Wang, Y., & Kim S. Y. (2013). Acculturation and Culture; A Critical Factor for Asian

Americans’ Health. Handbook of Asian American Health.

ASIAN AMERICANS AND MENTAL HEALTH 8

Asian American Cancer Disparities: The Potential Effects of Model
Minority Health Stereotypes

Alicia Yee Ibaraki and Gordon C. Nagayama Hall
University of Oregon

Janice A. Sabin
University of Washington

Racial/ethnic disparities exist in health care that are not fully explained by differences in access to care,
clinical appropriateness, or patient preferences (Smedley, Stith, & Nelson, 2002). An important health
disparity that exists within the Asian American population is in preventive cancer screenings. The rates
of physicians recommending cancer screening among Asian Americans are disproportionately lower than
justified by the relatively small ethnic group differences in cancer and mortality rates (U.S. Cancer
Statistics Working Group, 2012). Despite cancer being the leading cause of death for Asian Americans,
(National Center for Health Statistics, 2011) screening rates for cervical and breast cancer in Asian
American women, and colorectal cancer in Asian American women and men are well below those of any
other ethnic group (King, 2012; U.S. Cancer Statistics Working Group, 2012). In this article, we present
a conceptual model that seeks to explain a factor in these lower screening rates. We review and
incorporate in our model established mechanisms in the literature including physician-patient commu-
nication, patient variables, and physician variables. We also propose a new mechanism that may be
specific to the Asian American population—the impact of the model minority myth and how that may
translate into positive health stereotypes. These positive implicit or explicit health stereotypes can interact
with time pressure and limited information to influence physician decision making and cancer screening
recommendations. Suggestions are offered for testing this model including using the Implicit Association
Test and the Error Choice technique.

Keywords: cancer, Asian Americans, health disparities, model minority stereotype

Racial/ethnic disparities exist in health care that are not fully
explained by differences in access to care, clinical appropriateness,
or patient preferences (Smedley et al., 2002). Unequal Treatment,
a seminal 2002 publication by the Institute of Medicine (IOM),
identified racial/ethnic disparities in receiving necessary cardio-
vascular procedures, as well as in the treatment of cancer, cere-
brovascular disease, renal transplantation, HIV/AIDS, asthma, di-
abetes, pain, and maternal and infant health (Smedley et al., 2002).
Although these disparities have been clearly documented for over
a decade, they continue to persist. The IOM report speculated that
racial bias and stereotyping may contribute to these entrenched
disparities experienced by minority populations.

Health care disparities are primarily documented within African
American, and Latino/a patient populations. Fewer studies have
documented health care disparities within Asian American popu-
lations. For example, a search of the terms “African American”
and “health disparity” in PubMed yields 974 results. A search for
“Asian American” and “health disparity” yields 124. This reflects

the fact that, in some cases, after controlling for factors such as
age, gender, income, and insurance type, Asian Americans fare
similarly to White populations and disparities are minimal. It also
reflects that fact that very few studies include Asian American
populations in their samples and existing disparities are going
undocumented (Williams & Mohammed, 2009).

Known instances of disparities in health within the Asian Amer-
ican population are diabetes and certain cancers. Asian Americans
are about 30% more likely to have Type 2 diabetes than White
counterparts despite a lower body mass index (BMI), lower levels
of alcohol consumption, and lower rates smoking (Lee, Brancati,
& Yeh, 2011). Although both ethnic groups have increased in
diabetes prevalence rates over the last decade, the gap between
Asian Americans and Whites has remained stable (Lee et al.,
2011). Compared with other racial and ethnic groups, Asian Amer-
icans are also disproportionately infected with the chronic hepatitis
B virus, which is the leading cause of primary liver cancer (Misra
et al., 2013).

Heart disease is the leading cause of death of all adults in the
United States today except Asian Americans where the leading
cause of death is cancer (Murphy, Xu, & Kochanek, 2012). Cancer
accounts for 27% of all deaths among Asian Americans (National
Center for Health Statistics, 2011). This finding is not associated
with Asian Americans having a longer life expectancy than Whites
(U.S. Census Bureau, 2008). Cancer mortality rates among Asian
Americans relative to other ethnic groups are elevated due to Asian
Americans not being diagnosed until they have more advanced
stages of cancer, when survival rates are poorer (Smigal et al.,

Alicia Y. Ibaraki, Department of Psychology, University of Oregon;
Gordon C. Nagayama Hall, Department of Psychology and Center on
Diversity and Community, University of Oregon; Janice A. Sabin, Depart-
ment of Biomedical Informatics and Medical Education, University of
Washington.

Correspondence concerning this article should be addressed to Alicia Y.
Ibaraki, Department of Psychology, University of Oregon, Eugene, OR
97403. E-mail: ayee@uoregon.edu

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Asian American Journal of Psychology © 2014 American Psychological Association
2014, Vol. 5, No. 1,

– 81 1948-1985/14/$12.00 DOI: 10.1037/a0036114

mailto:ayee@uoregon.edu

http://dx.doi.org/10.1037/a0036114

2006). This suggests that either cancer treatment or cancer pre-
vention measures are not as effective within this population.
Screening rates for cervical and breast cancer in Asian American
women, and colorectal cancer in Asian American women and men
(see Table 1) are well below those of any other ethnic group (Ho
et al., 2011; Jun & Oh, 2013; Lee et al., 2010; U.S. Cancer
Statistics Working Group, 2012; Wu et al., 2005), and this health
care disparity persists after adjusting for access to care (King,
2012).

Colorectal Cancer Screening

Although acknowledging that there are important ethnic differ-
ences in cancer incidence and mortality rates (for a review see
Miller, Chu, Hankey, & Reis, 2008) we highlight colorectal cancer
because overall, among Asian Americans, colorectal cancer is the
second most commonly diagnosed cancer and the third highest
cause of cancer-related mortality (Wong, Gildengorin, Nguyen, &
Mock, 2005). Additionally, unlike breast and cervical cancer
screening guidelines which have undergone recent changes mak-
ing it less clear how often and at what age screenings are recom-
mended, the clinical guidelines for colorectal cancer are very clear.
Screenings are recommended for all individuals, regardless of
race, starting at age 50, and there is a high certainty that screenings
substantially reduce colorectal cancer mortality (U.S. Preventive
Services Task Force, 2011). Despite these guidelines, data from
the 2001, 2003 and 2005 California Health Interview Survey
(CHIS) found that as an aggregated group, Asian Americans’
colorectal screening (46.8%) was lower than that of non-Hispanic
Whites (57.7%; Lee, Lundquist, Ju, Luo, & Townsend, 2011). In
addition to lower screening rates, CHIS (2005) data also demon-
strated that rates of physician recommended cancer screening
among Asian Americans are disproportionately lower than justi-
fied by the relatively small ethnic group differences in cancer and
mortality rates (U.S. Cancer Statistics Working Group, 2012).
Colon testing of any type was recommended during the past 5
years by physicians for 48% of non-Hispanic White patients but
for only 27% of Asian American patients, controlling for age
(CHIS, 2005).

In a national sample of Japanese Americans, only 23% of those
who had received any type of colorectal screening in the last 5
years did so at the recommendation of a physician (Honda, 2004).

Additionally, when a physician did recommend screening, 66%
(fecal occult blood testing) and 71% (sigmoidoscopy/colonoscopy)
of patients followed through with the screening versus 28% and
12%, respectively, when no recommendation was made (Honda,
2004). In a more recent sample of older Korean Americans, only
29% had ever received a screening recommendation from their
doctor, although follow through rates (45%) were lower than in the
Honda (2004) study (Jo, Maxwell, Wong, & Bastani, 2008). The
reason for physicians’ low rate of recommendation for colorectal
cancer screening of Asian American patients remains unclear.

Regardless of patient demographic factors, physicians should
adhere to clinical guidelines for colorectal cancer screening. Even
though physicians are not able to control whether their patients are
actually following through with their medical advice, or cite con-
cerns that Asian American patients do not understand the role of
preventative medicine (Bodle et al., 2008), there is no clinical
rationale for racial or ethnic differences in the rate that physicians
are making the recommendation for colorectal cancer screening.
The act of physician recommendation is important in and of itself.
Patients who follow through with cancer screenings often cite
physician recommendation as the most important factor in them
getting the test (Honda, 2004; Jo et al., 2008; Ma et al., 2012).
Because regular cancer screenings have been shown to effectively
reduce cancer mortality rates (Nelson et al., 2009; Pignone, Rich,
Teutsch, Berg, & Lohr, 2002), it is puzzling that a group in which
cancer is the leading cause of death would also have the lowest
physician recommended cancer screening rates.

In this article we seek to explain this cancer screening disparity
in Asian American populations by formulating a working heuristic
model integrating the model minority myth and social information
processing. Specifically, we focus on the physician decision mak-
ing process for cancer screening among Asian American men and
women.

A Conceptual Model of Physician Cancer Screening

When an adult turns 50 years of age, clinical guidelines state
that physicians should recommend screening for colorectal cancer
regardless of gender or ethnicity (U.S. Preventive Services Task
Force, 2011). Figure 1 represents our hypothesized model of the

Table 1
Cancer Screening Percentages by Cancer Site and Race

Race
Breast
cancer1

Cervical
cancer2

Colorectal
cancer3

White 72.8% 83.4% 59.8%
Black/African American 73.2% 85.0% 55.0%
Asian 64.1% 75.4% 46.9%
Overall 72.4% 83.0% 58.6%

Note. Data is from the National Health Interview Survey, United States,
2010, as reported in King, 2012.
1 Mammography within 2 years among women aged 21– 65 years with no
hysterectomy. 2 Pap test within 3 years among women aged 21– 65 years
with no hysterectomy. 3 (a) Annual high-sensitivity fecal occult blood
testing, (b) sigmoidoscopy every 5 years combined with high-sensitivity
fecal occult blood testing every 3 years, or (c) screening colonoscopy at
intervals of 10 years among persons aged 50 –75 years.

Explicit Health
Stereotypes

Physician Characteris�cs
(gender, ethnicity,

language, experience)

Implicit Health
Stereotypes

Pa�ent Factors
(demographic,

structural, cultural)

Recommenda�on for
cancer screening

made?
Y/N

Provider Decision
Making

Figure 1. Proposed mechanisms by which health stereotypes influence
lower cancer screening rates.

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76 IBARAKI, HALL, AND SABIN

effects of bias and stereotypes on physician decision making
behavior to recommend screening when working with Asian
American patients. Although in this article we focus mostly on
physician and patient-level variables, we also acknowledge that
physicians and patients operate within a health care system that
can perpetuate disparities in the way that health care organizations
are organized, financed, and to the extent that they are or are not
equally accessible (Smedley et al., 2002). The role of organizations
in perpetuating cancer screening disparities is beyond the scope of
this article, but should be considered in future research.

Patient Factors

The path from patient factors to provider decision making
reflects the hypothesis that patient factors can contribute to cancer
screening disparities. Demographic factors such as younger age
(Honda, 2004; Yoo, Le, Vong, Lagman, & Lam, 2011) or low
levels of acculturation (Lee, Ju, Der Vang, & Lundquist, 2010;
Wu, West, Chen, & Hergert, 2006; Yoo et al., 2011), and structural
barriers such as not having insurance (Honda, 2004; Lee et al.,
2010; Ma et al., 2012), or not having a usual source of care
(Honda, 2004; Lee et al., 2010), have all been identified as patient
related factors that reduce the likelihood of Asian Americans
having been screened. However, screening rates are disproportion-
ately low after taking into account some of these structural barri-
ers. A national study of Japanese Americans with elevated risk for
colorectal cancer due to age or personal medical history found that
although 84% reported having regular access to care, 63% were
never advised by their physician to get colorectal cancer screening
(Honda, 2004). In a subsample of Korean Americans, all who had
a primary care physician and regular checkups, only 25% had
received screening (Jo et al., 2008).

In addition to structural barriers, patient cultural barriers may
also exist. For example ideas about fatalism and not fighting what
is destined by nature, are rooted in Buddhist beliefs. Holding
fatalistic attitudes, such as the belief that regardless of behavior
and lifestyle choices, a person cannot alter their chances of devel-
oping cancer, have been linked to lower rates of colorectal screen-
ing in an Asian American sample (Jun & Oh, 2013). Fatalistic
beliefs could deter medical help-seeking behaviors as the value of
preventive medicine and screening measures seem diminished.
However, CHIS (2005) data show that within the last 12 months,
a larger percentage of Asian Americans (18.9%) had seen a doctor
about their health than Whites (12.9%). This suggests that despite
possible cultural beliefs, Asian Americans are not overly averse to
medical help-seeking.

A patient’s ability to communicate with their physician is an-
other important patient factor. The quality of physician–patient
communication influences patient satisfaction (Cousin, Schmid
Mast, Roter, & Hall, 2012) and adherence to physician recommen-
dations (Zolnierek & DiMatteo, 2009). Communication is partic-
ularly important when physicians and patients start out with ex-
tremely disparate explanatory models of the illness, which may be
more common when physicians and patients come from different
cultural backgrounds (Ashton et al., 2003). Good communication
allows physicians and patients to agree on a shared explanatory
model for an illness which, in turn, influences patient adherence,
satisfaction, and ultimately, health outcomes (Ashton et al., 2003).
Verbal dominance on the part of the physician is associated with

lower levels of patient disclosure, which can have negative effects
on medical outcomes (Mast, Hall, & Roter, 2008).

In a review of real-world videotaped clinical interactions, John-
son, Roter, Powe, and Cooper (2004) found that physicians were
significantly more verbally dominant and engaged in significantly
less patient-centered communication with African American pa-
tients compared with White patients. They also displayed less
positive affect in interactions with minority patients. Cooper et al.
(2012) found that physician verbal dominance and positive affect
in these same clinical encounters were correlated with pro-White
implicit attitudes or bias. Implicit refers to attitudes and stereo-
types that are outside of an individual’s awareness and are not
available to report. (Greenwald & Banaji, 1995). Implicit attitudes
and stereotypes can exist even among individuals who endorse
egalitarian beliefs (Dovidio & Gaertner, 2000). In the Cooper et al.
(2012) study, as implicit pro-White bias increased, physicians
were more verbally dominant and displayed lower levels of posi-
tive affect. Physicians with higher pro-White implicit bias were
also likely to use slower speech, and less patient-centered dialogue
with ethnic minorities. Patients were more likely to rate these
physicians as less likable, less likely to treat them with respect, and
had lower levels of trust and confidence in their recommendations.

The quality of communication is particularly salient in Asian
American populations, where a larger number of patients have
limited English language abilities compared with White or African
American patients. Over 1.5 million Asian American or Pacific
Islander households live in linguistic isolation, meaning that there
is no one above the age of 14 that speaks English “very well”
(Smedley et al., 2002). This includes over half of the Hmong,
Cambodian, and Laotian families in the United States (Smedley et
al., 2002). In California, only 56% of Asian adults report that they
speak English in the home (AHRQ, 2012). In a recent study, 19%
of recent immigrants reported experiencing language discrimina-
tion in medical care settings during the previous 2 years (Yoo,
Gee, & Takeuchi, 2009). Being treated differently based on how
well you speak English, also known as language discrimination, by
a doctor or other medical staff is a significant predictor of the
number of chronic conditions a patient has (Yoo et al., 2009).

Physician Factors

Synthesizing social cognition and provider behavior research,
van Ryn and Fu (2003) proposed a model that explains the role of
well-meaning physicians in inadvertently contributing to health
disparities. A key component in their model is the provider’s
conscious (explicit) and unconscious (implicit) beliefs about the
patient. Physician beliefs about the patients’ race and ethnicity can
influence how the physician interprets the patient’s report of
symptoms, their diagnostic decisions, and treatment recommenda-
tions like needing cancer screening. In a vignette study, Green,
Carney, Pallin, Raymond, Iezzoni, and Banaji (2007) demon-
strated that implicit stereotypes about a patient’s level of cooper-
ativeness based on their race changed the likelihood of physicians
offering treatment to a patient complaining of chest pain. The
stronger the stereotype that black patients were uncooperative, the
more physicians were likely to perform a procedure on White
patients but not on Black patients.

The role of explicit and implicit stereotypes about Asian Amer-
icans in influencing decision making about recommending cancer

77HEALTH STEREOTYPES AND CANCER DISPARITIES

screening are represented by two distinct paths within the model.
In a study of over 2,500 doctors, pro-White implicit and explicit
biases were only modestly correlated, suggesting that they are
distinct processes (Sabin, Nosek, Greenwald, & Rivara, 2009). It is
possible that physicians may explicitly hold egalitarian beliefs, but
implicitly ascribe to biases about ethnic minority patients that
influence their decision making about recommending cancer
screening.

The paths from physician characteristics to explicit and implicit
stereotypes as well as directly to decision making represents the
hypothesis that physician characteristics such as ethnicity or gen-
der affects both implicit and explicit biases they held and the
clinical encounter. Sabin, Nosek, Greenwald, and Rivara (2009)
found evidence that preference for White Americans over Black
Americans varied as a function of physician race/ethnicity. Pref-
erence for White Americans was strongest for White physicians,
but present among physicians of all race/ethnic backgrounds, ex-
cept for African American physicians, who, on average, did not
show an implicit preference for either White Americans or Black
Americans. Both implicit and explicit biases also varied by gender
with male physicians showing stronger implicit and explicit pref-
erences for White Americans that than female physicians did
(Sabin et al., 2009).

Physician characteristics also affect the clinical encounter and
decision-making processes. Patients who had recently attended a
medical appointment were asked to rate the extent to which their
physician involved them in their appointment through consensus
seeking, and other forms of communication known as “participa-
tory decision making.” Participatory decision making is linked to
higher levels of patient satisfaction. Although African Americans
rated their visits as less participatory overall, both African Amer-
ican and White patients rated the visits as significantly more
participatory when they saw race-concordant physicians (Cooper-
Patrick et al., 1999). Female physicians were also rated as more
participatory than male physicians across all races/ethnicities
(Cooper-Patrick et al., 1999). There is also evidence that informa-
tion about patient race may affect male and female patients dif-
ferently. In a vignette study where patients suffered from identical
pain symptoms, and varied only in race and gender, male physi-
cians prescribed twice the dosage of pain medication for White
patients compared with African American patients (Weisse, So-
rum, Sanders, & Syat, 2001). Female physicians did the opposite
prescribing in higher dosages to African American patients.

Physicians may be particularly susceptible to cognitive short
cuts. They are constantly faced with a complex array of patient
information and limited time in which to process this information
to make diagnostic decisions. Human information processing in-
volves two modes, commonly referred to as “System 1” and
“System 2.” System 1 is an intuitive mode in which decisions are
made automatically and rapidly; System 2 is a controlled mode,
which is deliberate and slower (Kahneman, 2003). Because of time
constraints, physicians often employ System 1 in decision making
(Croskerry, 2009; Ely, Graber, & Croskerry, 2011). System 1 is
unable to process and interpret all the information available. In
order to efficiently process information, humans use short cuts
known as heuristics (Kahneman, Slovic, & Tversky, 1982). Two
common heuristics that may facilitate the diagnostic process are
representativeness and availability. Representativeness in a diag-
nostic context is used to judge how similar the patient is to the

typical person with the disorder. Availability involves diagnostic
information that is easily accessed or recalled. The use of heuris-
tics based on biased information such as ethnic group stereotypes,
however, can result in errors (Kahneman & Klein, 2009). Given
prior research in this area, we expect that stereotypes about the
Asian American population may contribute to disparities in cancer
screening recommendations which likely leads to disparities in
actual cancer screening.

The most well-known stereotypes about Asian Americans are
those perpetuated by the model minority myth. This term was
coined in the 1960s in the midst of the civil rights movement as a
way to prove that all races could be successful if they just worked
hard enough, and as an excuse to ignore institutionalize and
systemic racism (Gupta, Szymanski, & Leong, 2011). Over 50
years later, it is still a commonly held belief in the United States
(Chao, Chiu, Chan, Mendoza-Denton, & Kwok, 2012). Asian
Americans are stereotyped as quiet, hardworking, intelligent, and
disciplined. Model minority myth theory postulates that Asian
Americans have been stereotyped as a group that is more success-
ful than any other ethnic minority group, does not face societal
barriers, and therefore does not need help (Yoo, Burrola, & Steger,
2010).

The paradox in considering Asian American stereotypes and
disparities is that many stereotypes about Asian Americans sound
positive, and one would generally expect disparities rooted in bias
or discrimination to stem from negative stereotypes. Indeed, in the
stereotype literature, negative stereotypes that result in hostility or
other negative outcomes have historically received the most atten-
tion. Yet seemingly innocuous, or even complementary, positive
stereotypes can also have deleterious effects. In a recent study,
Asian American participants who heard positive stereotypes about
their group (e.g., Asians are good at math) experienced greater
negative emotions than participants who did not hear a stereotype
(Siy & Cheryan, 2013). Positive stereotypes are damaging because
they base the admired quality solely on group membership instead
of individual characteristics. They are restricting and can general-
ize identities and traits of groups to individuals where they do not
apply (Czopp, 2008). Model minority stereotypes of Asian Amer-
icans may lead to the perception that they do not need or deserve
help. Such stereotypes of Asian American self-sufficiency may
also generalize to Asian American health.

The general public may perceive Asian Americans to be health-
ier than other ethnic groups. We asked 351 undergraduates which
ethnic group (African Americans, Asian Americans, Hispanics, or
Whites) is least likely to suffer from a number of health conditions,
including stroke, diabetes, alcoholism, obesity, heart disease, and
cancer. The sample was 66% female and had a mean age of 19.6
years. Participants were primarily White (74%), followed by Asian
American (14%), more than one race (4%), and Latino/a (3%).
Native populations and African Americans each constituted less
than 2% of the sample. Respondents were significantly more likely
to choose Asian Americans as the least likely to suffer from all
diseases. These perceptions may be rooted in relatively low rates
of obesity (Shariff-Marco, Klassen, & Bowie, 2010), drinking
(Chartier & Caetano, 2010) and, among Asian American women,
smoking (Chae, Gavin, & Takeuchi, 2006). Moreover, generally,
the prevalence of cancer is somewhat lower among Asian Amer-
icans than among other groups (National Center for Health Statis-
tics, 2011). Physicians may also endorse these common beliefs.

78 IBARAKI, HALL, AND SABIN

However, there is a danger in over-generalizing these character-
izations. Perceptions of excellent health among Asian Americans
do not justify lower rates of cancer screening recommendations, as
failure to screen is associated with disproportionately high rates of
cancer-related deaths among Asian Americans (National Center
for Health Statistics, 2011).

Model minority stereotypes concerning East Asians may be
more pervasive than for other Asian groups (e.g., Southeast
Asians, Filipino/as) in part because East Asians are the largest
group of Asian Americans. There is heterogeneity across Asian
American ethnic groups, but at this stage our goal is to identify a
general bias. Moreover, many physicians are not sufficiently fa-
miliar with Asian Americans to hold Asian American ethnic
group-specific biases (e.g., Korean Americans) and they may not
be able to distinguish one Asian American ethnic group from
another based on appearance.

Future Research Directions

We contend that as research continues to look into the role bias
and stereotypes play in perpetuating health disparities, the role of
positive stereotypes should not be overlooked. Positive stereotypes
may not seem to be as harmful as negative ones, but may help to
account for a portion of health care disparities, such as differences
in recommendations for cancer screening in certain populations.
Additional research is needed to determine if the idea of the
“healthy Asian American” is not only a lay belief, but is held by
physicians as well. If the positive stereotype is present, the next
step would be to understand how these stereotypes influence
decision making, and then to develop interventions to reduce the
impact of these biases. Because the link between implicit and
explicit biases is modest, and because individuals are not always
conscious of or willing to report their biases, future research on
these stereotypes should target both explicit and implicit biases.
Explicit bias can be assessed with the Internalization of the Model
Minority Myth Measure (Yoo et al., 2010). The Unrestricted
Mobility subscale of this measure, which assesses the belief that
Asian Americans do not face societal barriers, is particularly
relevant. It is possible that physicians who adhere to this belief
may not believe that Asian Americans merit as much medical
attention as other groups.

Prior studies have demonstrated that implicit attitudes influence
physicians’ clinical decisions such as pain medication prescribing
behavior (Sabin & Greenwald, 2012) and treatment planning (Bo-
gart, Catz, Kelly, & Benotsch, 2001; Green et al., 2007). Implicit
pro-White bias was assessed with the Implicit Attitudes Test (IAT)
in which test takers quickly categorize facial images and value-
laden words. Pro-White bias is present when participants are
quicker to associate White faces with “good” words (e.g., joy,
love) relative to Black faces and slower to associate White faces
with “bad” words (e.g., agony, terrible) relative to Black faces. As
physicians’ implicit pro-White race bias decreased, prescribing a
pain medication, which was the appropriate medical treatment for
the scenario, significantly increased for African American patients
(Sabin & Greenwald, 2012). In another vignette study, physicians
were less likely to recommend more aggressive HIV treatment that
has been shown to reduce mortality and morbidity for African
American patients based on implicit assumptions about patient
cooperation and adherence to treatment (Bogart et al., 2001).

The IAT could be adapted to assess physicians’ medical biases
toward Asian American patients by examining an implicit stereo-
type of excellent Asian American health. It is possible that phy-
sicians’ underscreening is associated with beliefs of Asian Amer-
ican health as not simply good but excellent such that Asian
Americans are viewed as in less need of cancer screening than
other groups. Words such as robust, hearty, strong, vigorous, and
excellent could be used to represent the concept of “excellent
health.” For “good health,” words such as adequate, okay, good,
satisfactory, acceptable could be used. Using facial images of
Asian Americans and White Americans in the IAT methodology,
a stronger association with Asian Americans and the concept of
excellent health than with White Americans and the concept of
excellent health would be evidence of pro-Asian health bias.
Physicians having a pro-Asian health bias may be less likely to
make necessary cancer screening recommendations for Asian
Americans.

The error choice technique, an early indirect measure of atti-
tudes, may also be a useful way of assessing physician biases about
Asian American health (Hammond, 1948). In the error choice
technique, individuals are forced to answer factual questions to
which it is unlikely they know the answer (e.g., Per 100,000
individuals, what is the death rate from breast cancer in Asian
American women? (a) 3.5, (b) 7.8, (c) 12.4, (d) 18.2). Of the
answer choices provided, none is actually the correct answer
(which here is 10.7), but instead either overestimate or underesti-
mate the actual answer. Individuals have no choice but make an
error which is informative in both magnitude and direction. Over
a number of items, a guess pattern that is consistent with their
attitude may emerge. For example, one participant may always
slightly underestimate the prevalence, risk, or severity of cancer in
Asian Americans, yet another participant may always grossly
overestimate it.

Conclusion

Cancer is the leading cause of death for Asian Americans, yet
the rate of cancer screening among Asian Americans is lower than
in White Americans. One factor in this disparity is that physicians
recommend screening at lower raters for Asian Americans com-
pared with other populations. Although physicians cannot control
if patients actually follow through on their recommendations, there
is no reason that they should not be adhering to national guidelines
and making screening recommendations. Given the role of stereo-
types and heuristics in decision making processes, we suggest that
stereotypes about Asian American health may be contributing to
underscreening. Our conceptual model may guide future research
to identify the mechanisms of screening bias.

The goal of the approach developed in this article is to reduce
cancer screening disparities for Asian Americans. Physician edu-
cation should devote attention to the fact that Asian Americans are
the only U.S. ethnic group for whom cancer is the leading cause of
death. Awareness of underscreening for cancer among Asian
Americans should be another component of physician education.
To the extent that model minority health stereotypes are demon-
strated to influence underscreening, counterstereotypic informa-
tion about Asian American health and cancer would also be
important for physician education.

79HEALTH STEREOTYPES AND CANCER DISPARITIES

Despite the urgent need to address Asian American cancer
disparities, there is a paucity of research on this topic. Unfortu-
nately, the very model minority health stereotype that we describe
in this article may result in the neglect of Asian American health
needs, similar to the neglect of Asian American mental health
needs (Hall & Yee, 2012). The reduction of Asian American
cancer disparities will not occur unless it becomes a national
priority for policy, funding, research, training, and interventions.

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Received November 18, 2013
Revision received January 22, 2014

Accepted January 23, 2014 �

81HEALTH STEREOTYPES AND CANCER DISPARITIES

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Asian American Cancer Disparities: The Potential Effects of Model Minority Health Stereotypes

Colorectal Cancer Screening
A Conceptual Model of Physician Cancer Screening
Patient Factors
Physician Factors
Future Research Directions
Conclusion
References

The American Journal of Drug and Alcohol Abuse, 36:

214

–219, 2010
Copyright © Informa Healthcare USA, Inc.
ISSN: 0095-2990 print / 1097-9891 online
DOI: 10.3109/00952990.2010.493593

Risk and Protective Factors of Alcohol Use Disorders among
Filipino Americans: Location of Residence Matters

Wooksoo Kim, Ph.D., M.S.W.
School of Social Work, University at Buffalo, The State University of New York, Buffalo, New York, USA

Isok Kim, L.C.S.W. M.S.W., M.A.
School of Social Work, University of Michigan, Ann Arbor, Michigan, USA

Tom H. Nochajski, Ph.D.
School of Social Work, University at Buffalo, The State University of New York, Buffalo, New York, USA

Background: Despite the growing number of Asian Americans
(AA) in the United States, research on alcohol abuse in this popula-
tion is sparse. Although AA have few alcohol use disorders (AUD)
as an aggregate group, within-group variations in AUD need to
be explored among specific ethnic groups in this population. Ob-
jectives: This study compared correlates of 12-month prevalence
of AUD between Filipino Americans who currently drink alcohol
and live in San Francisco (SF) or Honolulu. Methods: Data from the
1998–1999 Filipino American Community Epidemiological Survey
(N = 537) were used to test two hypotheses: 1) current drinkers in
SF and Honolulu will differ in the characteristics and prevalence of
AUD and 2) current drinkers in SF and Honolulu do not share the
same protective and risk factors of AUD. Results: Current drinkers
from the two regions substantially differed in age, years of educa-
tion, age at first drink, religiosity, ethnic identity, psychological dis-
tress, the nativity status, as well as the prevalence of AUD. Logistic
regression models revealed that AUD risk factors were different
for SF current drinkers (higher psychological distress, U.S.-born,
and lower religiosity) compared to Honolulu drinkers (more years
of education and lower emotional support). Conclusion: Filipino
American drinkers living in SF and Honolulu have different risk
and protective factors for AUD. Health professionals need to be
aware of this difference when screening for factors associated with
AUD among Filipino Americans. Scientific Significance: The cur-
rent study revealed the importance of socioenvironmental context
(location of residence) in predicting AUD among an Asian ethnic
group.

Keywords Acculturation, alcohol use disorder, Asian Americans,
emotional support, Filipino Americans, mental health, so-
ciocultural contexts

Address correspondence to Isok Kim, School of Social Work,
University of Michigan, Ann Arbor, Michigan, USA. E-mail:
kimisok@umich.edu

INTRODUCTION
Asian Americans (AA) are the fastest growing and most di-

verse segment of the U.S. population (1), yet they are not well
represented in studies examining alcohol abuse and dependence
(2–4). In national surveys, AA are shown to have consistently
lower rates of alcohol use disorders (AUD) (i.e., alcohol abuse
and dependence) compared with other ethnic groups (5). How-
ever, recent studies also point to the increasing trend of preva-
lence and risk for AUD among AA (6).

More importantly, there are substantial variations in the pat-
terns of alcohol consumption, AUD, and the associated risk fac-
tors among AA (2). Alcohol use among Asians has been found
to be related to specific ethnic group membership (7, 8), and
nativity and gender (9). Thus, studies that aggregate Asian eth-
nic groups may gloss over significant within-group differences
and may perpetuate the myth of model minority (10). There-
fore, it is important for researchers to pay special attention to
variations within the AA population when considering alcohol
consumption and AUD.

Current research findings on the general population indicate
a number of risk factors associated with AUD: having the first al-
coholic drink at a young age (11, 12), lower educational achieve-
ment (13–15), lower religious participation (16, 17), and higher
psychological stress (18–21). However, AUD risk and protec-
tive factors may not be consistent across AA ethnic groups for
the following reasons. First, acculturation is considered an im-
portant moderating factor on certain mental health outcomes,
including AUD, for Asian ethnic groups. For example, Hender-
shot and colleagues (22, 23) found that while acculturation was
a risk factor for young Korean adults’ drinking behavior, it was a
negligible factor among their Chinese counterparts. Second Na-
tivity (being U.S.-born) may also be an important factor since
studies have shown that U.S.-born AA are at greater risk for de-
veloping AUD (24). Among young college students, Chinese,

214

ALCOHOL USE DISORDER AMONG FILIPINO AMERICANS 215

Filipino, Korean, and Vietnamese female undergraduates who
were born in the United States were at higher risk for increased
alcohol use compared to foreign-born females (9).

FILIPINO AMERICANS IN SAN FRANCISCO
AND HONOLULU

After the Immigration and Nationality Act of 1965 lifted
national-origin quotas, a large number of Asians immigrated to
the United States. In many cases, Filipino American immigrants
face an arduous task acculturating to U.S. society. However,
acculturative stress may depend on the specific interaction be-
tween an individual and his/her sociocultural environment. The
different reasons for immigrating to the United States may en-
gender different sociocultural environments with respect to the
level of family and community support, with the latter serving
as a buffer for negative outcomes (26). Filipinos immigrating
to Hawaii (Honolulu) did so to join their families, whereas
those who migrated to California (San Francisco [SF]) did so to
find employment (25). In addition, Asian and Pacific Islanders
(API) comprise a majority of the Honolulu County population
(52.1%), whereas the proportion of API is only 31.8% in SF
County (33). Due to the differences in the sociocultural envi-
ronments resulting from the reasons for immigrating, the same
ethnic group may experience differential adaptive and accultura-
tive stress. This may in turn result in differential health behavior
outcomes, such as AUD.

In this study, we compared the risk and protective factors of
AUD for Filipino American drinkers by location of residence
(SF versus Honolulu). We hypothesized the following: 1) Fil-
ipino American current drinkers in SF and Honolulu will differ
in the characteristics and the prevalence of AUD and 2) protec-
tive and risk factors for AUD will differ for Filipino American
current drinkers in SF and Honolulu.

METHODS

Sample
We analyzed data from the 1998–1999 Filipino American

Community Epidemiological Study (FACES). Data and a de-
tailed description of the sampling procedure can be found else-
where (27, 28). Using a stratified probabilistic sampling tech-
nique, only one eligible person was randomly selected for an
interview from each targeted household in Honolulu and SF. Re-
spondents were required to be of Filipino descent and between
the ages of 18 and 65 years. On average, 90-minute interviews
were conducted using the language that the respondents pre-
ferred, including English, Tagalog, or Illocano. A total of 2,285
interviews were completed from solicited households, which
reflected a response rate of 78%. Of the 2,285 total respondents
in the FACES study, our study used 537, who were identified as
current drinkers who consumed alcohol at least once in the past
12 months.

Measures
Alcohol Use Disorders (AUD)

Respondents who met the criteria for alcohol abuse or de-
pendence in the past 12-months according to Diagnostic and
Statistical Manual of Mental Disorders, Fourth edition (DSM-
IV) (29) were positively identified as cases with AUD (1 =
AUD, 0 = normal drinkers).

Age at First Drink
Age at first drink was measured based on respondents’ self-

reported age when they first drank alcohol intentionally.

Psychological Distress
Psychological stress was measured using a 20-item subscale

from the Symptom Checklist-90-Revised (SCL-90-R) (30), item
choices ranged from not at all (1) to extremely (5). The Cron-
bach’s alpha was .92 for the study sample.

Ethnic identity
Ethnic identity was measured by a 9-item scale derived from

the Multiethnic Identity Measure (MEIM) (31). A 4-point rating
scale, ranging from Strongly agree (1) to Strongly disagree (4),
was used to assess respondents’ level of ethnic identify. The
Cronbach’s alpha for this scale was .74 for the sample.

Acculturation
Nativity, years in the United States, age at immigration, and

English language proficiency were considered as proxies for
acculturation. After preliminary analyses indicated that includ-
ing all of these variables caused multicollinearity problems and
that the variable nativity was able to explain the largest vari-
ance in the regression model, Nativity was selected to report the
acculturation status (U.S.-born = 1, immigrants = 0).

Religiosity
Religiosity was measured using 3 items and reflected the fre-

quency of attendance at various religious and spiritual activities
or events, using a 5-point scale ranging from never (1) to once a
week or more (5), with the higher number indicating high levels
of religiosity. The Cronbach’s alpha for this scale was .72 for
the sample.

Emotional Support
Twenty items asked about the degrees to which the respon-

dents perceived emotional support from their spouse/partner,
relatives, and friends. The responses ranged from none at all (1)
to a lot (4). The Cronbach’s alpha for this scale was .91 for the
sample.

Years of Education
The number of years of education was used as a proxy for

socioeconomic status (SES). Initially, monthly income, employ-
ment status, and years of education were considered. Due to

216 W. KIM ET AL.

potential multicollinearity issues, the years of education, which
explained the largest variance, was included as the proxy for
SES in the model.

Demographic Variables
Demographic variables included age, gender (male = 1, fe-

male = 0), and marital status (married/cohabiting = 1, single,
divorced, separated, or widowed = 0).

Analyses
STATA 10.1 svy (32) commands were used to take into

account the sample design effects so that we could estimate
standard errors in the presence of stratification of probability
sampling. We used the bivariate analyses and examined the
Variance Inflation Factor (VIF) scores to rule out violations
of multicollinearity. In the descriptive analyses, variables were
compared between the SF and Honolulu samples using t-test
statistics for continuous variables or chi-square test for cate-
gorical variables. A series of logistic regression analyses were
conducted to identify protective and risk factors for SF and
Honolulu sample. First, hierarchical logistic regression analy-
ses testing the interaction effects were performed to determine if
the stratified analyses by region was warranted. Then a stratified
logistic regression model by location of residence (SF versus
Honolulu) was used to test the study’s hypotheses.

RESULTS

Descriptives
Table 1 presents weighted descriptive statistics on the vari-

ables included for overall current drinkers and by San Francisco
and Honolulu groups. The overall sample had a majority of
males (74.5%) with an average age of 38.7 years (range: 18 to
65 years), and about 56% of the sample was married/cohabiting.
The mean age at first drink was 16.7 years, with an AUD rate of
9.2%.

Gender composition, marital status, and emotional support
were not significantly different between the two subgroups.
However, relative to the individuals in the Honolulu group, in-
dividuals in the SF group were significantly younger and more
educated. They also reported higher levels of psychological dis-
tress and religious participation, lower levels of ethnic identity,
and were less likely to be native born. Additionally, they had
a higher prevalence of AUD and initiated their first drink at a
younger age than the Honolulu group. When analyzed by nativ-
ity and location of residence, Filipino immigrants in Honolulu
had the lowest AUD rate (2.8%), followed by U.S.-born Filipino
Americans in Honolulu (7.9%) and Filipino immigrants in SF
(9.3%). U.S.-born Filipino Americans in SF had the highest
(24.4%)—a more than 8-fold difference in the prevalence rate,
compared to Filipino immigrants in Honolulu.

TABLE 1.
Selected descriptive statistics among Filipino American current drinkers: 1998–1999, Filipino American Community

Epidemiological Study (FACES).

San Francisco (n = 317) Honolulu (n = 220)
All Current Drinkers

(N = 537)
Location of Residence 58.0% (.02) 42.0% (.02) 100%
Age† 37.4 (.75) 40.4 (.85) 38.7 (.57)
Gender

Male 74.0% (.03) 75.2% (.03) 74.5% (.02)
Female 26.0% (.03) 24.8% (.03) 25.5% (.02)

Marital Status
Married/Cohabit 53.9% (.03) 59.1% (.04) 56.0% (.02)
S/D/S/W 46.1% (.03) 40.9% (.04) 44.0% (.02)

Years of education‡ 14.5 (.12) 11.1 (.34) 13.1 (.18)
Age at first drink∗ 16.4 (.25) 17.2 (.30) 16.7 (.19)
Religiosity‡ 2.90 (.07) 2.52 (.07) 2.74 (.05)
Ethnic identity‡ 3.39 (.03) 3.59 (.03) 3.47 (.02)
Psychological distress† 1.45 (.03) 1.32 (.04) 1.40 (.02)
Emotional support 3.41 (.04) 3.48 (.05) 3.44 (.03)
Nativity‡

U.S. born 28.0% (.03) 45.4% (.04) 35.3% (.02)
Immigrant 72.0% (.03) 54.6% (.04) 64.7% (.02)

Alcohol use disorder (AUD)† 12.3% (.02) 5.0% (.02) 10.0% (.01)

Note: The analytic sample for the current study includes FACES respondents who drank alcohol in the past 12 months and who provided
complete data for all covariates. S/D/S/W = single, divorced, separated, or widowed. Standard errors are reported in parentheses.

∗p <.05; †p <.01; ‡p <.001. Bold-faced numbers indicate statistically significant differences in SF, compared to Honolulu sample.

ALCOHOL USE DISORDER AMONG FILIPINO AMERICANS 217

TABLE 2.
The results of the logit regression model with interaction terms
regressed on AUD among Filipino American current drinkers

by San Francisco and Honolulu: 1998–1999 FACES (N = 537).
Interaction between location of residence (San Francisco = 1)

and other independent variables

Interaction terms with Control Variables:
Age −.01 (.03)
Gender (male = 1) .57 (1.28)
Marital status (married = 1) .14 (.98)

Interaction terms with Main Variables:
Years of education −.24 (.14)ˆ
Age at first drink −.27 (.10)∗
Religiosity .14 (.83)
Ethnic identity −.22 (.84)
Psychological distress .80 (.64)
Emotional support 1.28 (.54)∗

Nativity (U.S.-born = 1) .18 (.69)
Constant (b) −3.49 (1.16)
Note: Only the interaction terms are reported with beta coefficients

for the purpose of providing statistical rationale for warranting subse-
quent stratified logistic regression analyses by location of residence.
All continuous variables are grand-mean centered to eliminate poten-
tial multicollinearity problem with interaction terms. Standard beta co-
efficients are reported with standard errors in parenthesis. Bold-faced
numbers indicate significant results (at ˆp < .10; ∗p < .05).

To test whether the stratified analyses by region (SF ver-
sus Honolulu) were warranted, we used the logit regression
analyses with interactions between location of residence and
other variables that included age, gender, marital status, years
of education, age at first drink, psychological distress, nativity,
religiosity, ethnic identity, and emotional support. The results
appear in Table 2 and indicate that there were significant inter-
actions between region and years of education (b = −.24; SE
= .14); region and age at first drink (b = −.27; SE = .10); and
region and emotional support (b = 1.28; SE = .54).

Table 3 shows the results of the two logistic regression analy-
ses predicting AUD. Results from two logistic regression models
stratified by region revealed different patterns in the regression
model. For the SF group, psychological distress (odds ratios
[OR] = 4.38; 95% confidence interval [CI] = 2.07, 9.24) and
nativity (OR = 2.94; CI = 1.24, 6.97) were positively associated
with having AUD. Marital status (OR = .35; CI = .13, .98), age
at first drink (OR = .84; CI = .75, .94), and religiosity (OR =
.62; CI = .42, .92) were negatively associated with having AUD.
In contrast, among the Honolulu group, years of education (OR
= 1.25; CI = 1.04, 1.50) were positively associated with having
AUD, while emotional support (OR = .40; CI = .22, .73) was
negatively associated with having AUD.

DISCUSSION
This study demonstrated a newer understanding of risk and

protective factors for AUD among Filipino American current
drinkers in SF and Honolulu. Past alcohol researchers have
pointed out the importance of within-group variation among
AA (2, 4), and recent findings have highlighted the heterogene-
ity among Asian ethnic groups regarding AUD risks (7, 22). The
present findings add to the growing body of knowledge con-
cerning the complexity of factors associated with AUD among
Filipino Americans.

Results from stratified analyses showed that the SF group
consisted of higher proportion of immigrants, who reported
more years of education, more religious participation, and
greater ethnic identity than the Honolulu group. Previous studies
have indicated that these factors have a tendency to lower risk
for AUD (24). However, the SF group (12.3%) had more than
twice the prevalence rate of AUD than those living in Honolulu
(5.0%). This outcome seems counterintuitive because the Hon-
olulu group had a higher proportion of U.S.-born individuals,
which is the group identified in the literature as having greater
risk for developing AUD (24). One reason for this counterintu-
itive finding may be related to the fact that API is the majority
of the population in Honolulu, and this may have engendered a
stronger sense of ethnic community, which has an influence on
the drinking patterns among Filipino Americans.

Almost a quarter of U.S.-born Filipino American drinkers in
SF (24.4%) had an AUD, while the prevalence rate of the Fil-
ipino U.S.-born drinkers in Honolulu was 9.3%. In other words,
U.S.-born drinkers living in SF were over 2.5 times more likely
than those in Honolulu to be at risk for AUD. This trend was con-
sistent with the immigrant groups. Filipino immigrant drinkers
living in SF had a 2.5 times higher rate of AUD (7.9%) than
their counterparts in Honolulu (2.8%). The difference between
the Filipino U.S.-born drinkers in SF and the Filipino immi-
grant drinkers in Honolulu was almost eightfold. If the data
had been aggregated, not accounting for nativity and location
of residence, the differences would have been missed, and con-
clusions would have been inaccurate. Future research needs
to further explore and explain the nature of important factors
that contribute to differences in AUD among Filipino American
drinkers.

Although we did not explore the specific question
about causality, we can speculate based on region differ-
ences. That is, Filipino Americans in Honolulu may have
more socioenvironmentally-based protection against develop-
ing AUD. This may be due to a longer immigration history
and a higher proportion of Asian populations in the surround-
ing community that may have generated a more effective social
support system. As Gee and colleagues (26) have demonstrated,
the visibility and availability of social supports from the ethnic
community are shown to protect against negative mental health
outcomes. Similarly, our results show that emotional support
protects against having AUD among Filipino drinkers in Hon-
olulu, but not those in SF.

218 W. KIM ET AL.

TABLE 3.
The results of Logistic regression analyses regressed on AUD among Filipino American current drinkers by San Francisco and

Honolulu: 1998–99 FACES.

San Francisco (n = 317) Honolulu (n = 220)
Age 1.01 (.97, 1.06) 1.02 (.97, 1.07)
Gender (1 = male) 2.24 (.64, 7.73) 1.26 (.14, 11.28)
Marital Status (1 = Married/ Cohabit) .35 (.13, .98)∗ .31 (.06, 1.56)
Years of education .98 (.81, 1.19) 1.25 (1.04, 1.50)∗

Age at first drink .84 (.75, .94)† 1.10 (.93, 1.31)
Religiosity .62 (.42, .92)∗ .54 (.11, 2.66)
Ethnic identity .88 (.32, 2.43) 1.09 (.30, 4.03)
Psychological distress 4.38 (2.07, 9.24)‡ 1.96 (.72, 5.34)
Emotional support 1.45 (.60, 3.51) .40 (.22, .73)†

Nativity (1 = U.S.-born) 2.94 (1.24, 6.97)∗ 2.04 (.75, 5.59)
Note: Odds ratios are reported with 95% confidence intervals in parenthesis. Bold-faced numbers indicate significant results (at
∗p < .05; †p < .01; ‡p < .001).

Importantly, findings from the logistic regression analyses in-
dicated that risk and protective factors of AUD were not equiv-
alent between Filipino drinkers in SF and those in Honolulu.
The results of the SF group were consistent with the current
literature (11–21). The following criteria were associated with
developing AUD: a high level of psychological distress, being
U.S.-born, having the first alcoholic drink at a younger age, and
low religiosity. Contrary to past findings, greater education sig-
nificantly increased the odds of having AUD among those in the
Honolulu group. Results from the Gilman et al. study (13), how-
ever, did find that years of education did not significantly predict
alcohol dependence in its Asian sample. Generally, most studies
suggest that the level of education is negatively associated with
AUD in the general population (13, 15), or no association in
an Asian sample (13). It is possible that for Filipino Americans
in Honolulu, the years of education engenders different social
expectations in terms of drinking alcohol and thus influences
the development of AUD in a different manner. Future studies
need to examine intervening factors responsible for the adverse
effects of years of education among Filipinos in Honolulu.

Two nonsignificant variables in both SF and Honolulu groups
are worth mentioning here. Contrary to previous findings, gen-
der was not a significant risk factor for having AUD among
drinkers in this population. In other words, female Filipino
drinkers were as vulnerable to the consequences of AUD as
male Filipino drinkers. In addition, the direction of association
between ethnic identity and AUD differed for SF and Hon-
olulu groups. This suggests that inconsistent findings regarding
the impact of ethnic identity on AUD may be explained when
researchers analyze region-specific factors. There might be un-
derlying socioenvironmental differences that interact with eth-
nic identity that need to be explored in future research among
this population.

Several limitations of this study should be noted. First, the
fact that it was cross-sectional data prevented us from claim-

ing causal relationships among variables of interests. Second,
self-reported survey designs can often influence the way that
respondents answer certain items, vis-à-vis social desirability
and recall biases. Third, despite the value of this dataset, the
data is rather dated (collected in 1999), so the results may not
be generalizable to the current Filipino population in the United
States. However, to our knowledge, this is the only data avail-
able to date that contains extensive data about alcohol abuse
and dependence in Filipino Americans, which made this study’s
analyses possible. Fourth, cross-cultural comparisons with non-
Filipino groups or Filipinos living in the Philippines would have
furthered our understanding of the etiology of AUD in this pop-
ulation, but this was not possible because the original data col-
lection was limited to Filipino Americans living in SF and Hon-
olulu. In addition, nativity was a proxy measure of acculturation,
and may not fully reflect stresses associated with acculturative
processes. Our study was not able to include potentially im-
portant factors of AUD, such as availability of alcohol. Recent
studies have also suggested that perceived racial discrimination
may be one of the critical factors influencing ethnic minorities’
health and mental health (3, 26–28). These factors should be
addressed in future studies to extricate the etiology among this
population.

Despite these limitations, our study contributed to the cur-
rent knowledgebase about AUD among Filipino Americans. We
demonstrated that important, yet rarely studied, within-group
variations, i.e., nativity and location of residence, were found
to affect the odds of having AUD. Second, our findings pro-
vide critical insight for clinicians working with the Filipino
populations in these two regions. Nationally based statistics
might provide misleading information when it is applied to
Asian ethnic groups because there is much variation within
Asian subgroups. This study demonstrated the importance of
sociocultural contexts in explaining health consequences. In this
regard, information related to health and mental health outcomes

ALCOHOL USE DISORDER AMONG FILIPINO AMERICANS 219

should be interpreted with caution considering sociocultural
environments where minority groups or Asian ethnic groups
are situated. Thus, findings from the present study may be most
useful in clinical setting where region-specific information is
more relevant, rather than national level epidemiological find-
ings.

Declaration of Interest
This study was partly supported by the Substance Abuse and

Mental Health Administration (SAMHSA) Minority Fellowship
Program (T06 SM058565-01), awarded to the second author
through the Council on Social Work Education. The authors
have no conflicts of interest to disclose. The authors alone are
responsible for the content and writing of the paper.

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CHNG ET AL.SEXUAL HEALTH AMONG AAPI MSM

A Model for Understanding Sexual Health
Among Asian American/Pacific Islander Men
Who Have Sex With Men (MSM) in the
United States
Chwee Lye Chng, Frank Y. Wong, Royce J. Park,
Mark C. Edberg, and David S. Lai

The model to understand sexual health among Asian American/Pacific Islander
men who have sex with men first locates the dynamic process in the home coun-
try, with its prevailing cultural norms including sexual mores, shame or stigma,
sexual attitudes, sexual behavior, and drug use/abuse. Second, these cultural
norms are modified by the migration/immigration experience. Third, these
norms, beliefs, and practices are continually influenced by the process of accul-
turation as these men try to adjust to life in the United States. The effects of the
first two domains may vary by the degree to which a particular immigrant com-
munity remains socially and culturally insulated from the mainstream commu-
nity. Conceivably, the effect of home country and migration/immigration would
be less significant for those who were either very young at the time of immigra-
tion or are born in the United States.

According to the Centers for Disease Control and Prevention (2001), when compared
to only men who has sex with men (MSM) in other racial/ethnic groups Asian Ameri-
can/Pacific Islander (AAPI) MSM have the second highest proportion of cumulative
AIDS cases (72%)—only 2 percentage points lower than White MSM. Proportion-
ately, AAPI MSM (53%) ranked second in number of AIDS cases in the year 2000,
again after White MSM (62%). More than half of all AAPI MSM with AIDS are born
overseas, as reported by epidemiological data (Sy, Chng, Choi, & Wong, 1998;
Wong, Crepaz, Campsmith, & Nakmura, 2002), suggesting that the cultural experi-
ences of an immigrant may have had an effect on their risk for HIV. This finding is re-
inforced by Chng and Geliga (2000) who reported that of the AAPI MSM born
overseas the shorter the time these men live in the United States the greater is their like-

AIDS Education and Prevention, 15, Supplement A, 21–38, 2003
© 2003 The Guilford Press

Chwee Lye Chng is with the Department of Kinesiology, Health Promotion and Recreation of the Univer-
sity of Texas, Denton. Frank Y. Wong is with the Center for Health Services Research and Policy and Pre-
vention and Community Health Department of the George Washington University School of Public Health
and Health Services. Royce J. Park is with the Center for Health Services Research and Policy of the George
Washington University School of Public Health and Health Services. Mark C. Edberg is with the Develop-
ment Services Group, Inc., Bethesda, MD. David S. Lai is in San Francisco.
Preparation of this article was supported in part by two National Institute of Drug Abuse grants
(R01DA14512 and R01DA15623) to the second author. All opinions expressed are those of the authors.
Address correspondence to Chwee Lye Chng, Ph.D., Department of Kinesiology, Health Promotion and
Recreation, University of North Texas, P.O. Box 311337, Denton, TX 76203-1337; e-mail:
chng@coefs.coe.unt.edu

lihood of engaging in unprotected anal intercourse. Evidently, behaviors placing
AAPI MSM at risk of HIV infection are often rooted in scripted sexual-social roles and
layered with cultural values (Houston-Hamilton & Day, 1998).

This article addresses the need to understand social roles among AAPI MSM in
the United States. Unlike the European American tradition, the social construction of
sexuality in many AAPI cultures does not dichotomize heterosexual or homosexual
orientations. Thus, AAPI MSM may or may not identify as gay, and may or may not
perceive a connection between their sexual behavior and their social role or sexual ori-
entation, complicating the process of HIV prevention. The extent to which social roles
or perceived sexual orientation are related to stigma, shame, and loss of face among
AAPI MSM, and whether these are in turn related to their HIV-related risk attitudes,
sexual practices, and drug use/abuse will be explored here.

SOCIAL ROLES AMONG EAST AND SOUTHEAST ASIANS: SEXUALITY

The concept of social scripts or roles refers to shared interpretations and behaviors in
a social-cultural context. The social scripts or roles people learn influence how they
perceive situations, the meanings they attribute to these situations, and the behaviors
in which they engage. As social scripts or roles are conveyed through cultural norms,
this framework argues that most behaviors and identities are consequences of social
scripts or roles (Chou, 2001; Lai, 1998; Ng & Lau, 1990; Wong, Chng, Ross, &
Mayer, 1998a ; Zhang, Li, Li, & Beck, 1999). In a relatively homogenous society, the
relationship among social scripts or roles (mostly likely to be “prescribed”), public
personae, and private personae are more or less congruent. For example, in Chinese
culture (based on the dominant Han tribe), there is a unique term to designate every
type of familial relationship (as opposed to such English terms as first cousin and sec-
ond cousin). The hierarchical structure defines one’s social script in the relationship.
The expectation of how one should act and behave in each type of setting depends on
the status of the other party in the interaction. This type of hierarchy permeates all as-
pect of “traditional” Chinese culture. One is allowed to marry a first cousin only if the
cousin is from the maternal side of the family (e.g., a cousin from a brother of the
mother). Any sexual contact and unions among relatives from the paternal side are
considered taboo (immoral). In extreme cases, some Chinese do not marry people
sharing the same last name due, in part, to the possibility that people from the same
village share the same last name, and might be related to each other. These examples il-
lustrate the powerful influence of prescribed social or cultural forces (often a number
of prescribed scripts work together in tandem) in shaping sexualities and sex scripts.

In other words, “same-sex activities are portrayed in predominately social, rather
than sexual terms, with homosexual roles being used in expressions such as . . . hanlu
(the dry canal), and . . . tuzi (little rabbit); homosexual relations are described in terms
such as . . . qidi and qixiong (adopted brothers), and hanlu yingxiong (stranded
heroes) . . . or as specific behaviorial practices such as . . . chui xiao (to play a vertical
bamboo flute)” (Chou, 2001, p. 29). Similarly, in Filipino culture, a bakla is a biologi-
cal male who assumes the role and behavior of a woman, not unlike the modern Amer-
ican Indian concept of “two spirits” (Wong et al., 1998). However, this practice
should not be confused with the Western notion of “gayness” (an ascribed concept).

The seminal study conducted by Ford and Beach (1951) on homosexuality sug-
gests that same-sex sexual behaviors or relationships are more prevalent than once

22 CHNG ET AL.

thought, but these behaviors are likely to be highly regulated by social factors or pa-
rameters (e.g., religious beliefs). For example, Liu and Chan (1996) argued that Con-
fucianism, Taoism, and Buddhism “coexist in a curious mixture in East Asian
societies and very much shape the nature of relationships within the family” (p. 140).
An important value of the family is the concept of “face.” That is, one must only en-
gage in activities and behaviors that will not “shame” the family. Another key value of
family is “lineage” or procreation—to pass on the family name according to a patriar-
chal lineage. These factors dictate many social exchanges and relationships. One
might surmise that homosexual behavior “will be tolerated by the family only to the
extent that it does not interfere with the individual’s and the family duties and even-
tual marriage. Furthermore, both the individual’s and the family’s face must be intact
in the context of the larger community” (Liu & Chan, 1996, p. 141).

Indeed, Carrier, Nguyen, and Su’s (1992) study on sexual behaviors and HIV in-
fection among Vietnamese Americans in Orange County, California, gives credence to
the premise of “social roles” in defining sexuality in East and Southeast Asians. Car-
rier et al. stated that

as some homosexuality involved adolescent males move into adulthood, and become
aware of their homosexuality and the societal beliefs that equates it with feminine behav-
ior, they restrict their sexual pleasures to the passive role of fellating “masculine” men.
They may use their feminine behavior to attract other males interested in homosexual en-
counters, and so become sexual targets, but their major focus appears to be on meeting
the sexual needs and pleasures of their partners. The sexual preference, then, generally
becomes less important than the sexual preferences of their partners (p. 553).

Although there is a rich body of cultural and historical literature and analyses address-
ing same-sex and bisexual sexual issues, expressions, and phenomena for some East
and Southeast Asians (e.g., see Manalansan, in press; Ruan, 1991), the same cannot be
said for the scientific field. Nonetheless, some of these “sexuality-related” issues could
be inferred and gleaned from the small set of studies addressing HIV- and drug-related
issues in both the APPI MSM and non-MSM communities.

HIV-RELATED RISK ATTITUDES AND PRACTICES AND DRUG USE
AMONG AAPI MSM

Nemoto et al. (1998) identified eight published studies that reported the
seroprevalence rates, HIV risk behaviors and/or attitudes toward HIV/AIDS among
AAPI MSM. Specifically, seven reported HIV seroprevalence rates, which were based
on either self-disclosure of HIV or HIV test results among study participants. Four
studies also reported findings about the relationships between HIV-related behaviors
and factors. In addition, two studies were intervention studies. With the exception of
two, all studies were conducted in California—four studies were in San Francisco Bay
Area, one in Los Angeles and one in Orange County; the two other studies were con-
ducted in Chicago and the greater Boston area. Only four of the eight studies specifi-
cally targeted AAPI MSM; the other studies targeted AAPI MSM among other groups.

The sampling methodology of the eight studies ranged from convenience sam-
pling (Choi, Coates, Catania, Lew, & Chow, 1995; Choi et al., 1996; Yep, 1992) to
participants recruited from a county HIV/STD clinic (Gellert, Moore, Maxwell, Mail,
& Higgins, 1994; Matteson, 1997) to targeted sampling (Lemp et al., 1994; Seage et
al., 1997) to probability sampling (Osmond et al., 1994). Estimated HIV

SEXUAL HEALTH AMONG AAPI MSM 23

seroprevalence rates ranged from a low of 1.4% (Matteson, 1997) to a high of 28%
(Gellert et al., 1994). Except for the studies by Choi et al. (1995a) and Choi et al.
(1996), sample sizes of AAPI MSM were very small and studies did not specifically tar-
get AAPI MSM. These limitations may likely underestimate or overestimate the HIV
seroprevalence rate among AAPI MSM. To provide relative comparisons among be-
havioral risk groups, we note that the AIDS Office of the San Francisco Department of
Public Health (1997) estimated that HIV seroprevalence rates in the city among AAPI
MSM and AAPI MSM who also inject drugs are 38% and 45%, respectively. While
recognizing design limitations, we note that these estimates are higher than the eight
studies cited earlier.

One of the studies (Choi et al., 1995a) revealed high rates of HIV risk behavior
among AAPI men in San Francisco. Ninety-five percent of the men reported multiple
sex partners within the past 5 years, 59% reported multiple sex partners in the past 3
months, and 27% had engaged in unprotected sex in the past 3 months. Substance
abuse was the strongest predictor of unsafe sex among the AAPI sample, and men who
engaged in high-risk behaviors were less likely to believe that they were at risk. Simi-
larly, Lai’s (1998b) study reported that among AAPI MSM who had sex in the last 3
months (n = 77), 31% engaged in unprotected anal intercourse. This potential for en-
gaging in risk behavior was later confirmed in the study by Chng and Geliga (2000),
where they reported that among all ethnic MSM surveyed (N = 302), AAPI MSM (n =
76) reported the highest rate of unprotected anal sex.

Unfortunately, none of the eight studies investigated how sociocultural factors
influenced, regulated, or shaped HIV-related risk behaviors and drug use among the
targeted AAPI MSM. This lack of attention is symptomatic of the inherent difficulty
for most AAPI MSM to discuss openly two major cultural taboos: sex and drugs
(Wong, Chng, & Choi, 1998; Wong, Chng, Ross, et al., 1998). Another contributing
factor to the lack of a science-based knowledge on these two topics is the portrayal of
AAPIs as “model minorities” (Zane, Takeuchi, & Young, 1994) with lower level of
sexual activity and less drug use (Zane & Kim, 1994; Zane & Sasao, 1992). Mean-
while, the sexual and drug use images of AAPIs being portrayed by the U.S. popular
media are limited and tend to promote negative stereotypes (Sanitioso, 1999; Wong,
Chng, Ross, et al., 1998b). For example, sexual images fall into four broad stereo-
types: asexual (see Choi et al., 1995b), china doll (e.g., the Suzie Wong type), dragon
lady (e.g., Yoko Ono), and effeminate men (e.g., submissive house boys; see Choi et
al., 1995; Ho & Tsang, 2000). In the words of a 22-year-old Chinese American gay
man in San Francisco, Alex, recalled his shock when his White boyfriend dumped him
while exclaiming, “I don’t date fortune cookies”:

I was completely shocked that he would reduce my whole existence into the equivalent
of a cookie. . . . I think the only reasons he dated me was because he was intrigued by my
“exoticness” and when I didn’t fit the stereotypes he expected, he lost interest (as cited in
Lee, 2000).

Similarly, although AAPIs are perceived to use drugs less than other racial/ethnic
groups, the image of an “opium den” is often associated with AAPIs. No doubt, the
lack of information is also due to the fact that major surveys, such as Monitoring the
Future, often group AAPIs into the category of “other.” In addition, the sampling
methodologies used are often inadequate in addressing the diversity of AAPI com-
munities. Research has worked the limited value of using the telephone to reach lim-
ited-English or monolingual AAPIs (Nemoto et al., 1998). However, in a study

24 CHNG ET AL.

examining the HIV-related risks among a multiracial/multiethnic young MSM (n =
125; aged 18-25) in Boston, Landers et al. (1998) found that AAPI MSM (n =25) are
more likely to use speed (7%) and ecstasy (11%) as well as nitrite (11%) than other
racial/ethnic MSM.

In an attempt to examine the effects of sociocultural and environmental factors
on HIV-related risk attitudes and practices among AAPI MSM, Choi et al. (1999) con-
ducted semistructured interviews with 40 AAPI MSM (25% Chinese, 33% Filipino,
15% Vietnamese, 20% multicultural, and 7% other Asian ethnicities) as part of a
larger 1997-98 study in San Diego and Seattle. The mean age of these men was 22, and
68% were foreign born and had lived in the United States an average of 12 years. Find-
ings reveal eight factors for promoting risky behaviors: (a) negative feelings about
oneself, (b) being “closeted,” (c) “trusting a partner in a relationship,” (d) wishing to
please a partner, (e) having judgment overwhelmed by passion, (f) being high on alco-
hol and drugs, (g) sexual attitudes in the gay and Asian communities (i.e., balance of a
dual identity), and (h) lack of support of Asian families. One of these factors, sexual
attitudes in the gay and Asian communities, speaks to the challenge for APPI gay/bi-
sexual men in maintaining a positive dual identity. One respondent noted:

But growing up you are not given a lot of Asian role models so you don’t have anything
to go along with. You have to create your own self-esteem. On top of that you are thrust
into this White mainstream society. You are a lot more inferior. If everyone wants to be a
model and all of them are Whites . . . there is lack of self-esteem. Being gay, sometimes it is
very superficial in the sense that many things are based on physicality. Physical beauty,
the standard is the model, and all the models are Whites. Then you think you are less than
that. (Choi et al., 1999, p.50).

Respondents also cited several factors associated with protective behaviors including
(a) having a positive self-image, (b) conservative sexual values, (c) living with one’s
parents, (d) sexual attitudes in the gay and Asian communities (i.e., balance of dual
identity), (e) values associated with the respondent’s family, (f) overt urging by the
family, and (g) wishing to avoid hurting one’s parents. There is variation among re-
spondents in dealing with the issue of dual identity. One respondent stated: “In the
Asian community they are always watching me. My way to prove them wrong is to be
safe. Why give them the chance to talk bad about me?” In sum, the issues of “dual
identity” and “family relationship” both have negative and positive effects on sexual
risk taking among AAPI gay/bisexual men and MSM.

A MODEL FOR UNDERSTANDING SEXUAL HEALTH
AMONG AAPI MSM

Theoretical models in the past designed to explain or predict risk behaviors have
sometimes ignored social, relational, and cultural factors involved in behavior and of-
ten viewed these forces as independent variables, without recognizing that they might
be interactive or reciprocal. Unsafe behaviors are rarely the direct product of merely a
deficit of knowledge, motivation, or skill but instead can have layered meanings
within a given, complex personal and social-cultural context. Our proposed model is
based on the premise that AAPI MSM develop their sense of self in a social-cultural en-
vironment marked by triple oppression: racism, homophobia and immigrant status.
We propose a conceptual model to understand sexual health among AAPI MSM as
outputs of a dynamic cultural process potentially encompassing multiple generations

SEXUAL HEALTH AMONG AAPI MSM 25

and moving through different “impact domains” (Wong & Edberg, 2000, 2001). In
this article, sexual health refers to the “integration of the physical, emotional, intellec-
tual and social aspects of sexual being, in ways that are positively enriching and that
enhance personality, communication and love” (World Health Organization, 1975).

As seen in Figure 1, the model first locates the process in the home country (Im-
pact Domain 1), with its prevailing cultural norms—including sexual mores, shame or
stigma, sexual attitudes, sexual behavior and drug use. Second, these norms, beliefs,
and practices will be modified by the migration/immigration experience (Impact Do-
main 2), which for some segments (especially Vietnamese and Cambodian refugees)
may include severe trauma and the endurance of prolonged hardship. Although many
Pacific Islanders are “native” to their lands and not “immigrants” in the traditional
sense, when they migrate to the mainland, they experience similar barriers that Asian
Americans face, and in that context and to that extent this model will be applicable to
them. Third, these norms, beliefs, and practices will be continually influenced by the
process of acculturation (Impact Domain 3), as these AAPIs try to adjust to life in the
United States. An important subset of the third domain is the “generation” factor.
Conceivably, the effect of Domains 1 and 2 will be less significant for those who were
either very young at the time of immigration or are born in the United States. The ef-
fects of the first two domains (cultural norms of home country and the effects of mi-
gration/immigration) on individuals may also vary by the degree to which a particular
immigrant community remains socially and culturally insulated (e.g., through lan-
guage, social networks, cultural practices, economic participation) vis-à-vis the sur-
rounding mainstream community and the larger influences of “American cultural
practices and norms” (using this term in a gross sense to include social norms, gender
roles, behavior codes, daily practices, values, commonly found in key socializing insti-
tutions such as schools and mass media).

IMPACT DOMAIN 1: HOME COUNTRY PATTERN
More specifically, in Domain 1, we include home country patterns that are rele-

vant to later (U.S.) lifestyles, such as gender roles, home country sexual mores, sexual
risk practices (especially MSM and multiple sex partners), drug use, and cultural con-
ceptions of shame and face. Sexuality remains a very private matter in many AAPI
countries. Because sexual issues are rarely or openly discussed in homes, schools or
community, many young AAPI adults have minimal experience or skills in coping
with relationships, sex, and sexuality issues in later life. This lack of experience can
lead many to feel socially awkward (Lai, 1998a). Candid discussions about sexual is-
sues in public is not easy with AAPI men, especially when non-Asians are also present,
as clearly evident in this comment from an AAPI outreach worker:

I found that to be the case when I did my first workshop, which was with the Long Yang
club and hardly anyone asked questions, and it’s a mixed group as far as Asians and
non-Asians, and it was primarily non-Asians who were asking questions. Ummm, when
I did the workshop with GAPIMNY, we actually had them write out the questions on
cards, index cards, which allow people to ask more questions, and that seemed to work a
lot better (Yoshikawa, Chin, Kim, Hsueh, & Rossman, 1999).

Aoki, Ngin, Mo, and Ja (1989) stated many years ago that little is known in terms of
HIV education and prevention in the AAPI community. Moreover, they reasoned that
within the Chinese American and Japanese American communities, education for pre-
venting AIDS is a daunting task because it brings up four taboo subjects: sex, homo-
sexuality, disease, and death. Sex, considered a private matter, is not talked about

26 CHNG ET AL.

publicly (Aoki et al., 1989; Chan, 1995). Confucianism sanctions sex only as a means
to continue the family lineage. Talking about illness is considered bad luck and
thought to bring about the illness. Aoki et al. reported that in contemporary Japan
many physicians routinely, as standard practice, do not disclose cancer diagnoses to
their patients. The subject of death is avoided at all cost in the Chinese and Japanese
cultures. For example, the Chinese words for three and four are homophones for birth
and death, respectively. Hence, many customs include groupings of three items and
avoid groupings of four. The Japanese shares the avoidance of four because the word
for four, shi, is also a homophone for death. In general, like the Chinese, the Japanese
avoid selling or presenting items in fours.

Likewise, sexuality is rarely discussed between the Issei (first) and Nisei (second)
generations in the Japanese community, partly due to a language barrier between the
two generations (Nagata, 1989). Moreover, recent data suggest that difficulty in dis-
cussing sexuality continues into the Sansei (third) generation. Studies found that Japa-
nese Americans express significantly greater sex-related guilt than White Americans.
Similarly, the language barrier has been found to impede discussions about sex be-
tween first- and second-generation Chinese Americans (Lai, 1998a). Because sex is
rarely discussed in Asian families, the Asian young adult often has a late start in learn-
ing how to deal with relationships. An AAPI MSM stated:

The communication pattern for API is more indirect. White Americans are direct, and so
if we have trouble talking about sex, it’s got to be compounded in the Asian community,
where homosexuality just isn’t spoken of, where the family ties are so strong, where car-
rying on the family name is so important for guys (Choi, Yep, & Kumekawa, 1998, p. 25).

SEXUAL HEALTH AMONG AAPI MSM 27

FIGURE 1. Impact domains.

Gay AAPI men have a very difficult time in their own communities because of the con-
tinual denial of their existence; there is a prevailing belief that homosexuality is a
Western phenomenon (Chan, 1995; Dynes & Donaldson, 1992; Nakajima, Chan, &
Lee, 1996), an indication of the “decline and evil of Western civilization” (Ruan,
1991, p. 121). The recognition of HIV in the AAPI communities often implies the ac-
knowledgment of homosexuality. However, because the family is such a powerful so-
cial unit, MSM have to choose between perpetuating the family name through
marriage or deriving personal satisfaction through same-sex relationships. The con-
flicts between ethnic identity and sexual identity might hinder safer sex behaviors
(Chng & Geliga, 2000; Yep, 1993). For example, whereas China has decriminalized
homosexuality in 1997, and has removed it from a list of mental illnesses in 2001, the
norm in the Chinese gay community is to get married, have children, and pass as het-
erosexual at work but frequent gay establishments at night. This growing under-
ground community of partly closeted, partly liberated, and sexually active gay males
with dual identities presents unique challenges to HIV prevention. However, Chinese
doctors are beginning to see the effects of AIDS in this poorly defined high-risk group,
whose members are sometimes still unclear about their sexuality and frequently have
sexual relations with both men and women (Rosenthal, 2002).

Because AAPI culture traditionally views the family across all time, the rejection
of the gay man by his family has a greater impact, because the family includes all mem-
bers across time—past, present, and future.

So you’re a White person. You tell your parents that you’re gay, and they reject you. Sure
it’s hard, but look at it this way: If you were Asian, not only your parents might reject you
but also your grandparents, your great-grandparents, and several thousand other ances-
tors. Now that’s a burden (Hippler, 1989, p. 1).

Being gay is strongly stigmatized by most AAPI families and communities, and the re-
sulting shame would keep many gay AAPI sons closeted, as illustrated by the com-
ments of an AAPI man interviewed by Choi et al. (1998, p. 25): “Asian culture looks
down on homosexuality. Even if the families did know that the son is gay, it is not dis-
cussed. I know very few gay Asians who are out to their families to the point where
they talk about things.” Sin, Myers, Souza, and Gardner (1994) reported that AAPI
MSM often struggle to find self-acceptance given the homophobia in their family and
the racism in the mainstream gay community. A large number of these men reported
that their parents taunted, teased, and joked about homosexuals despite the knowl-
edge that their sons were gay. The inability of the family to acknowledge the sexual
identity of these closeted men can lead to repression of sexual urges which can become
“overwhelmingly strong, and to satisfy sexual urges, people can go out and seek sex . .
. in strange places like in bathrooms, parks. If it has to be fast and loose, it could be
without protection, because that’s the only thing offered at that moment” (Choi et al.,
1998, p. 25).

Because of the shame and stigma of homosexuality in AAPI cultures, and the
threat of disclosure in their small community, some AAPI MSM actively avoid inter-
acting with other AAPI men. The work of Carrier (2001) and Carrier et al. (1992) has
demonstrated that the issue of “face” may be relevant when designing programs for
this population. In a description of recruiting strategies among AAPI men engaging in
bisexual behavior (Matteson, 1997), several important points emerged. No study sub-

28 CHNG ET AL.

jects were recruited through network or snowball techniques or through advertise-
ments in ethnic newspapers.

Implication for HIV Prevention. Sensitivity to social-sexual norms and histori-
cal experiences of AAPI subgroups is important when designing and implementing ef-
fective HIV interventions. Unfortunately, cultural norms and values sometimes can be
at cross-purposes with HIV prevention: The reticence in talking openly about sexual-
ity and other risk behaviors can result in difficulties with interpersonal sexual commu-
nication, weaker safer sex negotiations, and greater sexual discomfort (Aoki et al.,
1989; Chan, 1995). For example, the cultural need to maintain social harmony and
tendency to avoid interpersonal conflict in the highly hierarchical systems, such as
among Chinese and Japanese, can endorse silence rather than open dialog about sexu-
ality. For some AAPI MSM, sometimes protecting their partners from uncomfortable
feelings takes precedence over protection themselves from HIV.

Many AAPI cultures frown on exchanging information with strangers having
anything to do with sexuality. HIV/AIDS is associated with sexuality, and there-
fore any indications that materials are about HIV/AIDS are usually rejected out-
right. In AAPI cultures condoms are still associated with promiscuity and Asians
tend not to accept condoms for fear of being perceived as promiscuous, especially
when they are with family or friends, or partners. To overcome this resistance, con-
dom packaging has been modified to appeal to certain AAPI communities (e.g., red
packaging with gold letters to imitate Chinese New Year gift packaging). When
safer sex materials are introduced as health materials, AAPI clients are more likely
to accept them.

For AAPI MSM, social support within the family system constitutes an important
and powerful safe haven from which to cope with poverty, discrimination, and racism
that they experience as ethnic minorities in the United States. Sometimes they are
forced to choose between either remaining closeted in order to be involved with their
homophobic family or living open lives without family support or acceptance (Chng
& Geliga, 2000; Lai, 1998a; Wat, 2002; Wong, Chng, Ross, et al., 1998). Sexuality
for these men, often married with wives and children, finds expression in anonymous,
hidden sexual encounters with other men. Messages tailored for “gay men” will not
necessarily resonate with these men. Although research has shown that difficulties in
coming out as gay men and a lack of social support are predictors of high-risk behav-
iors (Catania, Coates, & Stall, 1991), within the AAPI immigrant world individual be-
havior cannot be accurately understood apart from the social cultural structures in
which it is rooted. Seen in this light, many of the “irrational” sexual choices made by
AAPI MSM immigrants become more understandable.

This avoidance of fellow AAPI men as sexual partners for fear that their behavior
would become known among other AAPIs; and concerns about confidentiality if
AAPI outreach workers were used suggest that data collection through face-to-face in-
terviews by AAPI interviewers may not be effective if the subject matter is perceived as
shameful or controversial.

IMPACT DOMAIN 2: MIGRATION EXPERIENCE
Migration is likely to involve a loss of the cultural environment of the “home

country” and an attempt at integrating sociocultural constructs and values of the new
“host country.” Migration, in essence, is a dynamic, time-dependent process of dis-
continuity and transition, whereby an individual moves from a familiar world to an
unknown, confusing, distressing, but sometimes rewarding life in a new country.

SEXUAL HEALTH AMONG AAPI MSM 29

Some of these same elements may also be experienced by the host culture receiving the
immigrants, but from a position of greater power than do immigrants (Chng &
Geliga, 2000; Haour-Knipe & Rector, 1996). It is important to clarify from the outset
that being an immigrant in and of itself, is not a “risk factor” for HIV. It is the circum-
stance encountered and the activities undertaken during the migration process that
are risk factors.

The challenges of providing HIV/AIDS prevention among AAPI immigrants are
unique because it involves sexual intimacy. Here, differential familial and social pres-
sures for continuity and conformity can create strong tensions not only in the immi-
grant community but also in the host society. The problem is further aggravated
because in many AAPI immigrant cultures, the issues of intimate relations and sexual
behavior are routinely shrouded in secrecy and taboo. Such cultures, which are usu-
ally more traditional, have a tendency to avoid public discussions of sexual matters
(Sabatier, 1996).

Sociological case examples highlight the migration-immigration experiences of
three major AAPI groups (Chinese, Filipino, and Vietnamese) to illustrate how home
country cultural norms can be modified by immigration to the United States. Al-
though Chinese Americans have been residing in the United States since the 1800s,
many were concentrated in ethnic enclaves such as those in San Francisco and New
York City. The 1965 Family Reunification Act has significantly increased the Chinese
population (from mainland China, Hong Kong, and Taiwan) in this country. The re-
laxation of migration policy by the mainland Chinese government in the late 1970s
has also contributed to an influx of migration. Thus, people of Chinese descent in the
United States are a mixed group, ranging from fifth-generation Chinese Americans to
recent immigrants. When it comes to their perspective on the family, Chinese Ameri-
cans can best be described as conservative, particularly in terms of their views of the
role of women, sexual attitudes, and political philosophy. Although Chinese Ameri-
cans are able to adjust to changing conditions in American society, it is also true that
they still maintain a strong cultural and ethnic identity.

The process of immigration is difficult for most and often has significant impact
on people’s psychological well-being. Chinese and Japanese immigrants face major
conflicts and difficulties assimilating into American culture. Of particular importance
for immigrants are prejudiced and discriminatory policies enacted by the American
government such as the Chinese Exclusion Act of 1882 and the internment of Japa-
nese Americans (Takaki, 1989). The imprisonment of the Japanese American citizens
during World War II seriously affected the lives of two generations of Japanese Ameri-
cans. The effects included a change in family structure, economic loss, psychological
stress, feelings of victimization (Nagata, 1989), and subsequent higher levels of assim-
ilation (Uba, 1994). Second-generation Japanese Americans who had been interned
made greater efforts to raise their children to be thoroughly “American” (Nagata,
1989). This resulted in few third generation Japanese Americans speaking Japanese or
adopting its cultural norms. It is not surprising, therefore, that studies have reported
that more acculturated Japanese Americans (primarily third-generation individuals)
have rates of drug use and other risk behaviors that mirror those of White Americans
(Price, Risk, Wong, & Kringle, 2001; 2002).

The Philippines holds a special place in U.S. military history and cultural connec-
tions (English is the lingua franca for many Filipinos); many Filipino Americans either
have immigrated here dating back to the 1950s or earlier, or were United States born
in the United States. In addition, during the 1960s there was a shortage of medical per-

30 CHNG ET AL.

sonnel, which led to a significant number of Filipino medical professionals (doctors
and nurses) migrating to the United States. As a higher proportion of Filipinas are in
the medical professions, more Filipino men are married to wives with higher levels of
education than they have, creating role conflicts. Many Filipino Americans have pur-
chased homes in the suburbs, with the result that they are highly integrated into White
American neighborhoods. Families who arrived first often served as host families for
later arrivals (Almirol, 1982), who all contribute to their mortgage payments. In es-
sence, the purchase of a home for many Filipinos is a “family affair,” as they not only
share household expenses but also make personal loans to one another. As family ties
are extremely close with Filipino Americans, living enmeshed lives can make it diffi-
cult for some Filipino gay men to come out of the closet to family members. For the
need to maintain boundaries around private versus public behaviors, central to many
AAPI cultures, can drive these gay men deeper into the closet. Whether for pleasure,
economic reasons, compulsion, or a lack of available women, these men have sex with
one another, despite strong cultural taboos against homosexuality. These men often
hide their sexual orientation by having clandestine sexual encounters with other men.
In these oftentimes hurried circumstances, condoms are unlikely to be used consis-
tently. Some men, married to women because of social or family expectations, have
been known to have sex with other men “on the side”—they do not view their
same-sex behaviors as linked to a sexual identity. As AAPI MSM—whether exclu-
sively or only occasionally—are at heightened risk of contracting HIV and transmit-
ting it to their partners and offspring, HIV prevention programs targeting AAPI MSM
is essential.

Vietnamese are one of latest additions to the “melting pot.” The “first wave”
came immediately after the fall of Saigon in 1975. Much of this wave was middle class
and urban, with some experience participating in a Western-style market economy,
and therefore has assimilated more easily than subsequent arrivals. However, despite
their skills and education, many in this initial wave of Vietnamese Americans had to
accept positions that were lower in status than those they had held in Vietnam. The
Refugee Resettlement Act brought on a second wave of Vietnamese between 1978 and
the mid-1980s. This wave included large numbers of poor, rural, and illiterate individ-
uals (Wong, Chng, Ross, et al., 1998), who remained trapped in low-paying jobs, iso-
lated from the mainstream by language and cultural barriers and from the more
affluent Vietnamese community by economic and regional differences. They often
have been forced to depend exclusively on their children who most often are the only
family members with a working knowledge of English. As such, in the United States
these adults had to relinquish their traditional social status and authority, while Eng-
lish-speaking youths assume more power in social interactions with the mainstream
society. This shift in power can produce negative social effects, such as the prolifera-
tion of Vietnamese youth gangs in the community. More important, persons who
have been subjected to war, political repression, torture, interpersonal violence, or
other traumas may experience residual power imbalances, which may play out in their
risk behaviors; these imbalances in power among AAPI need to be made explicit in or-
der for prevention interventions to be effective (Houston-Hamilton & Day, 1998).
Carrier et al. (1992), in their examination of Vietnamese American MSM, found that
social isolation complicates the process of sexual identification, especially for new im-
migrants. They tend to be isolated because of language barriers, lack of knowledge re-
garding the gay community, or the insularity of their community. This was reported
anecdotally also in the gay Chinese community.

SEXUAL HEALTH AMONG AAPI MSM 31

In sum, these differential migration experiences among various AAPI groups may
act as stressors that could contribute to risky health-related attitudes and practices
(Takeuchi & Young, 1994). For example, in the study conducted by Chng and Geliga
(2000) of those MSM in the sample who were born overseas, the majority was AAPI
(61%), followed by Latinos (29%). For men born overseas, the longer they have lived
in the United States, the less likely they are to engage in unprotected anal intercourse
with other men. Marin, Gomez, and Tscann (1993) have suggested that high accultur-
ation levels and exposure to mainstream gay community are factors associated with
consistent use of condoms among MSM of color. For many immigrants, time spent in
the United States is positively correlated to acculturation levels and exposure to main-
stream culture. As suggested by these findings, many immigrant AAPI MSM may not
have access to HIV prevention messages until they are exposed to the mainstream gay
culture.

Implications for HIV Prevention. Forced to work low-paying service industry
jobs that rarely provide health insurance, many AAPI MSM immigrants may overlook
serious HIV-related illnesses until they reach later stages of the disease—then rushing
to the hospital for emergency treatment. Until then many are unaware that they are
HIV-positive or have full-blown AIDS. Many illegal immigrants who suspect having
HIV avoid testing or seeking medical care, fearing that a positive HIV result will ruin
any chance of gaining legal residency. Undocumented HIV-positive immigrants often
fear returning to their native countries where potentially lifesaving AIDS medicines
are rare and where they are more likely to face discrimination. Instead they choose to
go underground and risk deportation. In addition, AAPI MSM immigrants without
marketable skills attempting to escape extreme poverty may resort to trading sex for
goods, services, and cash. Because of language, cultural, and power disparities, many
AAPI MSM, particularly newly arrived immigrants, are unaccustomed to initiating
sexual discussions with their partners.

AAPI migrant populations have a great risk for poor health in general and HIV
infection in particular (Chng & Geliga, 2000; Wong, Chng, & Choi, 1998). More
generally, AAPI migrants have other concerns far more pressing than a seemingly dis-
tant threat of AIDS, such as legal, housing and employment problems. Health may not
be a first priority, and an effective HIV intervention may have to widen its scope in or-
der to be acceptable to this population.

For effective HIV prevention, it is important to involve migrant communities at
all stages, starting with needs assessment and planning. Employing AAPI profession-
als from the migrant population as HIV educators/case managers and training them to
work in the field of HIV/AIDS serve more than one purpose. When trained, they could
enhance the delivery of HIV messages from one culture to another. They are also the
most appropriate people to serve as cultural mediators in the United States health,
welfare, and educational systems. Being knowledgeable of the nuances of their own
society, they could inject cultural insights into the development, training, and imple-
mentation processes of HIV prevention.

IMPACT DOMAIN 3: U.S. EXPERIENCE
There are significant stressors created by the acculturation process to life in the

United States, regardless of migration experience (Takeuchi & Young, 1994). The ac-
culturation process may include significant changes in social status, challenges to tra-
ditional gender roles, the effects of coping with racism and homophobia.

32 CHNG ET AL.

Using the categorization proposed by Fung (1994), we will illustrate the effects of
acculturation to life in the United States on AAPI MSM. Fung (1994) differentiated
three distinct groups of AAPI MSM: (a) men who are both AAPI identified and gay
identified, (b) men who are gay identified but not AAPI identified, and (c) men who
are AAPI identified but not gay identified. Although the categorization of three dis-
tinct groups may be a simplistic overgeneralization of a diverse community, it does of-
fer a framework to examine how AAPI MSM acculturate to life in the United States.
The first group, men who are both AAPI identified and gay identified, is usually the
group who is least closeted and most politically involved (Choi et al., 1995b). These
individuals are most likely to form and participate in queer AAPI groups such as the
Gay Asian Pacific Alliance (GAPA) and Cal-B-Gay (at the University of California,
Berkeley).

The second group, men who are gay but not AAPI identified, makes up the largest
of these three groups and is most diversified (Fung, 1994). This segment of the com-
munity was described by Choi et al. (1995) and Nakajima et al. (1996) as having more
affinity toward the gay community than the AAPI community. Nakajima et al. (1996)
observed that many do not have AAPI self-awareness and go through an internalized
racism stage where they believe they are “White.” This phenomenon is reflected in the
dating patterns of AAPI men with specific pejorative terms used among them: where
the majority of AAPI men (“potato queens”) are dating exclusively White partners
(“rice queens”), who are men exclusively attracted to AAPIs, and where AAPI men
dating other AAPI men are referred to as “sticky rice.” Nakajima et al. (1996) attrib-
uted this pattern to the internalization of dominant cultural portrayal of AAPI men as
un-masculine and undesirable. Perhaps such AAPI men believe that their self-worth is
dependent on their assimilation and acceptance by the gay, White mainstream com-
munity. Nakajima et al. reported the common stereotype held by some Whites of
AAPI MSM as “passive partners and sexually subservient” (p. 572). This stereotype
has two implications. First, those AAPI MSM with difficulty asserting themselves are
now reinforced by the mainstream society to be passive. Second, AAPI MSM are ex-
pected to be the “passive” partner in anal sex—the role that carries the highest risk for
HIV infection.

In fact, Fung (1994) reported members of this second group have feelings ranging
from indifference to hostility toward other AAPI men. They participate mostly in gay
“mainstream” dance clubs and social groups that are not AAPI identified. Many expe-
rience cultural ambivalence, having to choose between values of their ethnic commu-
nity and the values of the predominantly White gay culture. Many end up choosing
gay White values and demonstrate internalized racism by believing they are “White”
and associating only with Whites. This observation has been corroborated by the Gay
Asian and Pacific Islander Men’s Study, which found that 63% of participants who
were in primary relationships were partnered with White men (Choi et al., 1995a).
This is consistent with field observations in an ongoing National Institute of Drug
Abuse-funded study in New York City (T. Case, personal communication, November
1, 2001). The investigator noted that many Cantonese-speaking Chinese gay men are
engaging in “club drug use and/or trade” in Chelsea (a New York City’s gay district)
as a way to gain acceptance into the predominately “White, gay, Chelsea boy” circle.
The use of “club drugs” by these Cantonese-speaking Chinese gay men may represent
a form of acculturation to the “mainstream American culture” in general and/or “gay
culture” (being a Chelsea Boy) in particular (cf. Ross, Fernandez-Esquer, & Seibt,
1995). Fung found many members of this second group express low self-esteem espe-

SEXUAL HEALTH AMONG AAPI MSM 33

cially when they are “trying to be ‘one of the boys’ without ever being permitted into
the exclusive club of the White beauty standard” (p. 3). This second group is often
underrepresented in studies because of low self-esteem and reluctance to assist their
own community. In Lai’s study (1998a), participants who identified with both the
AAPI and gay community had significantly (p =. 01) higher self-esteem (M = 18.14)
than those who did not identify with both communities (M = 16.08). Similar to Chan’s
(1989) findings, for those who did not identified with both communities, more partic-
ipants identified with being gay (n = 26, 25.2%) than being AAPI (n = 11, 10.7%).
This might be the phenomenon of White identification in the AAPI MSM community
described by researchers (Choi et al., 1995b; Nakajima et al., 1996; Wat, 2002).

Uba (1994) reported that Chinese Americans and Japanese Americans males are
perceived to be less masculine than White males. This might be related to the fact that
cultures influenced by Confucianism emphasize scholarship, learning, and other non-
physical endeavors (Nakajima et al., 1996). In contrast, the American gay culture
places a great emphasis on masculine physical appearance. Hence, AAPI MSM might
have lower self-esteem due to the mismatch of social-sexual ideals and stereotypes.
Many experience difficulty adjusting to the ideal image of male beauty and negative
stereotyping of AAPI MSM in the mainstream gay community (Choi et al., 1998). Be-
cause AAPI MSM do not fit the White standard of male beauty (e.g., chiseled,
healthy-looking, young White man with blond hair and blue eyes), many have devel-
oped a low sense of self-esteem about their physical appearance (Ona, Cadebes, &
Choi, 1996; Wat, 2002).

According to Ona et al. (1996), many AAPI MSM indicated that they engaged in
unsafe sex as a consequence of low self-esteem. These assaults on their self-esteem take
place in a more general atmosphere of discrimination, racism, negative stereotypes,
and cultural ambivalence. Discrimination can encourage AAPIs to adopt self-esteem
hampering personality traits, becoming self-abased (deferring to others and feeling in-
ferior), less assertive, more conforming, less expressive, and less extroverted (Lai,
1998a). Negative stereotypes can keep them from developing positive identities (Wat,
2002).

The third group refers to AAPI men who are not gay identified. This group may
also be the most closeted and hardest to reach. They are not activists in the AAPI com-
munity but are limited in their ability to live freely in the gay community due to their
immigration status, language and cultural barriers. These individuals are most likely
to participate, if they participate at all, in social clubs organized by White men who
want to meet AAPI men, such as Pacific Friends, Asians and Friends, and the Long
Yang Club. This is the group that most accurately reflects the definition and charac-
teristics of AAPI MSM, as they seldom perceive themselves as gay.

Implications for HIV Prevention. To reach out to unacculturated AAPI MSM it
may be important to reframe the process to include (a) identification of new social net-
works and settings in which specific AAPI MSM community members gather; (b) sat-
uration of those settings with HIV relevant information; and (c) diffusion of new
norms concerning HIV risk and protective behaviors, through a series of presenta-
tions.

For example, as reported by Yoshikawa (1999), in New York City, ethnic gro-
cery stores and restaurants had been identified by HIV educators as informal social
support settings for immigrant Bangladeshi men and cabdrivers, respectively. Many
of these men appeared to engage in unprotected sex with men. In both these initiatives,
repeated contacts were made with members of these settings (in one case, the owners

34 CHNG ET AL.

of grocery stores, and in the other, Bangladeshi cabdrivers who regularly congregate
in a few ethnic restaurants on their breaks). Next, to promote location-wide reduc-
tions in HIV risk, peer educators saturated the settings with HIV outreach materials,
distributing condoms and brochures to virtually everyone entering the restaurants or
grocery stores. In the third step, HIV educators attempted to diffuse new norms about
HIV risk and protective behaviors among tightly knit social networks. A series of
house parties in Bangladeshi communities have made use of the high levels of cohesion
in networks of Bangladeshi individuals to diffuse awareness about HIV/AIDS. In a
typical scenario, an initial house party will generate interest among friends of those
who attended, and that group is then invited to a subsequent party. Using diffusion of
innovation, peer educators have presented multiple workshops in the same apartment
building or residential area. Such a method may potentially result in reductions in HIV
risk across the given setting (e.g., apartment building or area), through a process of
diffusion of new information and norms for risk behavior in existing social networks.

CONCLUSIONS

Three conclusions emerge from this review. First, popular behavioral models in use do
not serve the needs of AAPI MSM because these models essentially ignore important
cultural practices, beliefs, and attitudes of this population. Second, cultural back-
grounds (e.g., social and sexual norms from their home country, migration experi-
ences, and acculturation experiences in the United States) can have significant effects
on risk behaviors of AAPI MSM, and their responses to HIV prevention messages and
interventions. Finally, researchers and practitioners serving AAPI MSM must inte-
grate social-cultural factors into research designs and program structures.

Researchers are encouraged to explore issues of xenophobia and stigmatization
of immigrants; impact of legislation on access to prevention and mental health ser-
vices; impact of policies on HIV testing, status disclosure, names reporting, and con-
tact tracing on health seeking behaviors; and perceptions of stigma/shame related to
HIV and homosexuality/bisexuality in AAPI subgroups. In the course of their HIV-re-
lated research, investigators should also consider including in general assessments
items related to current immigrations status of respondents; length of time in the
United States; health coverage and access to health care, and whether respondents
have been tested for HIV or not (Gilmore & Sommerville, 1994).

SEXUAL HEALTH AMONG AAPI MSM 35

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Runninghead: ASIAN AMERICANS, ACCULTURATION, AND SEEKING OF PSYCHOLOGICAL HELP 1

Asian Americans and the Relationship between Levels of Acculturation and the Obstacles to

Seeking Psychological Help

Student Name

San Francisco State University

ASIAN AMERICANS, ACCULTURATION, AND SEEKING OF PSYCHOLOGICAL HELP 2

Studies are conducted to analyze different minority group’s levels of acculturation and

the link they possess to likelihood of seeking medical services. This review will focus

specifically on Asian American individuals and their beliefs regarding mental health/disorders,

and how said beliefs influence the attitudes they hold regarding seeking of psychological

treatment. It should be noted that Asian Americans as a group are very diverse and should not

necessarily be grouped as a whole when analyzing social theories and trends. The

underutilization of mental health resources by Asian Americans is a topic that is still in the

process of being studied, though there are studies and analysis available. In this review

acculturation shall viewed as one’s ability to become acquainted with, knowledgeable of, and

comfortable participating in the beliefs and systems of their second culture. Enculturation should

be defined as one’s level of adhering to their original culture (Lin 2014). Startling statistics such

as the fact that about 70 percent of Vietnamese refugees meet the criteria for PTSD yet are the

group underutilizes mental health resources the most (Nguyen 2013) make it clear that there is a

problem present. Asian Americans have historically low rates of utilization of mental health

resources (Frey & Roysircar 2006). This is due in part to one’s culture and beliefs about health

and medicine. Furthermore, levels of acculturation and enculturation are proven to be related to

attitudes and willingness to seek psychological help (Lin 2014). I hypothesize that higher levels

of acculturation will be linked to a more positive view of Western medicine and treatment

regarding mental health.

Methods

Information was gathered for this review through extensive searches in scholarly

databases. Dissertations and theses using ProQuest under the databases: “Ethnic NewsWatch”,

“Social Sciences”, and “Sociological Abstracts”. The topic of the relevancy of acculturation in

ASIAN AMERICANS, ACCULTURATION, AND SEEKING OF PSYCHOLOGICAL HELP 3

regards to likelihood of seeking psychological treatment amongst the Asian American population

seemed intriguing mainly due to the fact that it has never been properly addressed. I found when

searching through various articles that depending on the group (i.e. Vietnamese, Laotian, and

Japanese) there were different trends and rates of turnout.

Questions that guided research into this topic were: “Why do Asian American

populations historically underutilize mental health resources?”, “Why is acculturation have such

an identifiable link to whether someone of Asian American decent has positive or negative

attitudes about seeking help for mental problems?”, “What values and beliefs from one’s

original culture discourage people from seeking help for mental problems?”, “What are barriers

are present that make it difficult for someone to seek out help even in their second culture?”,

“Why is mental health stigmatized in Asian American culture, therefore leading many to be

hesitant to seek out help even once moved into the new culture that is accepting?”, and “Is it

possible to be both fully enculturated in one’s original Asian culture, whilst also acculturated in a

new one and possess positive attitudes towards seeking psychological treatment?”.

Many of the answers to these questions were found in studies conducted on college

students in the US of various ethnicities that fall under the “Asian American” umbrella. When

searching under the various databases listed previously, many studies appeared that addressed

refugees and immigrants. A common trend amongst articles and experiments conducted was the

usage of the term “help-seeking attitudes” when referring to how certain populations viewed the

stigma of receiving help for their psychological problems.

Once conducting an ample amount of research into the articles and dissertations

available it quickly became apparent that due to a lack of field research into the topic, in order to

collect a sufficient amount of credible evidence it would be better to center my analysis on the:

ASIAN AMERICANS, ACCULTURATION, AND SEEKING OF PSYCHOLOGICAL HELP 4

beliefs, stigmas and trends, of help-seeking attitudes amongst AAPI populations as a whole. This

involved focusing on acculturation in a more macro, holistic level in the AAPI community.

Results/ Discussion

Research suggests ideas and values about health in Asian culture plays a large factor in

the correlation between level of acculturation and help-seeking attitudes. There are noticeable

disparities and differences between concepts about mental health in Asian culture and

American/western culture. Asian American families often believe that mental l problems or

disorders should not be brought outside of the home like physical ones (Lin, 2014). A concept

such as yin/yang is present across many Asian cultures which influences views on health, but

also lifestyle as a whole. The concept of mind and body being linked and harmonious is present

cross-culturally amongst Asian countries. As expressed by (Lin, 2014) a mental problem or

disorder is often described as “demons, spirits, punishment, or a weak mind”. In this case, a less

acculturated individual is less likely see the importance of seeing a counselor or mental health

professional. Research suggests that South East Asians specifically, see mind and body being

inseparable. An example of this is what Western medicine would describe as anxiety, a South

East Asian would describe as a result of something physical such as kidney malfunction (Frey &

Roysircar, 2006). Psychotherapy and medicine involving the mind is foreign to many Asian

cultures. This being said, if an individual is less acculturated to Western society, they are less

likely to have knowledge on or put much focus into their mental health therefore explaining the

low rates of utilization by Asian Americans. Going by the unilineal model of acculturation, it can

be assumed that the more entrenched one is in the ideas of their original culture (i.e. mental

problems are demons), the less acculturated they are in the ideas of their new one (mental

problems are common and can be fixed) (Lin, 2014). Therefore, someone who is less

ASIAN AMERICANS, ACCULTURATION, AND SEEKING OF PSYCHOLOGICAL HELP 5

acculturated to Western ideals of medicine is less likely to go out of their way to seek help for

their mental health problems. This might also explain the historically low levels of utilization of

psychotherapy by Asian Americans.

Level of adherence to one’s original culture and ideas about medicine previously

mentioned seemed to be a common theme throughout various pieces of research. Adherence to

traditional Asian values was proven by to have a direct correlation to help-seeking attitudes. The

higher the level of enculturation, the more negative ideas toward seeking help for mental health

(Yin, 2014). Asian cultures are collectivist cultures stated by (Frey&Roysircar, 2006). This

seemingly impacts how their help-seeking attitudes because collectivist societies emphasize the

importance of the greater group as a whole and discourage complaining about individual

problems one may possess. Another value expressed in Asian culture is the importance of

‘saving face’ so to speak, which is used to maintain harmony in collectivist cultures (Nguyen,

2013). The emphasis of the goals of the group rather than the individual, especially in family,

likely explains why less acculturated individuals are hesitant to seek treatment. Asian families

are also more likely to make decisions as a group (Nguyen, 2013) so if a problem is seen as

‘weak’ or shameful (such as depression or anxiety) the problem will likely stop there without

publically seeking help. When comparing the ideas of Western culture (where it is indeed

acceptable for a child to individually seek help from a counselor or other mental health

professional) and Asian culture (where it is discouraged, not thought of as critical, and often

shamed) it becomes clear why there is a link between level of enculturation and help-seeking

attitudes.

A final theme discovered is the correlation between length of stay in the new culture, and

help-seeking attitudes. One example of this is a study referenced by (Nguyen,2013) that involved

ASIAN AMERICANS, ACCULTURATION, AND SEEKING OF PSYCHOLOGICAL HELP 6

a study of 202 Asian American college students that found that higher levels of acculturation

correlated with a positive view of help-seeking for mental problems and vice versa. This once

again shows a direct link between acculturation and likelihood of seeking help at least among

college students. In addition, level of acculturation has been proven to influence one’s preference

of ethnicity when looking for a counselor (Frey&Roysircar, 2006) and considering there is

significant lack of culturally representative/sensitive healthcare available in Western medicine it

is no surprise that many individuals are hesitant or reluctant to seek help. A study also conducted

by (Frey&Roysircar, 2006) showed the significance of gender in being likely to seek help. The

study showed that Asian American women were much more likely to have positive-health

seeking attitudes towards seeking help for mental illnesses possibly due in part to the fact that it

is more acceptable for women to show emotion in Asian culture. Cutting out half of the

population of Asian Americans (men) from the group of people likely to seek psychological

help, might help explain the low levels of utilization by Asian American individuals if they are

heavily encultured in their original culture and possess beliefs on gender roles that are

synonymous to said culture.

Conclusion

In conclusion, after conducting research into the topic of acculturation and correlation to

help-seeking attitudes amongst Asian Americans I noticed several themes. It is clear that

traditional Asian values about mental health and health as a whole, influence individuals that are

residing in their new culture. Secondly, the attitudes common in Asian societies such as

collectivist ideals on group goals and views on weakness influence many Asian Americans in

their decision making when contemplating help-seeking. The more someone is anchored in the

beliefs of their specific Asian culture and is less impacted by Western medicine ideas, the more

ASIAN AMERICANS, ACCULTURATION, AND SEEKING OF PSYCHOLOGICAL HELP 7

likely they are to avoid seeking help for mental problems or disorders. Lastly, it is clear that the

more time spent in Western culture, the more positive the help-seeking attitudes due to the

accepting nature of psychotherapy in Western culture.

These results are significant to Asian American health because it displays a hole in our

healthcare system. Mental health is important and arguably makes up half of one’s health status,

which would make it concerning that there such a disparity between Asian American mental

health resource utilization and Caucasian’s. Levels of mental disorders such as depression,

anxiety, bipolar disorder, are serious problems and it is dangerous to wait until the situation is

dire.

If I had to make recommendations for future research into the topic, I would suggest

conducting experiments and analysis on more age groups (as opposed to solely college students)

and focus on specific groups within the race as a whole. Studies also appeared to be relatively

new which indicates a need for more research in mental health seeking tendencies amongst Asian

Americans in general. A few conflictions were apparent between various studies which possibly

made findings less definitive than desired, proving furthermore a need for more research into the

topic. These things are needed in order to produce more concrete evidence.

ASIAN AMERICANS, ACCULTURATION, AND SEEKING OF PSYCHOLOGICAL HELP 8

References

Frey, L.L., & Roysircar, G. (2006). South Asian and East Asian International Students’

Perceived Prejudice, Acculturation, and Frequency of Help Resource

Utilization(Unpublished master’s thesis). Journal of Multicultural Counseling and

Development; Washington. Doi:http://search-

proquest-

com.jpllnet.sfsu.edu/ethnicnewswatch/docview/235999332/fulltextPDF/17AA839B73D0

41D8PQ/1?accountid=13802

Lin, R. (2014). Asian American Acculturation and Psychological Help-Seeking Attitudes: Meta-

Analysis(Unpublished master’s thesis). Wheaton College. Retrieved December 15, 2017,

from http://search-proquest-

com.jpllnet.sfsu.edu/dissertations/docview/1609204968/358ADE8925CD4861PQ/2?acco

untid=13802

Nguyen, M. V. (2013). The Effects of Psychoeducation on the Help-Seeking Attitudes of

Vietnamese Refugees for Post-Traumatic Stress Disorder(Master’s thesis, The Chicago

School of Professional Psychology). Proquest Disserations Publishing. doi:http://search-

proquest-

com.jpllnet.sfsu.edu/ethnicnewswatch/docview/1524722566/2321DF8ABFB94C54PQ/1

4?accountid=13802

http://search-proquest-com.jpllnet.sfsu.edu/dissertations/docview/1609204968/358ADE8925CD4861PQ/2?accountid=13802

Questions that guided research into this topic were: “Why do Asian American populations historically underutilize mental health resources?”, “Why is acculturation have such an identifiable link to whether someone of Asian American decent has positiv…
Many of the answers to these questions were found in studies conducted on college students in the US of various ethnicities that fall under the “Asian American” umbrella. When searching under the various databases listed previously, many studies appe…
Once conducting an ample amount of research into the articles and dissertations available it quickly became apparent that due to a lack of field research into the topic, in order to collect a sufficient amount of credible evidence it would be better …

O R I G I N A L P A P E R

Acculturation and Disability Rates Among Filipino-Americans

Leanne R. De Souza • Esme Fuller-Thomson

Published online: 11 October 2012

� Springer Science+Business Media, LLC 2012

Abstract Filipinos are the fastest growing Asian

subgroup in America. Among immigrants, higher accul-

turation (adaptation to host society) predicts disability

outcomes and may relate to disability prevalence among

older Filipinos. We conducted a secondary analysis of the

2006 American Community Survey using a representative

sample of older Filipinos (2,113 males; 3,078 females) to

measure functional limitations, limitations in activities of

daily living, blindness/deafness and memory/learning

problems. Filipino males who were Americans by birth/

naturalization had higher odds of blindness/deafness (OR

2.94; 95 % CI = 1.69, 5.12) than non-citizens. Males who

spoke English at home had higher odds of blindness/

deafness (OR 1.82; 95 % CI = 1.05, 3.17) and memory/

learning problems (OR 2.28; 95 % CI = 1.25, 4.15), while

females had higher odds of memory/learning problems (OR

1.75; 95 % CI = 1.13, 2.73). Acculturation is associated

with greater odds of disabilities for Filipino men. Males

may be more sensitive to acculturation-effects than females

due to culturally prescribed roles and gender-specific

experiences at the time of immigration.

Keywords Filipino � Disability � Activities of daily
living � Immigration � Assimilation �

Functional limitations

Introduction

The Asian American and Pacific Islander (AAPI) popula-

tion is the fastest growing minority group in the United

States, accounting for approximately 4 % of the total

population, with estimates projecting increases to 11 % or

41 million U.S. residents by the year 2050 [1]. To date,

studies about the health of Asian Americans have typically

aggregated ethnic groups into one category despite the fact

that there are considerable ethnic diversities in culture,

language, and immigration history among the different

Asian groups. However, recent research has highlighted the

importance of separating the study of each AAPI group

separately to focus on disparities among subpopulations

[2–5].

Among AAPIs in the United States, Filipinos form the

second largest subgroup after the Chinese, with one in five

Asians reporting Filipino ancestry [6]. The number of

Filipinos and other Asians immigrating to America

increased dramatically following amendments to immi-

gration laws in 1965 that removed Asian immigration

quotas. As such, by 2007 over 90 % of Filipinos in the U.S.

were foreign-born [7].

Older Filipino-Americans are comprised of three dis-

tinct groups based on their age at immigration: 35 %

immigrated before age 40, 30 % immigrated between 40

and 59 years of age and 35 % immigrated at 60 years or

older [7]. Growing evidence underscores the disparities in

health outcomes among individuals of Filipino ancestry

compared to their AAPI and Caucasian counterparts.

Studies range from child and adolescent health showing

higher prevalence of neonatal mortality, malnutrition, and

obesity [8], to studies demonstrating higher rates of cancer,

cardiovascular disease, diabetes, and mental illness among

adults [9–15]. Many of these chronic diseases show

L. R. De Souza (&)
Institute of Medical Sciences, University of Toronto, Toronto,

ON, Canada

e-mail: leanne.desouza@utoronto.ca

E. Fuller-Thomson

Sandra Rotman Chair in Social Work, Factor Inwentash Faculty

of Social Work, University of Toronto, 246 Bloor Street West,

Toronto, ON M5S 1V4, Canada

e-mail: esme.fuller.thomson@utoronto.ca

123

J Immigrant Minority Health (2013) 15:462–471

DOI 10.1007/s10903-012-9708-1

increasing prevalence with increasing age and accultura-

tion [14]. Though only a few studies have compared older

Filipinos to other AAPI subgroups, these consistently

report substantial vulnerabilities with respect to self-

reported mortality, depression, chronic diseases, physical

inactivity and disabilities [5, 16–18]. Moreover, higher

incidence and prevalence of blindness/deafness occurs

among immigrants, which may be related to socioeconomic

inequalities [19], type of employment and limited access to

job-related resources [20]. In the same way, blindness may

also be affected by similar socioeconomic variables and is

associated with many chronic diseases as a common

comorbidity [21].

In keeping with much of the recent gerontological

research [22, 23], we define ‘‘older’’ as age 55 and over.

Research indicates that functional health inequalities peak

in the 55–64 year old group, whether socioeconomic status

or differenes among visible minorities [24] are examined.

Indeed, studies have also demonstrated gender disparities

in disability outcomes that increase with age, where men

have worse outcomes of a serious medical nature than

women, while women have greater functional limitations

as they age [25]. The association between gender differ-

ences and health outcomes is complex and is affected by

variables such as reporting bias, acquired risk and biolog-

ical risk [26], and these in turn translate into different

mortality and morbidity outcomes [27].

A national survey study revealed that compared to their

U.S.-born counterparts, Chinese, Japanese and Filipino

immigrants had lower life expectancy and the risk of disability

and chronic disease increased according to length of residence

[28]. We recently showed that compared to Chinese respon-

dents, Filipinos had lower odds of cognitive problems, higher

odds of functional limitations and comparable odds of

ADL

limitations [18]. Similarly, Kim and colleagues [17] found that

Filipinos exhibited marked differences in chronic diseases and

disability rates, and tended to have poor overall physical

health compared to Chinese, Japanese, and Koreans [17]. A

growing body of research underscores the apparent need to

disaggregate research of AAPIs to accurately portray the

varying disease burden of especially vulnerable subgroups

and to examine their respective life histories that lead to dis-

parities in disability rates.

Socioeconomic status (SES) and indicators of accultur-

ation are thought to influence health status [29]. A

comparison of older Asian-Americans with U.S.-born non-

Hispanic Whites showed that in later life, immigrant status

confers few disability advantages [30]. Moreover, disabil-

ity rates are influenced by the combined effects of age at

immigration and duration of residence in the U.S. [30].

Indeed, Cho and Hummer [16] found marked differences in

disability status across AAPI subgroups with variations

attributable to nativity, age and SES status.

Chronic health conditions often culminate in some form

of disability with older age and in turn, disability can

reflect the severity of chronic diseases and their co-

morbidities [29, 30]. Accordingly, disability is considered a

reliable quality-of-life indicator capturing the diseased and

healthy conditions and has been proposed as a more

accurate assessment of well-being than traditional mor-

bidity and mortality data [31]. Careful monitoring of dis-

ability rates in vulnerable populations can facilitate

intervention strategies [32, 33] and health promotion.

Considering the disparities of chronic diseases among adult

Filipinos compared to other AAPIs, it is evident that dis-

ability prevalence is an important issue to examine in this

group.

Previously we described the variability in disability rates

across seven AAPI subgroups [18]. In the present study, we

conducted a secondary analysis of the Filipino subgroup to

develop a profile of older Filipino-Americans living with

disabilities. This may provide insight to help policy makers

drive decision-making, resource allocation and develop-

ment of social support programs targeting the needs of

older Filipino-Americans. In addition, such an analysis

may also improve health care professionals’ ability to tailor

services to the most vulnerable Filipino-Americans.

Methods

The American Community Health Survey (ACS) is a

nationally representative survey of community-dwelling

and institutionalized Americans, conducted annually by the

U.S. Census Bureau [34]. The ACS replaces the long-form

of the U.S. Census. Sampling is based on the US Census

Bureau’s Master Address File [35]. Data collection started

with multiple mailed surveys; non-respondents were then

contacted through computer-assisted telephone surveys. A

random sample of those who were non-responders to both

the mail and telephone survey were visited in person and

interviewed face to face. This strategy resulted in a

response rate of 97.5 %. Institutionalized community

members included those living in nursing homes, in-patient

hospice facilities, psychiatric hospitals, and adult correc-

tional facilities were included [34].

In the present study, we use the 2006 ACS (98 %

response rate) to examine disability outcomes of older

Filipino adults aged 55 and older (n = 5,192) to charac-

terize a disability profile in this cross-section of the pop-

ulation. Four self-reported disability outcomes were

examined: Respondents were asked if they had any of the

following long-lasting conditions: (a) ‘‘Blindness, deafness

or a severe vision or hearing impairment’’ (vision/hearing

limitations) (b) ‘‘A condition that substantially limits one

or more basic physical activities such as walking, climbing

J Immigrant Minority Health (2013) 15:462–471 463

123

stairs, reaching, lifting, or carrying’’ (functional limita-

tions); and whether ‘‘Because of a physical, mental, or

emotional condition lasting 6 months or more’’ they had

difficulty: (a) ‘‘Learning, remembering, or concentrating’’

(memory loss and learning difficulties) and/or (b) ‘‘Dress-

ing, bathing, or getting around inside the home’’ (ADL

limitations). Each item included a dichotomous yes/no

response option.

Demographic variables collected included age groups

(55–64, 65–74, 75–84, and 85 years or older) and marital

status (never married, separated, divorced or widowed

versus ‘‘now married’’). The socioeconomic variable

measured was level of education (only primary school or

less, some high school, high school graduate, bachelor

degree and graduate degree). Factors of acculturation

included age at immigration (U.S. born, immigrated prior

to age 20, aged 20–39, 40–59, 60 or older), citizenship

(American by birth or naturalization, non-citizen), and

speaking English at home (yes, no).

Because the only socioeconomic variable available for

the institutionalized respondents was level of education we

used it as a surrogate for SES in our analysis.

Marital status, education level, speaking English at

home, age at immigration and citizenship were included in

each analysis in a nationally representative sample of Fil-

ipino-Americans. Each of these variables was included in a

series of gender-specific multivariate logistic regression

analyses to characterize factors associated with each of the

four types of disability. The weighted prevalence, odds

ratios (OR), and 95 % confidence intervals (CIs) for each

disability type were calculated. All statistical analyses were

conducted using SPSS 17.0. Due to the dichotomous out-

come measure in logistic regression, a regular R-Square

could not be used. The Nagelkerke R-square is a pseudo-

R-Square measure for logistic regression analyses that

provides a measure of the explained variability in the

model.

Results

Results for demographic information and all four disability

types: ADLs, functional limitations, blindness/deafness,

and memory/learning disabilities are shown in Tables 1

through 5 respectively. We report the Odds Ratios (OR)

and 95 % Confidence Intervals (CI) in the tables.

Acculturation Factors

The odds of memory or learning disabilities (Table 5) were

significantly higher among women who spoke English at

home compared to those who did not (OR 1.75; 95 %

CI = 1.13, 2.73) and among women who immigrated at

age 60 years or older in comparison to those born in the

U.S. (OR 1.93; 95 % CI = 1.03, 3.62). Alternatively,

among Filipino males, those who immigrated at age

20 years or younger had significantly higher odds for all

four disability types, in comparison to those born in the

U.S. as follows: ADLs (Table 2: OR 4.19; 95 % CI =

1.73, 10.15), functional limitations (Table 3: OR 1.95;

95 % CI = 1.13, 3.36), blindness or deafness (Table 4: OR

1.91; 95 % CI = 1.00, 3.67), and memory or learning

problems (Table 5: OR 3.30; 95 % CI = 1.40, 7.78).

Compared to non-citizens, Filipino males with Ameri-

can citizenship had significantly higher odds of blindness

or deafness (Table 4: OR 2.94; CI 1.69, 5.12). Compared to

those who did not speak English at home, males who spoke

English at home had significantly higher odds of blindness

or deafness (Table 4: OR 2.09; 95 % CI = 1.29, 3.39) and

memory or learning problems (Table 5: OR 2.28; 95 %

CI = 1.25, 4.15). Women who spoke English at home in

comparison to those who did not had increased odds of

memory or learning problems (Table 5: OR 1.75;

CI = 1.13, 2.73).

Demographic Factors

In comparison to females in the 55–64 year old age

bracket, each older age cohort had higher odds of disabil-

ity. For example as shown in Table 2, the odds of limita-

tions in ADLs were 2.05 (95 % CI 1.28, 3.28) times higher

for 65-74 year old women, 6.20 times higher (95 % CI

3.79, 10.16) for 75–84 year olds and 20.26 (95 %

CI = 11.18, 36.69) times higher for women aged 85 or

older. Similarly, for females, odds of functional limitations

were 2.6, 4.9 and 10.9 times higher, in the 65–74, 75–84

and 85? cohorts, respectively (Table 3). The patterns were

also similar for the other disability types: for those aged 85

and older in comparison to those aged 55–64, females odds

of blindness/deafness reached 13.20 (Table 4: 95 %

CI = 7.41, 23.53) and the odds of memory/learning prob-

lems was 11.05 (Table 5: 95 % CI = 6.47, 18.86). Similar

outcomes were found for males (Tables 2, 3, 4, 5).

Unmarried females had significantly higher odds of

functional limitations (Table 1: OR 1.28; 95 % CI = 1.05,

1.56), memory or learning problems (Table 5: OR 1.50;

95 % CI = 1.13, 2.00) and blindness or deafness (Table 4:

OR 1.63; 95 % CI = 1.19, 2.22), in comparison to married

females. Among males, unmarried status was associated

with higher odds of functional limitations in comparison to

married males (Table 3: OR 1.48; 95 % CI = 1.10, 2.01).

Socioeconomic Factors

Lower levels of education were associated with higher

odds of disability. In comparison to those with a graduate

464 J Immigrant Minority Health (2013) 15:462–471

123

degree, higher odds of functional limitations were apparent

for both males (OR 2.12; 95 % CI = 1.19, 3.77) and

females (OR 2.01; 95 % CI = 1.28, 3.16) who had only

completed primary school (Table 3). Similarly, the odds of

blindness or deafness were higher among males (OR 2.32;

95 % CI = 1.09, 4.91) and females (Table 4: OR 3.26;

95 % CI = 1.19, 7.82) with only primary school education

and the same was true for memory or learning problems

among males (OR 6.98; 95 % CI = 2.07, 23.54) and

females (OR 4.94; 95 % CI = 2.24, 10.90). The odds of

Table 1 Demographic
description of Filipino male and

female respondents to the 2006

ACS survey

Variables Males

(n = 2,113)
Females

(n = 3,079)

Total

(n = 5,192)
p value

ADL

No 2,000 (94.7 %) 2,883 (93.0 %) 4,883 (93.7 %) 0.014

Yes 113 (5.3 %) 196 (7.0 %) 309 (6.3 %)

Functional limitations

No 1,742 (83.2 %) 2,452 (79.4 %) 4,194 (80.9 %) 0.001

Yes 371 (16.8 %) 627 (20.6 %) 998 (19.1 %)

Blindness/deafness

No 1,899 (89.5 %) 2,844 (92.1 %) 4,743 (91.1 %) 0.001

Yes 214 (10.5 %) 235 (7.9 %) 449 (8.9 %)

Memory/learning

No 1,970 (93.4 %) 2,808 (90.5 %) 4,778 (91.6 %) 0.000

Yes 143 (6.6 %) 271 (9.5 %) 414 (8.4 %)

Demographics

Age

55–64 1,134 (53.7 %) 1,636 (50.9 %) 2,770 (52.0 %) 0.013

65–74 604 (27.9 %) 864 (28.5 %) 1,468 (28.3 %)

75–84 296 (14.9 %) 457 (16.0 %) 753 (15.6 %)

85? 79 (3.4 %) 122 (4.6 %) 201 (4.1 %)

Marital status

Never married/divorced/

separated/widowed

322 (16.1 %) 1,237 (44.2 %) 1,559 (33.1 %) 0.000

Yes 1,791 (83.9 %) 1,842 (55.8 %) 3,633 (66.9 %)

Education in levels

Primary 166 (7.8 %) 429 (14.8 %) 595 (12.0 %) 0.000

High school (no diploma) 110 (4.9 %) 210 (6.3 %) 320 (5.8 %)

High school (diploma ? other

education/not bachelors)

913 (42.5 %) 1,047 (35.6 %) 1,960 (38.3 %)

Bachelors degree 717 (34.5 %) 1,149 (35.5 %) 1,866 (35.1 %)

Graduate degree 207 (10.4 %) 244 (7.7 %) 451 (8.8 %)

Age at immigration

Born in the US 245 (11.4 %) 240 (7.4 %) 485 (9.0 %) 0.000

\ 20 146 (6.4 %) 84 (2.3 %) 230 (3.9 %)
20–39 954 (43.1 %) 1,429 (43.0 %) 2,383 (43.0 %)

40–59 553 (27.4 %) 984 (33.8 %) 1,537 (31.2 %)

60–100 215 (11.8 %) 342 (13.6 %) 557 (12.9 %)

Citizenship

Not a citizen 370 (19.6 %) 637 (23.3 %) 1,007 (21.8 %) 0.002

Citizen by birth or

naturalization

1,743 (80.4 %) 2,442 (76.7 %) 4,185 (78.2 %)

English-speaking

Does not speak English at home 1,829 (87.2 %) 2,697 (87.8 %) 4,526 (87.5 %) 0.52

Speaks english at home 284 (12.8 %) 382 (12.2 %) 666 (12.5 %)

J Immigrant Minority Health (2013) 15:462–471 465

123

ADL disabilities were increased among females with only

primary school education (OR 2.48; 95 % CI = 1.06, 5.83)

compared to those with a graduate degree (Table 2). Fur-

thermore, women with only some high school had higher

odds of blindness or deafness (Table 4: OR 4.08; 95 %

CI = 1.60, 10.40) and memory or learning problems

(Table 5: OR 3.10; 95 % CI = 1.30, 7.41) than women

with a graduate degree. Women with a high school diploma

reported greater odds of memory or learning problems than

their peers with a graduate degree (Table 5: OR 2.54; 95 %

CI = 1.16, 5.55).

Males with only a high school diploma had higher odds

of blindness or deafness (Table 4: OR 2.53; 95 %

CI = 1.33, 4.80) compared to those with a graduate

degree. There was also a graded increase in the odds of

functional limitations among males who graduated from

high school (OR 1.64; CI 1.02, 2.63), to completion of only

some high school (OR 2.06; CI 1.09, 3.89), to only primary

school education (reported above) compared to those with

a graduate degree (Table 3). This increasing risk compared

to those with a graduate degree, was also observed for

memory or learning problems among Filipino males

(Table 5), from high school graduate (OR 5.42; CI 1.71,

17.18), to only some high school completed (OR 6.62; CI

1.83, 23.97), to only primary school (reported above).

Discussion

Few studies have investigated health outcomes of older

adults from distinct AAPI subpopulations [5, 16–18].

Disaggregating the study of AAPIs to evaluate the impact

Table 2 Logistic regression of
limitations in activities of daily

living (ADL) according to

demographic, socioeconomic

and immigration-related

variables in older Filipino males

(n = 2,113) and Females

(n = 3,079)

Per cent change in Nagelkerke

R Square associated with the

addition of education

level = 0.8 % male, 0.6 %

female

Per cent change in Nagelkerke

R Square associated with

addition of age at

immigration = 2.6 % male,

0.2 % female

Per cent change in Nagelkerke
R Square associated with

addition of citizenship status

and language spoken at

home = 0.01 % male, 0.1 %

female

Total Nagelkerke R-Square

value for full model = 0.179

male, 0.207 female

Nagelkerke R Square associated

with age and marital

status = 0.144 male, 0.198

female

Male Female

OR 95 % CI OR 95 % CI

Demographic variables

Age

55–64 1.00 Referent 1.00 Referent

65–74 1.05 (0.56, 1.93) 2.05 (1.28, 3.28)

75–84 4.23 (2.36, 7.58) 6.20 (3.79, 10.16)

85? 12.04 (5.85, 24.77) 20.26 (11.18, 36.69)

Marital status
Marital status

Not married 1.19 (0.72, 1.96) 1.21 (0.87, 1.69)

Married 1.00 Referent 1.00 Referent

Adult socioeconomic status

Education

Primary 1.59 (0.60, 4.25) 2.48 (1.06, 5.83)

Some high school 2.66 (0.96, 7.36) 2.00 (0.77, 5.20)

High school graduate 1.51 (0.64, 3.55) 2.15 (0.93, 4.94)

Bachelor degree 1.36 (0.55, 3.34) 1.46 (0.62, 3.42)

Graduate degree 1.00 Referent 1.00 Referent

Immigration and citizenship

Age at immigration

U.S. born 1.00 Referent 1.00 Referent

\ 20 4.19 (1.73, 10.15) 0.97 (0.27, 3.44)
20–39 0.90 (0.37, 2.23) 1.42 (0.69, 2.90)

40–59 1.33 (0.53, 3.31) 1.48 (0.74, 2.97)

60–100 1.58 (0.61, 4.09) 1.74 (0.84, 3.61)

Citizenship

American by birth or naturalization 1.44 (0.76, 2.72) 1.05 (0.71, 1.56)

Not a citizen 1.00 Referent 1.00 Referent

Speaks english at home

Yes 0.98 (0.48, 1.99) 1.25 (0.73, 2.15)

No 1.00 Referent 1.00 Referent

466 J Immigrant Minority Health (2013) 15:462–471

123

of migration histories, indicators of acculturation and

socio-demographic variables on health outcomes reveals

important insights into the health of vulnerable subgroups

[5] such as older Filipino-Americans.

Among the adult Filipino population we found that older

age, marriage, education and common indicators of

acculturation: speaking English at home, age at immigra-

tion and citizenship, were associated with higher odds of

functional disability, limitations in ADLs, memory or

learning problems and blindness or deafness. These asso-

ciations were different between men and women, indicat-

ing unique sex-specific factors associated with disability

outcomes.

Older age often involves some deterioration in physical

(functional limitations, ADLs, blindness or deafness) and

cognitive function (memory or learning problems) that

varies between genders regardless of ethnicity [36–38].

Research indicates that older women have a higher prev-

alence of disability and functional limitations than their

male peers [39]. The incidence of new disability among

older adults is generally higher in women, than in men

[40]. However, a systematic review of the literature indi-

cates that when studies control for socioeconomic factors

and health conditions, the gender differences in incidence

of functional disability are often reduced to non-signifi-

cance [40].

We found that unmarried females demonstrated signif-

icantly higher odds of functional limitations, blindness or

deafness and memory or learning problems in comparison

to married women. Conversely, marital status of males

showed no significant association with any of the four

types of disability and only approached significance with

functional limitations. Approximately half of Filipinos in

America are married, according to the 2000 U.S. census

Table 3 Logistic regression of
functional limitations according

to demographic, socioeconomic

and immigration-related
variables in older Filipino males

(n = 2,113) and females

(n = 3,079)
Per cent change in Nagelkerke
R Square associated with the
addition of education

level = 1.3 % male, 0.7 %

female
Per cent change in Nagelkerke
R Square associated with
addition of age at

immigration = 1.1 % male,

0.0 % female

Per cent change in Nagelkerke
R Square associated with
addition of citizenship status
and language spoken at

home = 0.3 % male, 0.1 %

female
Total Nagelkerke R-Square

value for full model = 0.168

male, 0.182 female

Nagelkerke R Square associated
with age and marital

status = 0.141 male, 0.174

female
Male Female
OR 95 % CI OR 95 % CI
Demographic variables
Age
55–64 1.00 Referent 1.00 Referent

65–74 1.37 (1.00, 1.88) 2.62 (2.05, 3.34)

75–84 4.49 (3.15, 6.41) 4.90 (3.64, 6.60)

85? 7.82 (4.45, 13.72) 10.88 (6.98, 16.94)

Marital status
Marital status

Not married 1.48 (1.10, 2.01) 1.28 (1.05, 1.56)

Married 1.00 Referent 1.00 Referent
Adult socioeconomic status
Education

Primary 2.12 (1.19, 3.77) 2.01 (1.28, 3.16)

Some high school 2.06 (1.09, 3.89) 1.58 (0.93, 2.67)

High school graduate 1.64 (1.02, 2.63) 1.45 (0.95, 2.22)

Bachelor degree 1.16 (0.70, 1.89) 1.21 (0.79, 1.85)

Graduate degree 1.00 Referent 1.00 Referent
Immigration and citizenship
Age at immigration
U.S. born 1.00 Referent 1.00 Referent

\ 20 1.95 (1.13, 3.36) 0.90 (0.43, 1.90)
20–39 0.94 (0.58, 1.52) 0.91 (0.60, 1.40)

40–59 0.88 (0.53, 1.48) 0.90 (0.59, 1.39)

60–100 1.16 (0.65, 2.05) 0.96 (0.60, 1.55)

Citizenship

American by birth or naturalization 1.42 (0.98, 2.08) 1.03 (0.80, 1.33)

Not a citizen 1.00 Referent 1.00 Referent
Speaks english at home

Yes 1.25 (0.83, 1.90) 0.84 (0.59, 1.19)

No 1.00 Referent 1.00 Referent

J Immigrant Minority Health (2013) 15:462–471 467

123

[6]. Research studies have described marriage as a pro-

tective factor for disability outcomes [7]. Moreover, evi-

dence shows that cognitive decline is more apparent in

women without a stable partnership [7].

Higher levels of education are considered protective

against cognitive problems and other disabilities [16]. In

the present study, for both genders, lower education levels

were associated with higher odds of functional limitations,

blindness or deafness and memory or learning problems.

A particularly strong association was apparent between

lower education level and memory or learning disabilities.

Education is a surrogate indicator of SES as it usually

indicates the propensity for job acquisition and career

development [7, 38, 41, 42]. Those individuals with higher

education are more likely to be employed and may receive

benefits that support resources for medical care and

improved quality of life, important factors to delaying

disability. Even with lower education, men in this cohort

may have been able to access job opportunities for financial

security. Moreover, men in our cohort may have belonged

to a population of early immigrant Filipino men who were

active members of the U.S. military and as such, acquired

citizenship through the U.S. Immigration and Naturaliza-

tion Act, which in 1990 permitted special provision of U.S.

citizenship to Filipino male veterans. Many of the older

Filipino males in our sample may have belonged to this

unique group, which could in turn contribute to some

specific cohort effects in our study [43].

Our findings are consistent with other research demon-

strating that higher SES as indicated by education corre-

sponds to lower mortality and morbidity rates [5, 44]. The

major exception in this study was the lack of a significant

Table 4 Logistic regression of
blindness/deafness/severe

sensory impairment according

to demographic, socioeconomic
and immigration-related
variables in older Filipino males
(n = 2,113) and females
(n = 3,079)
Per cent change in Nagelkerke
R Square associated with the
addition of education

level = 1.9 % male, 1.4 %

female
Per cent change in Nagelkerke
R Square associated with
addition of age at

immigration = 1.0 % male,

0.8 % female

Per cent change in Nagelkerke
R Square associated with
addition of citizenship status
and language spoken at

home = 2.1 % male, 0.0 %

female
Total Nagelkerke R-Square

value for full model = 0.220

male, 0.211 female

Nagelkerke R Square associated
with age and marital

status = 0.170 male, 0.189

female
Male Female
OR 95 % CI OR 95 % CI
Demographic variables
Age
55–64 1.00 Referent 1.00 Referent

65–74 2.76 (1.83, 4.17) 2.49 (1.61, 3.87)

75–84 6.66 (4.23, 10.50) 6.17 (3.87, 9.84)

85? 15.66 (8.39, 29.22) 13.20 (7.41, 23.53)

Marital status
Marital status

Not married 0.92 (0.62, 1.36) 1.63 (1.19, 2.22)

Married 1.00 Referent 1.00 Referent
Adult socioeconomic status
Education

Primary 2.32 (1.09, 4.91) 3.26 (1.36, 7.82)

Some high school 2.02 (0.88, 4.63) 4.08 (1.60, 10.40)

High school graduate 2.53 (1.33, 4.80) 2.31 (0.98, 5.47)

Bachelor degree 1.32 (0.66, 2.63) 1.90 (0.79, 4.57)

Graduate degree 1.00 Referent 1.00 Referent
Immigration and citizenship
Age at immigration
U.S. born 1.00 Referent 1.00 Referent

\ 20 1.91 (1.00, 3.67) 0.37 (0.08, 1.62)
20–39 1.06 (0.59, 1.91) 0.78 (0.41, 1.50)

40–59 1.30 (0.70, 2.41) 1.35 (0.73, 2.48)

60–100 1.75 (0.90, 3.40) 0.97 (0.50, 1.88)

Citizenship

American by birth or naturalization 2.94 (1.69, 5.12) 1.19 (0.82, 1.72)

Not a citizen 1.00 Referent 1.00 Referent

Speaks English at home

Yes 2.09 (1.29, 3.39) 0.97 (0.56, 1.67)

No 1.00 Referent 1.00 Referent

468 J Immigrant Minority Health (2013) 15:462–471

123

link between education and ADL limitations for males.

Speaking English at home and citizenship status were each

measured as common indicators of acculturation. The 2000

U.S. census reports that 29 % of Filipinos have less than a

9
th

grade education and that 17 % are linguistically iso-

lated, with 56 % reporting that they do not speak English

very well [6]. Males who speak English at home had higher

odds of blindness or deafness. Speaking English at home

was also associated with higher odds of memory or

learning problems for both males and females. These sur-

prising findings should be replicated in other, large,

nationally representative surveys. Future research is also

needed to examine possible pathways and/or confounding

factors that may shed light on this association.

We also found that Filipino males who were U.S. citi-

zens had increased odds of blindness or deafness compared

to non-citizens. Foreign-born persons are thought to be

healthier than their U.S.-born counterparts because of the

self-selectivity of immigration and prerequisite health

requirements to migrate to the U.S. [45], their strong

family support systems [46] and resilience [7]. These

characteristics that describe the ‘healthy migrant effect’ are

thought to diminish over time with longer residence in the

U.S. due to deterioration of healthy behaviours [7, 28] and

adoption of American lifestyle and practices. In addition,

reasons for migration such as family reunification and

pursuit of job opportunities, alongside acculturation factors

can also have a positive influence toward improved

opportunities, access to healthy behaviours in the host

nation, knowledge and attitudes about health, stress man-

agement and accumulation of health resources [5].

In comparison to the US-born, only Filipino males who

immigrated before 20 years old had significantly higher

odds of all four disability types. This may be due to the

Table 5 Logistic regression of
memory/learning problems

according to demographic,

socioeconomic and

immigration-related variables

for older Filipino males

(n = 2,113) and females
(n = 3,079)
Per cent change in Nagelkerke
R Square associated with the
addition of education

level = 2.6 % male, 2.6 %

female
Per cent change in Nagelkerke
R Square associated with
addition of age at

immigration = 1.7 % male,

0.4 % female

Per cent change in Nagelkerke
R Square associated with
addition of citizenship status
and language spoken at

home = 0.8 % male, 0.3 %

female
Total Nagelkerke R-Square

value for full model = 0.189

male, 0.212 female

Nagelkerke R Square associated
with age and marital

status = 0.138 male, 0.179

female
Male Female
OR 95 % CI OR 95 % CI
Demographic variables
Age
55–64 1.00 Referent 1.00 Referent

65–74 1.19 (0.70, 2.02) 2.36 (1.61, 3.47)

75–84 3.63 (2.13, 6.19) 4.82 (3.16, 7.37)

85? 8.89 (4.48, 17.62) 11.05 (6.47, 18.86)

Marital status
Marital status

Not married 0.94 (0.59, 1.50) 1.50 (1.13, 2.00)

Married 1.00 Referent 1.00 Referent
Adult socioeconomic status
Education

Primary 6.98 (2.07, 23.54) 4.94 (2.24, 10.90)

Some high school 6.62 (1.83, 23.97) 3.10 (1.30, 7.41)

High school graduate 5.42 (1.71, 17.18) 2.54 (1.16, 5.55)

Bachelor degree 3.17 (0.97, 10.42) 1.70 (0.77, 3.78)

Graduate degree 1.00 Referent 1.00 Referent
Immigration and citizenship
Age at immigration
U.S. born 1.00 Referent 1.00 Referent

\ 20 3.30 (1.40, 7.78) 0.56 (0.15, 2.19)
20–39 1.84 (0.80, 4.21) 1.48 (0.81, 2.71)

40–59 2.26 (0.96, 5.30) 1.69 (0.93, 3.04)

60–100 4.71 (1.95, 11.41) 1.93 (1.03, 3.62)

Citizenship

American by birth or naturalization 1.24 (0.74, 2.09) 1.04 (0.74, 1.45)

Not a citizen 1.00 Referent 1.00 Referent
Speaks english at home

Yes 2.28 (1.25, 4.15) 1.75 (1.13, 2.73)

No 1.00 Referent 1.00 Referent

J Immigrant Minority Health (2013) 15:462–471 469

123

early age at immigration, or potential cohort effects of this

particular age group. On the other hand, both men and

women who immigrated over the age of 60 years had

higher odds of memory or learning disabilities than US

born Filipino-Americans, which may reflect the reason for

immigration. The reasons for immigrating and timing of

migration among Filipinos are diverse and their experience

in the U.S. varies accordingly [7, 32]. Perhaps adult chil-

dren established in the U.S. sponsor their parents to

immigrate through family reunification policies when their

parents are in need of care, as would be the case for those

with Alzheimers disease or other chronic disease. [47].

There are a several limitations of this study that should be

considered when interpreting the results. Income and wealth

vary greatly among AAPI subpopulations [4, 42, 43,48] and

are highly correlated with level of disability in older adults.

However, information about wealth was not available in the

dataset, which precluded our analysis of this relationship.

Additionally, this data is based on a cross-sectional sample

that did not provide information about the onset and pro-

gression of disability; therefore we cannot determine causal

relationships in our findings [7]. Also, as described earlier,

another limitation inherent to the cross-sectional design of

this study is the potential cohort effects of particular waves of

immigrants that may render some of our findings specific to

this population.

Future cohorts of AAPI elders will differ with respect to

their early life experiences, education and economic status

that may correspond to improvements to functional status

[49].

Finally, the behavioural risk factors of Asian subpopu-

lations may change with time and could affect future

cohorts of aging Filipinos. For example, current neonatal

and childhood diabetes and obesity trends [8], and a shift

in employment opportunities away from agricultural jobs

[3–5], may change future disability trends. The rapid

growth of the AAPI population necessitates accurate and

representative data to make informed health policy and

planning decisions. Each AAPI ethnic group deserves

distinct attention in order to offer culturally-sensitive rec-

ommendations for vulnerable populations. The data

reported here were obtained from a nationally-representa-

tive sample including community-based and institutional-

ized elders. This study identified factors associated with

each of the four types of disabilities among older male and

female Filipino-Americans. Older adults, those who speak

English at home, the unmarried and those with only a

primary school education had higher odds of disability and

therefore Filipino-Americans with these characteristics

should be targeted for improved prevention and treatment

interventions.

Continued surveillance of national surveys and pro-

spective studies will permit further understanding of the

trends in disability outcomes among older Filipinos and

other under investigated AAPI subgroups. There is likely a

complex interplay between migrant selection effects,

positive versus negative acculturation effects, and SES

factors that relate to both timing of immigration and

country of origin [50]. This area of public health research is

especially important given the high prevalence and inci-

dence rates of chronic diseases and disability. Both chronic

diseases and disabilities result in a substantial economic

burden for the country as well as decreased quality of life

for the individual.

Acknowledgments The authors would like to thank Rachel Zhou
for her assistance with preparation of the tables.

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Accessing sexual and reproductive health care and information:
Perspectives and recommendations from young Asian
American women
Madeline Frost a,*, Alexa Cares a, Katie Gelman a, Rita Beam b

a OMNI Institute, 899 Logan Street, Suite 600, Denver, CO 80203, USA
b Tri-County Health Department, 6162 South Willow Drive, Suite 100, Greenwood Village, CO 80111, USA

A R T I C L E I N F O

Article history:
Received 13 May 2016
Revised 16 September 2016
Accepted 25 September 2016

Keywords:
Asian American
Asian Pacific Islander
Sexual health
Reproductive health
Adolescent health
Health communication

A B S T R A C T

Objectives: Understanding the influence of culture on how sexual and reproductive health is perceived
and addressed in Asian American communities is important for the effective provision of care and health
information. This study aimed to explore how and when sexual and reproductive health information is
shared within Asian American families and communities, barriers and facilitators to accessing sexual and
reproductive health care and information for young Asian American women, and their recommenda-
tions to improve access.
Methods: Qualitative data were collected through six focus groups conducted with a total of 33 young
Asian American women.
Results: The majority of participants reported that stigma created a barrier to discussing these topics
within their families and communities, and discussed ways in which they confidentially seek out care
and information. Responses varied with respect to participants’ preferred means of increasing access to
care and information; some recommended strategies that would increase communication about these
issues in their families and communities, while others expressed a desire to maintain confidentiality.
Conclusions: These findings suggest that diversified strategies are needed to connect Asian American women
with sexual and reproductive health care and information in order to meet their varied preferences, in-
cluding strategies that are community-driven and culturally appropriate.

Introduction

Asians are now the fastest-growing racial group in the United
States, and make up approximately 6% of the total population. Nearly
three-quarters of Asian American adults were born abroad, meaning
that the majority of this group is composed of recent immigrants
and their children [1]. Understanding the influence of culture on
how sexual and reproductive health is perceived and addressed in
Asian American communities is important for the effective provi-
sion of care and health information.

In many traditional Asian cultures, sexuality is generally con-
sidered an inappropriate subject to be discussed with others, and
topics such as sexual and reproductive health may be avoided in
Asian American families and communities [2]. Limited research sug-
gests that Asian American parents may communicate with their
children about sex less frequently than parents in other

racial/ethnic groups [3–5], and they are perceived by their chil-
dren to provide very little information about sexual topics [6,7].
Research also suggests that lower use of sexual health-related care
in Asian American communities may be related to cultural factors,
in addition to barriers such as lack of insurance and discrimina-
tion [2,8]. Additionally, Asian American adolescents have reported
being reluctant to discuss sexual and reproductive health issues with
healthcare providers due to concerns about confidentiality [9]. These
factors may create challenges for healthcare providers seeking to
connect Asian American patients with sexual and reproductive care
and information.

An intergenerational communication gap may be negatively af-
fecting some Asian American adolescents’ sexual and reproductive
health. As young Asian American women become more accultur-
ated to U.S. norms, the likelihood that they will become sexually
active increases [10]. Asian American adolescents have been found
to delay sexual intercourse relative to their peers; however once sex-
ually active they are just as likely to engage in risky sexual behavior
[11–14]. Rates of some sexually-transmitted infections (STIs) are in-
creasing for Asian American women under 25 years old, and Asian
American women have lower rates of STI screening than other groups
[8]. Evidence suggests that sexual health interventions are more

* Corresponding author. OMNI Institute, 899 Logan Street, Suite 600, Denver, CO
80203, USA.

E-mail address: mcfrost@uw.edu (M. Frost).

http://dx.doi.org/10.1016/j.srhc.2016.09.007
1877-5756/© 2016 Elsevier B.V. All rights reserved.

Sexual & Reproductive Healthcare 10 (2016) 9–13

Contents lists available at ScienceDirect

Sexual & Reproductive Healthcare

j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g

mailto:mcfrost@uw.edu

http://www.sciencedirect.com/science/journal/18775756

http://www.srhcjournal.org

http://crossmark.crossref.org/dialog/?doi=10.1016/j.srhc.2016.09.007&domain=pdf

effective when tailored to specific populations [15], and efforts to
promote sexual and reproductive health among young people should
consider the cultural contexts of Asian American families and
communities.

Although some research has examined barriers to sexual and re-
productive health care and information for Asian American
populations (e.g., Vietnamese Americans, Chinese Americans, Indian
Americans, etc.), few studies have engaged young Asian American
individuals to share their recommendations for increasing access
to sexual and reproductive health care and information [4,9]. This
paper describes findings from six focus groups that were con-
ducted with young Asian American women in 2012 and 2013. The
focus groups explored how and when sexual and reproductive health
information is shared; barriers and facilitators to accessing sexual
and reproductive health care and information; and young Asian
American women’s recommendations to improve access.

Methods

Research design

This study took a qualitative approach to exploring young Asian
American women’s experiences and recommendations related to
discussing sexual and reproductive health and accessing care and
information. A local health department in the Denver metro area
contracted with a research organization to develop a focus group
protocol asking about participants’ experiences and recommenda-
tions, as well as a questionnaire that gathered supplemental data
on demographics and health behaviors. Prior to beginning data col-
lection, the instruments were piloted with two Asian American
community members who met focus group participant eligibility
criteria, and were subsequently revised to improve their clarity.

Over a two-year period from 2012 to 2013, six focus groups were
facilitated with a total of 33 women. The focus groups ranged from
three to eleven participants. A purposive sampling method was used
in order to assess perspectives of the target population. Eligibility
criteria required participants to be women of Asian descent, between
15 and 24 years old, living in the Denver metro area, and able to
speak and understand English due to the unavailability of transla-
tion services.

Participants were recruited through contacts with local educa-
tional and community organizations, email listservs, flyers, and social
media. Recruitment materials asked participants to engage in a “dis-
cussion about women’s health.” Twenty organizations were
contacted to help facilitate recruitment, and flyers were posted at
32 locations, including colleges, neighborhoods with large Asian
American populations, and storefronts. The majority of partici-
pants were recruited through their involvement with educational
institutions or community organizations, and so, as a group, they
were likely more highly educated and engaged with community or-
ganizations than the broader Asian American population. It is
possible that this education and engagement made them more
knowledgeable about and willing to discuss sexual and reproduc-
tive health topics. In an effort to recruit a more diverse sample during
the second round of focus groups, the research team intentionally
targeted women who may be less engaged in such institutions by
posting more flyers in Asian American neighborhoods and store-
fronts. However, no participants were successfully recruited by these
flyers.

All participants underwent an informed consent process in which
they were told the purpose of the study, that participation was op-
tional and that they could discontinue at any time, and that their
responses would be kept confidential. They were given the oppor-
tunity to ask questions, and then signed a consent form. Guardians
of participants younger than 18 years old also signed a consent form.

Participants received a $50 gift card for their participation in 2012,
and a $25 gift card in 2013.

Each focus group lasted about 90 minutes, and was conducted
by a trained facilitator from the research team in a small confer-
ence room. Before the discussion, participants were asked to
complete the supplemental questionnaire. Discussions were audio-
recorded while an assistant moderator took notes. All researchers
who were present during the focus groups were women, and did
not have any previous relationship with the participants. The fa-
cilitator was a member of the Asian American community. The focus
groups had a semi-structured design, allowing the facilitator to gather
information on key topics of interest while also allowing the par-
ticipants to steer the discussion toward topics they felt were
important.

Analysis

Focus groups were audio-recorded and manually transcribed, and
transcripts were subsequently reviewed for accuracy. The re-
search team integrated deductive and inductive approaches to
qualitative data analysis: preliminary codes were developed based
on a review of the existing literature and research questions (how
sexual and reproductive health care and information is obtained,
barriers and facilitators to such care and information, and partic-
ipant recommendations to improve access). During the process of
coding the first two transcripts, the research team refined the coding
structure to improve clarity and address emerging themes.

Two members of the research team used NVivo qualitative data
analysis software (QSR International Pty Ltd. Version 10, 2012) to
code focus group transcripts. Both coders were research profes-
sionals experienced in qualitative analysis. Inter-rater reliability was
calculated after the coders had analyzed the first two transcripts
(33% of the data) and revised the codebook, with a kappa of 0.86
across all codes indicating strong agreement. The coders then sep-
arately analyzed the remaining transcripts. Focus group data were
aggregated by code and further analyzed to identify subthemes, and
key findings were summarized. Findings and recommendations were
later reviewed with an Asian American community coalition to
ensure their accuracy and usefulness.

Results

Participant demographics

In total, 33 women participated in focus groups during 2012–
2013. Participants ranged from 15 to 24 years of age, and the average
age was 20.1 years. Within a single focus group, the age difference
between the youngest and oldest participant ranged from three to
five years. All women were of Asian descent, and over half (52%)
indicated that their country of origin was the United States. The rest
identified their countries of origin as Vietnam (18%), Korea (15%),
India (6%), Pakistan (3%), Canada (3%), and Malaysia (3%).

At the time of the focus groups, nearly half of participants (49%)
indicated that they were either in college or had completed college.
Two participants (6%) had completed a graduate degree and one (3%)
had completed an Associate’s Degree. The remaining participants
had completed 9th grade (3%), 10th grade (9%), 11th grade (15%),
and 12th grade (15%). The majority of participants (85%) indicated
their occupation as “student,” four (12%) indicated other occupations,1

and one (3%) indicated no occupation. Over half of participants (52%)
indicated that their relationship status was single; the rest indi-
cated that they were dating or in a relationship (44%), or married

1 Other occupations included “quality control analyst,” “family service worker,”
“program assistant,” and “information technology.”

10 M. Frost et al. / Sexual & Reproductive Healthcare 10 (2016) 9–13

(3%). One participant had been pregnant at the time of the focus
group.

Discussing sexual and reproductive health topics

A major theme that emerged in all focus groups was commu-
nication barriers surrounding sexual and reproductive health in
participants’ families and communities. Most participants felt that
there is a “stigma” or “taboo” associated with discussing these topics
in their communities, which some directly attributed to their culture.
Many felt that this prevented them from having a safe forum to start
discussions or ask questions.

“In my culture, the expectation is that you can only get pregnant
if you’re married…There are just some things that you can’t talk
to your parents about it.”

“When I was young, I actually talked to my dad before I talked to
my mom about certain things, like even my period. My mom’s Korean
and my dad’s [white], so I felt more comfort in talking to my dad
about it. I couldn’t talk to my mom about it at all.”

While some participants indicated that they do discuss sexual
and reproductive health issues with sisters, cousins, friends, or co-
workers, most said that they would not talk to their parents, partners
or significant others, or members of their church. Some partici-
pants also felt that their parents and members of their communities
equated birth control with promiscuity, even though it may be taken
for purposes other than contraception (e.g., to regulate periods or
prevent acne).

Participants made frequent distinctions between the values of
Asian American families compared to non-Asian families (some-
times referred to as “American” or “Americanized”) and felt that non-
Asian families are typically more open to discussing and addressing
sexual and reproductive health. A few participants described their
families as being more “relaxed” or “progressive” than other Asian
American families, but some still felt pressure to adhere to their com-
munity’s cultural norms. Several participants discussed how
generational differences shape behaviors and perspectives related
to health, emphasizing how these differences could make health-
related discussions with their parents and grandparents challenging.

“For Asians, having sex at like this age before marriage is a danger.
And then in the American community, [there are] safe ways to have
sex, like it’s different.”

“My mom’s a little different. I mean she’s progressively Asian if that
make sense…she’s very open about, ‘You need to know all your
options and you need to be informed when it comes to that.’ But
that’s not something I’m going to get from her. That’s something I
need to go out and get on my own…I didn’t feel comfortable just
saying, ‘Oh mom I think I should get [a gynecological examination].’ ”

“I think my parents’ views are slowly aligning with mine. They’re
getting more aware of just the typical culture that we – their daugh-
ters and sons – are living in, so they’re trying to understand what
we’re going through because it’s so much different than what they
went through. So they’re slowly being Americanized and under-
standing we can go out there and access whatever we want, and
they trust us.”

Additionally, some participants indicated that their families and
communities did not discuss preventative healthcare more gener-
ally. They felt that individual health is not discussed unless it is an
emergency or critical issue, and that their families did not under-
stand the need for preventative care unless a doctor explained it
to them.

“I think for my family, at least what I’ve seen within the Vietnam-
ese community, a lot of [health] is discussed if something major

happens because it’s an emergency and it has to be, but it’s never
discussed as a preventative thing, or like let’s be healthy and talk
about this. We never talk about it unless we have to, and I think
that’s a major issue, and to prevent pregnancy you kind of have to
talk about it beforehand.”

“I feel like I should be more active about preventative care…but I
think in my culture, you don’t really go to the doctor unless some-
thing’s wrong, like you don’t go just for a checkup.”

Accessing sexual and reproductive health care and information

Focus group participants discussed how stigma and communi-
cation barriers surrounding women’s health in their families and
communities can influence whether and how they access sexual and
reproductive health care and information. Some participants ex-
pressed that their concerns about confidentiality would deter them
from talking with a family doctor about these topics, corroborat-
ing findings from Zhao et al. [9]. Many participants were compelled
to navigate these issues in ways that would offer them anonymity
and privacy, such as finding their own OB/GYN provider or going
to clinics such as Planned Parenthood.

“I know there are HIPAA laws, but I felt like I couldn’t go to my
primary care because she and my mom are friends and there’s that
sort of community, like they’re in the same community. And so I
was like, ‘I’m gonna find an OB/GYN.’ ”

“You wouldn’t have an Asian mom say, ‘Oh, you should have your
OB/GYN when you’re eighteen.’ … I was twenty-one and then I did
it with my friend, and we both have the same family background
and so we’re like, ‘We have to do this.’ So we made back-to-back
appointments and it was our first time and we were scared about
it, you know. We didn’t know what to expect, but we did it together.”

“I know some of my friends have gotten a lot from Planned Par-
enthood and I’ve heard such good things about them and their
experience with it, because they couldn’t talk to their parents about
going on birth control or have it go on their health plan. They want
to keep it on the [down-low], so they go to Planned Parenthood and
get it.”

Many participants said that they access women’s health infor-
mation on the Internet because it is confidential, and they feel like
they can seek answers to their questions without judgment. However,
they also expressed concerns about the accuracy of information, as
well as the quantity of information they have to sift through in order
to find credible information.

“I always go to the Internet first for confidentiality. I know this is
anonymous, but I recently contracted an STD, which is a really
common one that one in four women have. I was freaking out and
I didn’t know what to do and I needed a confidential source, so I
read more articles than was good for me on the Internet, and it really
gets in your head.”

“For the most part I feel like a lot of people would just go online
and Google it which is not the most, you know, you can’t trust every
website. But most people are able to distinguish between a reli-
able source and a not so reliable internet source… It might be the
most convenient thing for you outside of what you hear from people
and friends.”

Participant recommendations for improving access to health care
and information

Participants gave recommendations to improve access to sexual
and reproductive health care and information in their communi-
ties. Recommendations tended to fall into two categories: (1)

11M. Frost et al. / Sexual & Reproductive Healthcare 10 (2016) 9–13

strategies that promoted increased communication about these
health issues in their families and communities, and (2) strategies
that would allow women to maintain confidentiality when seeking
health information and care.

Many, but not all, participants shared a desire to open doors for
increased communication about sexual and reproductive health in
their families and communities. Participant recommendations related
to this goal included:

• Organizing discussion groups that allow Asian American women
to discuss their health questions and experiences, with a health-
care professional available to respond to questions

• Matching women with one-on-one peer mentors, or young
women with older mentors, to create a safe space to discuss
sexual and reproductive health-related issues

• Offering free sexual and reproductive health information in a
neutral format (e.g., pamphlets or posters) at Asian American
community centers or events

• Engaging campus organizations such as Asian student groups,
Asian sororities and LGBTQ groups to plan forums and dissem-
inate information on an ongoing basis

• Including young Asian American men in conversations about
sexual health, particularly regarding pregnancy prevention and
consensual sex

Participants disagreed as to whether parents should be in-
cluded in conversations about reproductive and sexual health. While
some recommended that parents be included, others did not wish
to have such discussions with their parents, preferring to have them
with other mentors or friends. Participants also provided mixed re-
sponses about whether or not they would want to know other
attendees in discussion groups; some said it would be more com-
fortable to be with people they know, while others said that they
would not want to share information if friends or acquaintances were
present.

“There are a lot of events in the [Asian American]
community…gathering of a lot of people, so there’s that exposure.
So, even if you’re seeing pamphlets and posters, and not necessar-
ily talking about it just yet, at least there’s that visibility, that this
is an issue that is worth bringing up.”

Many participants also expressed a desire for strategies that
would allow them to maintain confidentiality when seeking and ac-
cessing sexual and reproductive health care and information.
Recommendations related to this goal included:

• Offering text message-based information dissemination, where
students can receive information on an ongoing basis or text in
their questions anonymously

• Informing women about credible online resources that will allow
them to seek out accurate information privately

• Creating a credible online forum for women to discuss health
issues anonymously

• Providing sexual education curriculum in schools that is not based
on an abstinence-only approach, but rather offers specific in-
formation about preventing pregnancy and sexually transmitted
diseases

• Informing high school students about options for sexual and re-
productive health care, such as clinics

• Encouraging healthcare providers to proactively and confiden-
tially provide young women with information about sexual and
reproductive health and available resources

“Well, I think because I didn’t find out about the clinic until I was
nineteen, which was pretty recent, and I just felt like, if more people

told me about it when I was still in high school it would have been
better.”

“Maybe having [healthcare providers] also know other re-
sources… I’m not comfortable talking to him, but then if he said,
‘These are the resources, if you’re not comfortable talking to me, you
also have these places that you can go to.’ … because if a teenager
is under their parents’ plan, they have another way of going outside
but getting help from within the people we already have.”

Discussion

There were several limitations to this study. First, although a qual-
itative approach provides rich data reflecting the experiences and
recommendations of participants, these results cannot be viewed
as generalizable. Notably, the recruitment challenges described in
the methods section resulted in most participants being highly
engaged with educational or community institutions, and their per-
spectives may not accurately reflect those of other Asian American
women. Additionally, this study did not have adequate resources
to translate materials or use interpreters, limiting participation to
English-speaking women. Finally, due to small sample size, the anal-
ysis was unable to assess any potential differences between different
Asian ethnic groups.

Further studies are needed that can assess differences between
Asian American sub-populations. A more diverse sample may help
determine what health promotion strategies are preferred by Asian
American women of different educational backgrounds, English-
speaking abilities, and levels of engagement with institutions.
Additionally, although participants in this study suggested that
culture plays an important role in Asian American women’s health,
a larger sample is needed to better assess the role of culture through
examining differences by ethnicity and generation status.

These focus groups revealed that Asian American women may
face barriers to accessing sexual and reproductive health care and
information related to communication and stigma, and that they
use varied strategies to obtain such care and information. Our find-
ings corroborate previous research suggesting that young Asian
American individuals perceive communication about sexual and re-
productive health to be limited in their families and communities
[3–7], and may be hesitant to discuss these topics with providers
[9]. Perceived stigma and confidentiality concerns have been iden-
tified as barriers to sexual and reproductive health care for the
adolescent population broadly [16], and other U.S. minority groups,
such as Latina women, have also attributed limited parent–
adolescent communication about sexual topics to cultural norms
[17]. Although the barriers experienced by Asian American women
may not be completely unique, it is important to recognize that par-
ticipants in this and other studies have explicitly linked these barriers
to Asian cultural norms, and therefore consideration of culture may
be necessary to address them.

Through asking young Asian American women to share their rec-
ommendations, our study further revealed that this group is not
uniform with respect to their preferred means of increasing access
to sexual and reproductive care and information; some recom-
mended strategies that would increase communication about these
issues in their communities, while others expressed a desire to main-
tain confidentiality. This finding raises the need for a multi-
pronged and varied approach to connecting Asian American women
with sexual and reproductive health care and information in order
to meet their diverse preferences related to communication and con-
fidentiality. However, it is necessary to consider that the following
specific recommendations are based on the responses of women
who are highly educated and/or engaged with institutions, and who
may be more comfortable discussing these topics in confidential or

12 M. Frost et al. / Sexual & Reproductive Healthcare 10 (2016) 9–13

public settings than Asian American women not represented in this
sample.

Our findings support the maintenance and expansion of oppor-
tunities for young women of all races and ethnicities to discretely
or confidentially access sexual and reproductive care and informa-
tion. Strategies may include information dissemination through
electronic media such as text messaging, credible online re-
sources, and online forums. Other strategies include providing
information proactively in person, such as sexual education in schools
or information offered in a confidential and neutral manner by
healthcare providers. Additionally, based on concerns raised by some
participants, it seems important that providers emphasize their ob-
ligation to maintain confidentiality regarding these issues to young
patients, particularly when they know their parents.

Simultaneously, strategies that seek to increase communica-
tion about sexual and reproductive health within Asian American
families and communities are also important to consider, as this was
a desire expressed by many participants in this study. Some ideas
suggested by participants include in-person discussion forums, pro-
viding information at community centers or events, engaging Asian
American student groups, and including young Asian American men
in information dissemination. Such programming may also address
the need to promote the importance of preventive health care more
generally in Asian American communities. Importantly, we believe
it is essential that these efforts be developed and implemented either
by or in close partnership with members of Asian American com-
munities. Community-driven efforts are more likely to effectively
address the challenges described by participants in this study and
result in culturally-appropriate interventions.

Providers working with Asian American families and commu-
nities should be aware that sexual and reproductive health may be
an uncomfortable topic of discussion for their patients, and that
young Asian American women may be particularly concerned about
their confidentiality with respect to these topics. Further, provid-
ers should recognize that one approach will not meet the needs of
all community members: while some young Asian American women
may desire increased opportunities to discuss sexual and repro-
ductive health within their families and communities, others may
wish to maintain discretion and anonymity in accessing care and
information. Differences in cultural and communication norms can
present challenges to providers in connecting individuals with sexual
and reproductive health care and information. However, illuminat-
ing these differences presents opportunities to improve practice and
meaningfully engage with communities in order to improve sexual
and reproductive health in all populations.

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Accessing sexual and reproductive health care and information: Perspectives and recommendations from young Asian American women

Introduction
Methods
Research design
Analysis
Results
Participant demographics
Discussing sexual and reproductive health topics
Accessing sexual and reproductive health care and information
Participant recommendations for improving access to health care and information
Discussion
References

Peace Review 16:2, June (2004), 149–156

Asian American Activism for

Environmental Justice

JulieSze

Julie Sze

By foregrounding race as a central analytic category, the Asian immigrant and
Asian Pacific American (APA) environmental justice movement is distinct from
the mainstream environmental movement in several ways. The former considers
itself more ideologically inclusive than the latter because it integrates social and
ecological concerns. It treats and links social oppression, exploitation, and
injustice as inseparable from environmental degradation of the natural world.
The concept of environmental justice defines the environment to include public
and human health concerns, such as the exposure of farmworkers to pesticides
and lead, in addition to natural resources such as air, land and water. This
expansive view of what constitutes the “environment” repudiates the elitist, racist
and classist wilderness/preservationist dichotomy, which sees the environment as
being equal to “nature.” Environmental justice (EJ) also utilizes a “holistic
methodology” and worldview that see the environment as a site where people (in
particular people of color) “live, work and play.”

If we see the environment as sites where people live, work and play, this viewcan help explain the wide diversity of environmental justice activism in
low-income Asian immigrant and Asian American communities in the United
States. A wide range of issues are linked to the complex diversity within the
community, in terms of income, experiences and national origin. For example,
almost half of the Asian Pacific Islander population has lived in the United States
for 20 years or less. This group includes large populations of Southeast Asians,
such as the Vietnamese, Cambodians, Laotians and Hmong. Environmentally,
Asian Pacific American communities face many of the same hazards affecting
other communities of color and low-income communities throughout the United
States. For example, according to the 1987 United Church of Christ report Toxic
Wastes and Race, half of all Asians, Pacific Islanders and Native Americans and
three out of five African Americans and Hispanic Americans lived in communi-
ties with uncontrolled toxic waste sites. Urban Asian immigrant populations, like
other poor communities of color, often live in substandard housing, are exposed
to high levels of lead and enjoy fewer environmental amenities such as parks and
playgrounds. At the same time, some of their issues are unique.

Asian immigrant communities have been crucial in expanding definitions of
environmentalism and in advancing the legal and community-based activist
approaches for environmental justice. In particular, the Asian Pacific Environ-
mental Network has been crucial in alleviating the environmental and health

ISSN 1040-2659 print; ISSN 1469-9982 online/04/020149-08 © 2004 Taylor & Francis Ltd
DOI: 10.1080/1040265042000237680

150 Julie Sze

problems of Asian immigrant communities in the San Francisco Bay Area
through their community-based organizing strategy. And yet, Asian Pacific
Islander (API) contributions to EJ have not been well documented in the
literature, or well recognized by the wider environmental justice community.
Thus, the first goal of this essay is to be simply a documentary project. It
introduces the environmental justice movement, and the role of Asian immigrant
and Asian American communities in furthering the agenda for environmental
justice. I introduce the major environmental issues facing Asian immigrant
communities. In particular, I’ll focus on those examples in which there has been
significant organizing around these issues as environmental and environmental
justice concerns. This framing leaves out those issues that have an environmental
component but which have been constructed in another way.

For example, the military pollution of Native Pacific Islander land in Hawaii
is constructed by activists primarily as a land sovereignty issue, and not an
environmental justice concern. Thus, the API EJ issues I’ll address are: occu-
pational health activism in the garment and semiconductor manufacturing
industries, urban redevelopment issues (including housing and gentrification) and
food consumption and production issues (health hazards from contaminated fish,
and the greening of ethnic restaurants). Of these issues, there are some that are
unique to particular Asian immigrant communities and their historical and
cultural trajectory (that is, the consumption of contaminated fish by immigrants
from Vietnam, Cambodia and Laos) while others are shared with other com-
munities of color (urban redevelopment and occupational health concerns).

Second, this essay considers the contributions made by the Asian immigrant
and Asian American environmental justice movement, and by the activism of
African American, Latino and Native American communities. The essay offers
further insights about the possibilities and also the limits of constructing multira-
cial, progressive EJ activism.

The environmental justice movement emerged in the 1980s in the UnitedStates when community-based activities began to dovetail with the growing
documentation of environmental racism. According to Bullard, the environmen-
tal justice movement contends that race correlates to environmental hazards as
an independent factor not reducible to class and poverty. The term
“environmental racism” came to national prominence after reports from the
United States General Accounting Office, the United Church of Christ and the
National Law Journal documented that people of color in the United States suffer
disproportionately from environmental pollution and from unequal protection
from this pollution by the state. According to the seminal report Toxic Wastes and
Race, race proved to be the most significant among the variables tested in
association with the location of commercial hazardous waste facilities. According
to the National Law Journal report, which looked at penalties for environmental
pollution, the disparity in penalties for pollution under the toxic waste laws ran
along racial lines and not income. Lavelle and Coy report that penalties at sites
having the greatest white population were 500 percent higher than penalties with
the greatest minority population, suggesting that regulatory agencies prioritize
the concerns of white communities more than non-white ones, even when the
non-white community is composed of higher-income residents.

Asian American Activism for Environmental Justice 151

The environmental justice movement has several key start dates. It’s typically
held to have been the 1982 protests in Warren County, North Carolina, against
the building of a facility to hold polychlorinated biphenyl (PCB) contaminated
landfill in a poor, predominantly black community. Polychlorinated biphenyls
are highly toxic chemicals known to disrupt hormone function and are linked to
cancer. They were used to manufacture electrical equipment as well as a host of
other industrial and consumer products that have been banned since the 1970s.
These protests represent the first time people went to jail to stop the building of
a toxic waste landfill and are also important because the direct action nature of
the protests suggests linkages with the civil rights and anti-nuclear movements.

Another landmark date was the First National People of Color Environmental
Leadership Summit in 1991. Over 600 delegates met and passed the 17
Principles of Environmental Justice. According to Hofrichter, the preamble
reads,

We, the people of color, gathered together at this multinational People of Color
Environmental Leadership Summit, to begin to build a national and international
movement of all peoples of color to fight the destruction and taking of our lands and
communities, do hereby re-establish our spiritual interdependence to the sacredness of
our Mother Earth; to respect and celebrate each of our cultures, languages and beliefs
about the natural world and our roles in healing ourselves; to insure environmental
justice; to promote economic alternatives which would contribute to the development of
environmentally safe livelihoods; and, to secure our political, economic and cultural
liberation that has been denied for over 500 years of colonization and oppression,
resulting in the poisoning of our communities and land and the genocide of our peoples,
do affirm and adopt these Principles of Environmental Justice.

By beginning with “We, the people of color,” the Summit preamble enshrined
the concept that members of this movement were linked through the pollution
and harm they experience as a result of racism.

The practical implication of constructing the movement in this way is that it
links diverse communities across races, whether they be urban or rural, from
different regions of the country, or immigrant or native-born. The main limit of
this construction is that it can collapse differences between different communities
of color, may ignore class differences, can fail to recognize the unique contribu-
tions of particular racial/ethnic groups, and may perhaps deny the very diversity
at the base of the movement. The environmental communities of Latino, Asian,
Native and African American problems are numerous and often distinct from
one another, varying locally from community to community. These issues also
vary based on specific historical, geographical and cultural trajectories. But the
issues and the activism from Asian American and Asian immigrant communities
is shared the most with Latino immigrant communities, primarily on occu-
pational health issues and the injustices associated with being limited-English-
speaking populations and immigrant populations.

Since the Summit, an increasing number of organizations have identified with
the environmental justice movement. A few Asian American organizations and
key individuals were present at the Summit, although they were not represented
in large numbers. Young Hi Shin of the Asian Immigrant Workers Advocates
(AIWA) and Pam Tau Lee of the University of California at Berkeley Labor
Occupational Health Program presented seminal papers at the 1991 Summit. It

152 Julie Sze

is not surprising that Shin and Lee presented papers on occupational issues, since
this is the main way Asian immigrant organizations have defined their issues as
environmental justice concerns.

Over half of all textile and apparel workers in the United States are Asian
women. Garment workers in sweatshops face increased exposure to fiber parti-
cles, dyes, formaldehydes and arsenic, leading to high rates of respiratory illness.
Tai points out that more than 70 percent of production workers in Silicon Valley
are Asian or Latino immigrant women who hold jobs where occupational illness
rates are more than three times those of any other basic industry.

Sociologists David Pellow and Lisa Park document the occupational health
hazards computer production-line workers in Silicon Valley, California face, and
the fact that most of these laborers are non-unionized, low-income Asian and
Latina immigrant women workers. The health and environmental effects of
computer production-line labor are numerous, and particularly destructive to
reproductive and nervous systems (such as triggering miscarriages). Activist
organizations such as the Silicon Valley Toxics Coalition (SVTC) are on the
front lines in the fight to clean up the computer production line. Asian
immigrant organizers are a central component of SVTC’s education and
organizing programs, because of the demographics of the production line. In the
past, SVTC’s Family and Community Environmental School (FACES) edu-
cation and organizing project has worked with Cambodian, Vietnamese and
Filipino populations. Asian populations are targeted as part of a wider multilin-
gual, multiracial and multiethnic organizing program.

In both the San Francisco Bay Area and the East Coast of the United States,
there has been substantial Asian immigrant environmental justice organizing
around housing and urban redevelopment issues. These include organizing in
coalitions against particular sites and facilities, as well as sustained organizational
efforts on a broader range of issues. In terms of single campaigns, there have
been at least three examples of environmental justice organizing in three East
Coast Chinatowns: Boston, Philadelphia and New York City. All three were
successful in fighting development projects and used the language of environ-
mental racism and the discourse of the environmental justice movement as parts
of its rationale against each facility.

Boston’s Chinatown is squeezed between two medical institutions, which haveswallowed up one-third of the surrounding land in the last few decades. One
of these institutions made an offer to Boston in early 1993 to acquire a small plot
of land in Chinatown called “Parcel C” in order to build a large parking garage.
The Chinatown neighborhood council, an old guard alliance of Chinatown
business interests, approved a deal for the site for U.S.$1.8 million. Other
community residents were angered at this deal and organized rallies, petitions
and community meetings. The opposition was formalized into the Coalition to
Protect Parcel C. The Coalition persuaded the state environmental agency to
mandate a full environmental review. The state ordered the hospital to study the
impact the building would have on air pollution, traffic, open space and
recreation issues. The coalition also sponsored a referendum on the garage, in
which the community voted overwhelmingly against it. After an intense year and

Asian American Activism for Environmental Justice 153

a half of community mobilization and protest, the proposal was withdrawn. The
mayor signed an agreement with the older Chinatown development interests to
preserve the parcel for housing and forbid institutional use. The Coalition has
since transformed into the Campaign to Protect Chinatown, which, according to
Leong, has become a center for environmental projects in the community.
In early 2000, Philadelphia Mayor John Street announced a plan to build a

new Major League baseball stadium in Chinatown. In immediate response, the
Stadium Out of Chinatown Coalition formed. The Coalition argued that their
neighborhood would be destroyed from the traffic congestion and air pollution
as well as from the noise and disruption caused by construction. As in Boston,
Philadelphia’s Chinatown has been ravaged by urban renewal and highway
projects. The Coalition requested the City’s findings on stadium financing,
economic impact, environmental impact, planning studies and community devel-
opment. The Coalition did its own feasibility study, threatening to take legal
means to block the stadium, through environmental and civil rights lawsuits. As
reported by Asian Week, ultimately, on November 13, 2000, Mayor Street
abandoned plans for the stadium in part due to community pressure, as well as
major concerns over the financing.
Lastly, in the early 1990s, a multiracial, multiethnic organizing campaign took

place in Sunset Park, Brooklyn against a proposed sludge treatment plant.
Environmental justice themes acted as a bridge issue for Asians and Latinos in
the neighborhood. According to prominent community leaders, Sunset Park is
divided along ethnic, linguistic, geographic and other lines, such as citizenship
and political culture. It was all the more remarkable, then, for the deeply
fractured Latino and Asian community to have worked as a single coalition in
response to the sludge treatment plant proposal (sludge is the solid byproduct of
waste and wastewater treatment). The main argument made by the Sunset Park
community against this particular facility concerned the health risks and in-
creased air pollution emissions. This rationale holds true for the primarily Latino
population immediately adjacent to the proposed facility, as well as for the
Chinese community, which is farther from the waterfront. The coalition that
formed against the facility highlighted the contradiction between Mayor David
Dinkin’s election as the first non-white mayor in New York City—centered on
the image of a “gorgeous mosaic”—and his policies that, opponents argued,
contributed to environmental racism. The Sunset Park sludge treatment plan
proposal was withdrawn in February 1993 in large part due to community
pressure.
Besides these single-site campaigns against particular facilities, other organiza-

tions have focused on direct organizing on a wide range of issues that affect
low-income Asian immigrant urban populations, including lack of open space,
housing and gentrification. Most prominent is the Asian Pacific Environmental
Network (APEN) and its Laotian Organizing Project (LOP) in the Bay Area. The
APEN is the only organization in the United States that focuses exclusively on
Asian environmental justice issues. The Laotian Organizing Project emphasizes
direct organizing and youth mobilization within the Laotian community in
Richmond, California. This population, primarily refugees who entered the
United States after the 1970s, is predominantly low-income. Richmond, a city in
Contra Costa County in northern California, is home to the Chevron/Texaco

154 Julie Sze

oil refinery and over 350 industrial facilities, including chemical plants and
chemical and petroleum-based industries. Some of the facilities have suffered
major industrial accidents over the past 30 years. The Chevron refinery, the
largest oil refinery in the western United States, has been a major source of
pollution, toxic releases and industrial accidents that have threatened the health
and safety of workers and community members.
The LOP was formed in 1995 to work on community empowerment through

direct organizing on issues of community concern. One concrete result of the
LOP was a victory of a multilingual warning system for toxic releases, whereas
previously the warning system was only in English. The LOP was successful in
emphasizing the community’s unique cultural and linguistic resources and needs
as well as because it worked for years developing community-based leadership,
especially among Laotian youth. The LOP has organized on many issues over
the years, as Tai points out, such as citizenship drives, education issues and
building political clout to fight incineration facilities.
Housing and gentrification are other urban issues that progressive Asian

immigrant communities have organized around. The APEN is a key member of
the Stop Chinatown Evictions Committee, which formed in 2003 to halt the
evictions of elderly and low-income residents in Oakland’s Chinatown. Housing
and gentrification are also organizing issues in New York City’s Chinatown.
According to the Chinatown Justice Project of the Committee Against Anti-
Asian Violence (CAAAV), Organizing Asian Communities in New York City,
housing is a basic environmental issue because poor housing and substandard
living conditions in tenement buildings, including lead paint and vermin,
negatively affect the health of residents. CAAAV cleverly defined community
organizing centered on issues of housing as an environmental justice issue, as
Geron argues, in direct response to the discourse of “improving the environ-
ment” as used by more affluent non-Chinese residents to move out Chinese
businesses and residents in order to gentrify areas bordering Chinatown.
Food consumption and production issues are another area of environmental

and environmental justice concern for Asian immigrant communities. Many
Southeast Asian refugee communities suffer from elevated exposure to toxins in
their food, often as a result of subsistence fishing. For example, Laotian refugee
families in the Richmond area as well as Vietnamese communities in the
southeastern United States, fish regularly due to their low income levels and their
cultural practices. Unfortunately, due to high pollution levels, there are high
levels of mercury and other contaminants in the fish, which when consumed
cause severe negative health effects, particularly for pregnant women and
children. In addition to the pollution, warning signs for the pollutants are not
adequately posted in non-English languages. Making these warning signs intelli-
gible to affected communities is another example of how APEN and the LOP
work on linguistic issues as a pathway to improving environmental health and
achieving greater community justice.
Another way that food is an environmental issue can be seen in the work of

an organization named Thimmakka, also based in the San Francisco Bay Area.
Thimmakka has developed an innovative program called “Greening South Asian
Restaurants” (GSAR). The program conducts outreach to Afghani, Burmese,
Persian, Indian, Pakistani, Vietnamese, Thai and Ethiopian restaurants in 20

Asian American Activism for Environmental Justice 155

languages, to communicate environmental and consumption issues such as
pollution prevention, solid waste reduction, and water and energy conservation
generated through their food preparation activities. Restaurants benefit by saving
money through their waste reduction efforts.

Although the environmental justice movement has made great strides in thepast two decades, the leadership and the base of the movement still struggle
with how to put into practice the lofty principles adopted in 1991. There is a
constant struggle at national gatherings and conferences to ensure class, cultural
and linguistic diversity among participants. Many times, the mantra of environ-
mental justice as a multiracial, multiethnic progressive movement is belied by
practices and beliefs, whether conscious or unconscious, of the movement’s
leaders and membership. For example, at the Second People of Color Environ-
mental Leadership Summit in 2002, the lack of language translation was raised
by Spanish-speaking attendees. The logistics and costs of translation are often
given as a reason for the absence of these services, but organizations such as
APEN prioritize linguistic equity as a precondition for full and equal partici-
pation for Asian immigrant communities.
The perception of Asian immigrant community activism within the environ-

mental justice movement is another example of the gap that still exists between
rhetoric and reality. While virtually all of the people and organizations that
identify with the environmental justice movement recognize that EJ should be
multiracial and multiethnic, far fewer would be able to cite examples of Asian
immigrant environmental justice activism. This illuminates the problem of Asian
invisibility in progressive multiracial activism, which this essay hopes to squarely
repudiate. In reality, Asian immigrant communities are taking the mantle of
community activism and of the EJ issues that affect them in their own localities.
These range from urban issues to occupational concerns, but in general they are
linked through the prism of exclusion based on race, culture, language and
citizenship issues, all of which affect the ability of Asian immigrant communities
to fully participate and achieve full justice.

RECOMMENDED READINGS

AsianWeek and Associated Press. 2000. “Philadelphia Chinatown Wins Stadium Fight.” November
24–30. � http://www.asianweek.com/2000 11 24/news1 nophillieschinatown.html � .

Brugge, D. Undated. “Environmental Justice and Asian Americans.” Asian American Revolutionary
Movement Ezine. � http://www.aamovement.net/community/aaej.html � .

Bullard, R. (ed.). 1994. Unequal Protection: Environmental Justice and Communities of Color. San Francisco:
Sierra Club.

Hofrichter, R. (ed.). 1993. Toxic Struggles: The Theory and Practice of Environmental Justice. Philadelphia:
New Society.

Geron, T. 2002. “The Greening of Asian Pacific America: APAs and the Environmental Justice
Movement.” AsianWeek.com, October 4–10. � http://www.asianweek.com/2002 10 04/
home.html � .

Lavelle M. & M. Coyle. 1993. “Unequal Protection: The Racial Divide in Environmental Law.”
in Hofrichter, R. (ed.), Toxic Struggles: The Theory and Practice of Environmental Justice. Philadel-
phia: New Society.

Leong, A. 1995/1996. “The Struggle over Parcel C: How Boston’s Chinatown Won a Victory in
the Fight against Institutional Expansion and Environmental Racism.” Amerasia Journal 21(3):
99–119.

156 Julie Sze

Myers, S. 1993. “Proposal for Sludge Plant in Brooklyn Is Withdrawn.”
New York Times, February 20: 23.
Pellow, D.N. & L. Park. 2003. The Silicon Valley of Dreams: Environmental Injustice, Immigrant Workers

and the High-Tech Global Economy. New York: New York University Press.
Tai, S. 1999. “Environmental Hazards and the Richmond Laotian American Community: A Case

Study in Environmental Justice.” Asian Law Journal 6: 189.
Taylor, D.E. 2002. Race, Class, Gender and American Environmentalism. Seattle: U.S. Forest Service.

� http://www.fs.fed.us/pnw/pubs/gtr534 � .
United Church of Christ, Commission for Racial Justice. 1987. Toxic Wastes and Race in the United

States: A National Report on the Racial and Socio-Economic Characteristics of Communities with Hazardous
Waste Sites. New York.

Julie Sze is an Assistant Professor in American Studies at University of California at Davis.
Correspondence: Department of American Studies, University of California, Davis, Mart Hall, Davis,
CA, 95616, USA. Email: jsze@ucdavis.edu

Health Promotion Practice
September 2013 Vol. 14, Suppl 1, 40S –47S
DOI: 10.1177/1524839913484762
© 2013 Society for Public Health Education

40S

There is growing interest in understanding individual
and environmental influences on youth risk behaviors,
including tobacco use. The purpose of this article is to
describe the processes and findings from a study that
sought to increase the capacity of Asian American and
Pacific Islander (AAPI) community-based organiza-
tions to understand and address the environmental
influences on tobacco use among AAPI youth. Using a
multimethod approach to data collection that included
GIS (geographic information system) mapping,
Photovoice, and individual youth surveys, a team of
community and university researchers conducted a
3-year study to assess and address the environmental
influences of tobacco use among youth. Community-
based participatory research principles guided the
study and facilitated unique capacity building and
analyses throughout the study period. Results in Long
Beach from all three methods highlighted the associa-
tions between youth smoking and environmental fac-
tors: GIS mapping identified at least 77 separate
locations of pro-tobacco influences, photographs cap-
tured many of these locations and provided youth lead-
ers with opportunities to identify how other influences
contributed to smoking risk, and surveys of youth indi-
cated that perceived community safety and proximity
to pro-tobacco influences were associated with smok-
ing in the past 30 days. Subsequent community-based
organization activities undertaken by study partners
are also discussed, and lessons learned summarized.

Keywords: advocacy; Asian; minority health; com-
munity-based participatory research;
health research; Pacific Islander; tobacco
prevention and control

484762HPPXXX10.1177/1524839913484762H
ealth Promotion Practice / MonthTanjasiri et al. / Short Title
2013

1California State University, Fullerton, Fullerton, CA, USA
2Asian Pacific Partnership for Empowerment, Advocacy and
Leadership (APPEAL), Oakland, CA, USA
3University of Michigan, Ann Arbor, MI, USA
4St. Mary’s Medical Center, Long Beach, CA, USA

Environmental Influences on Tobacco Use Among
Asian American and Pacific Islander Youth

Sora Park Tanjasiri, DrPH, MPH1

Rod Lew, MPH2

Michele Mouttapa, PhD1

Rob Lipton, PhD3

Lillian Lew, MEd, RD4

Sovanna Has4

Michelle Wong, MPH

Authors’ Note: We thank all of the community adult and youth
staff from Asian Pacific Psychological Services; Families in Good
Health/St. Mary’s Medical Center, Guam Communications
Network, Inc.; the Orange County Asian Pacific Islander
Community Alliance; and the Washington Asian/Pacific Islander
Families Against Substance Abuse. In addition, we want to
recognize the special contributions of the following study team
members to this article: Ladine Chan, Lisa Fu, Darrah Goo
Kuratani, Chork Nim, and Roger Sur. Last, we are grateful to all
the adult and youth study participants who participated in the
key informant interviews and/or completed individual surveys.
This project was supported by the California Tobacco-Related
Disease Research Program (Grant Nos. 13AT-3000 and 13AT-
3001, part of which paid for a percentage of Sora Park Tanjasiri’s
salary to work on this study), with additional support from the
National Cancer Institute’s Center to Reduce Cancer Health
Disparities (Grant No. CA 5U54153458). Address correspondence
to Sora Park Tanjasiri, California State University, Fullerton,
Department of Health Science, 800 N. State College Boulevard,
Fullerton, CA 92834-3599, USA; e-mail: stanjasiri@fullerton.edu.

Supplement Note: This article is published in the supplement
“Promising Practices to Eliminate Tobacco Disparities Among
Asian American, Native Hawaiian and Pacific Islander Communi-
ties,” which was supported by the Asian Pacific Partners for
Empowerment, Advocacy and Leadership (APPEAL) through CDC
Cooperative Agreement 5U58DP001520.

Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 41S

>IntroductIon

Despites decades of aggressive educational and advo-
cacy efforts in the united States, tobacco use remains
high among american adolescents and young adults,
with one in five being daily cigarette smokers at age 18
(Johnson, O’Malley, bachman, & Schulenberg, 2009).
available data on asian american and Pacific Islander
(aaPI) youth point to similarly high rates of use. for
instance, smoking prevalence in californian and
Hawaiian ninth graders was 12.1% among filipinos
and 19.7% among Pacific Islander ninth graders com-
pared with 16.3% among Whites (Wong, Klingle, &
Price, 2004). Such data may not be surprising since
tobacco use is highly ingrained in the culture of asian
countries, where smoking rates are high (e.g., over 40%
of men in East and Southeast asia) in large part because
it is considered socially and culturally acceptable (banta
et al., 2012; Yel, bui, Job, Knutsen, & Singh, 2011).
because of gender norms, tobacco use prevalence among
aaPI adult men is among the highest in this country:
(e.g., 48% to 72% among Laotian, 24% to 71% among
cambodian, and 42% among native Hawaiian males;
friis et al., 2012; Lew & Tanjasiri, 2003).

Effective youth tobacco prevention must consider
the environmental context in which youth live. access
to tobacco products, commercial images through local
advertising, as well as movie images all may influence
youth decisions to smoke (cummings & coogan, 1992;
Difranza, norwood, Garner, & Tye, 1987; Lipton,
banerjee, Levy, Manzanilla, & cochrane, 2008). In addi-
tion, research has shown aaPIs to be at high risk for
such environmental exposures. for instance, research-
ers studying tobacco industry marketing found that
tobacco advertising (including billboards and store-
front displays) are more prevalent in ethnically diverse
and low-income communities compared with White,
affluent ones (Laws, Whitman, bowser, & Krech, 2002;
Wildley et al., 1992). In another study of tobacco indus-
try documents, aaPI youth were targeted with free
cigarette giveaways and other promotion campaigns
(Muggli, Pollay, Lew, & Joseph, 2002). Interestingly,
perceived community social cohesion and living in an
ethnic enclave were found to be important protective
factors against youth smoking in aaPI neighborhoods
(Kandula, Wen, Jacobs, & Lauderdale, 2009).

The purpose of this article is to describe the pro-
cesses and findings from a study that sought to increase
the capacity of youth within aaPI community-based
organizations (cbOs) to assess and address the envi-
ronmental influences on tobacco use in their commu-
nities. This effort helped identify important tobacco
prevention needs and contribute to youth and cbO

efforts to develop and implement education programs
and advocacy efforts.

>MetHod

This was a 3-year (2005-2008) descriptive study of the
perceived individual and environmental influences on
tobacco use among aaPI youth aged 15 to 25 years.
The goals were (a) to design and test the feasibility of
environmentally-oriented data collection methods to
understand tobacco use influences on aaPI youth and
(b) to use a community-based participatory research
(cbPR) approach that promotes capacity building in
each community to not only understand but also develop
policy advocacy-oriented actions to address the environ-
mental influences in their lives. four cbOs in california
and Washington were approached during the study
design phase, due to their previous involvement in a
national aaPI tobacco control network through which
they had expressed their interests in better understand-
ing and addressing issues facing their cambodian,
chamorro, Laotian, and multi-aaPI communities. Once
the study was funded, the research partnership incorpo-
rated core principles of cbPR in all phases of the study
design, implementation, and evaluation (Israel, Schulz,
Parker, & becker, 1998; Tanjasiri, Kagawa Singer, nguyen,
& foo, 2002): shared principal investigators representing
both cbO and university researchers, monthly confer-
ence calls with the community and university investiga-
tors, and biannual in-person daylong meetings with the
entire study team during which assessment approaches
and instruments were drafted and finalized. cbO staff
selected youth who served in leadership positions
within their agencies to participate in the design and
implementation of the study. Trainings on recruitment
and data collection procedures, as well as on public
speaking and advocacy planning, were provided at these
meetings by university researchers to address needs and
requests by the cbO adults and youth leaders. all study
protocols, instruments, and consent forms that involved
data collection by youth and adults were submitted and
approved by the university institutional review board.
all cbOs received monetary support from the grant for
their involvement.

Data Collection Methods

Our community-informed assessment of environ-
mental influences on aaPI youth smoking was
informed by three mixed-method data collection strate-
gies: geographic information system (GIS) mapping,
Photovoice, and individual youth surveys.

42S HEaLTH PROMOTIOn PRacTIcE / September 2013

GIS mapping. GIS mapping involves the collection of
geo-coded data to locate sites of interest on maps and
has been used to show the correlation between per-
ceived access and objective access in studies of healthy
environments (caspi, Kawachi, Subramanian, adam-
kiewicz, & Sorensen, 2012; Moore, Diez Roux, & brines,
2008). In this study, we used global positioning system
(GPS) devices to collect and store location data (called
“waypoints,” which are exact longitude and latitude
coordinates) on community locations of particular inter-
est. Through discussions at biannual in-person meet-
ings, our study community partners were most interested
in identifying the locations of items (e.g., tobacco adver-
tisement) or activities (e.g., hangouts where youth
smoked together) that promoted smoking as an appeal-
ing behavior for youth. furthermore, cbO adult staff
were also interested in identifying those places (e.g.,
community centers) where healthy behaviors were pro-
moted that could help protect youth from smoking.
next, key informant interviews with 36 youth and com-
munity leaders (e.g., social service agency staff, minis-
ters, and elders) were conducted to (a) understand the
physical boundaries of the ethnic community, (b) iden-
tify the kinds of locations they perceived as having pro-
tobacco (our term for locations that promoted smoking)
influences on youth, and (c) identify the kinds of loca-
tions that they perceived as having anti-tobacco (our
term for locations that promoted healthy behaviors
other than smoking) influences on youth. In Year 1, key
informant interview trainings were conducted by cbO
adult staff and youth leaders to discuss informed con-
sent, informant selection, and interview processes. Each
interview lasted approximately 1 hour, and after com-
pletion cbO adult staff and youth leaders wrote sum-
maries of the interviews based on written notes and tape
recordings.

Summaries from key informant interviews were
shared with all study team members, who then devel-
oped a list of all types of community influences on
youth tobacco use. Each item on this list was assigned
a waypoint code number and categorized as a pro-
tobacco or anti-tobacco influence. In Year 2, GPS
devices (Garmin eTrex) were purchased from a local
sporting goods store and programmed with the way-
point code numbers. for approximately a 2-month
period, pairs of cbO adult staff and youth leaders
walked through the entire community (using bounda-
ries defined via key informant interviews) and inputted
the waypoints (n = 111 total) by perceived category
(pro-tobacco or anti-tobacco) into their GPS devices.
for each waypoint, youth also used written log forms
to provide brief descriptions of each location.

Photovoice. Photovoice is a process that promotes com-
munity empowerment by engaging people in identify-
ing the needs of their own communities through
photography by using the photographs as the focal
point of group discussions about why these needs exist
and sharing the photographs with policy makers in
order to create positive community changes (Wang &
burris, 1997). During GIS data collection in Year 2, a
total of 32 youth leaders also took pictures of any com-
munity location that they believed influenced youth
toward tobacco use. Photographs were uploaded onto
the cbO computer and displayed for the youth, at
which time the youth selected specific photographs
that appealed to them. The youth then used the Photo-
voice “SHOWeD” mnemonic to develop written analy-
ses of each picture that described what they saw, why
they believed the situation existed, and what they rec-
ommended to address the situation (Wang & burris,
1997). a more in-depth description our Photovoice
methodology and results are presented in a previous
publication (Tanjasiri, Lew, Kuratani, Wong, & fu,
2011).

Youth surveys. Due to a limitation in funding, a self-
administered survey of youth was undertaken only in
Long beach to quantitatively explore the relative influ-
ences of interpersonal and community factors on youth
smoking. The survey included standard items from the
national Health Interview Surveys and california
Tobacco Surveys on the use of tobacco and other drugs,
as well as demographics and ethnic identity (Pierce et
al., 1998; Pierce, fiore, novotny, Hatziandreu, & Davis,
1989). In addition, items were also included on commu-
nity safety and violence, youth access to tobacco and
other drugs, and youth participation in leadership and/
or other protective programs in their communities. This
subjective assessment of a youth’s neighborhood pro-
vides some insight into environment/neighborhood
stressors and mitigators of stress that might bear on
tobacco use. at the end of Year 1, the survey was pilot-
tested with 12 youth to confirm comprehension and
time duration, and was then implemented in Year 2. a
total of 10 youth leaders at each cbO were trained on
identifying and recruiting youth respondents (from
shopping malls and other youth hangouts), consent pro-
cedures, and administering the surveys. at the conclu-
sion of each completed survey, youth respondents were
given two movie tickets valued at approximately $15.
by the end of Year 2, a total of 298 surveys were com-
pleted by cambodian youth 15 to 25 years old. a total of
33 youth who were approached refused to participate
(for an overall response rate of 90%) with reasons for

Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 43S

refusal including the lengthiness of the survey and dis-
interest in the incentive items.

Data Collection, Management, and Analyses

Due to the multiple data activities and unique cbO
efforts in each geography area, the remainder of this
article will focus on describing the processes in Long
beach, california. Data collection proceeded over
approximately 8 months in Year 2, during which time
GPS and Photovoice data were conducted, and indi-
vidual surveys were collected in Long beach. because
youth were interested in seeing a different city environ-
ment, they also went to Pasadena, california, and con-
ducted Photovoice. Throughout this time, cbO staff
coordinated the transfer of GPS data and log forms,
photographs with SHOWeD analyses, and individual
surveys to the university study team members for data
input and analyses. Geo-coded data was downloaded
from the GPS devices and coded as either a pro-tobacco
or an anti-tobacco community influence on youth
tobacco use. Photos were stored as image files on cDs,
whereas any text-based data were maintained in elec-
tronic word-processing files. all of the photos were
reviewed and coded for themes reflective of the con-
cerns raised by the SHOWeD analyses.

all individual survey data were entered using SPSS
Version 16. Outcome variables for this study were ever
smoking and smoking within the past 30 days, whereas
predictor variables included a six-item scale that
assessed negative attitudes toward smoking (e.g., I dis-
like being around people who are smoking), number of
similar-aged peers they know who smoke cigarettes or
use other tobacco products, perceived level of safety
and perceived level of stress in the neighborhood they
live in, and having ever participated in a community
youth program where they live (yes or no). In Year 3,
descriptive statistics were calculated for the variables
listed above, as well as for the demographic variables
of age, ethnicity, gender, grade in school, born in the
united States (yes or no), and the approximate amount
of discretionary money that participants have per
week to spend on themselves. Two multiple logistic
regression models were calculated: one predicting
smoking 100 cigarettes and one for past 30 day smok-
ing. These models included only predictor variables
and demographic variables mentioned that were sig-
nificantly associated with the outcome variable in
bivariate analyses. Last, survey and GIS data were also
analyzed in Year 3 to determine associations between
smoking and proximity to pro- or anti-tobacco influ-
ences in the community. average distance (in miles)

between home address (obtained from individual sur-
veys) and positive influence locations for smoking
(collected by GPS devices) were calculated and then
entered as a predictor variable in a logistic regression
with the outcome smoking in the past 30 days (yes or
no) and ever having smoked 100 cigarettes for one’s
whole life (yes or no).

>results

as shown in Table 1, the overwhelming majority (n =
74) of waypoints in Long beach were categorized as
pro-tobacco because youth leaders perceived these
locations as promoting smoking as appealing to youth.
These pro-tobacco locations included tobacco adver-
tisement, convenience shops, fast-food restaurants,
residences, schools, community spaces, faith institu-
tions, and bus stops. Many locations (n = 27) were
perceived by youth leaders to be both anti- and pro-
tobacco, such as one middle school (that was per-
ceived to fight smoking through anti-tobacco education
but that also had areas on campus where youth com-
monly smoked) and one church (where healthy com-
munity values were promoted but also where smokers
congregated and left their butts on the sidewalk). Only
10 locations were perceived by the youth leaders to be
anti-tobacco influences, including three liquor stores
(that did not promote tobacco sales), the community
recreational center, and a high school (both of which
strictly enforced no-smoking policies).

Spatial analyses found associations between prox-
imity to pro-tobacco influences and youth smoking
behavior. as shown in Table 2, youth who smoked
within the past 30 days lived significantly closer in
proximity to negative influences compared with youth
who did not smoke in the past 30 days. Youth who
smoked at least 100 cigarettes in their lifetime, how-
ever, did not appear to live any closer in proximity to
negative influences, perhaps indicating that such sites
did not influence maintenance as much as initiation.
Last, youth who were involved in leadership programs
(e.g., at their schools, at cbOs, etc.) lived significantly
farther away from negative influences than youth who
did not participate in such programs.

Photographs and descriptions developed by the
youth exemplified four different kinds of environmen-
tal factors on smoking: (a) youth-targeted cigarette
advertisements, (b) the abundance of smoke shops dis-
playing cigarette advertisements of any kind, (c) the
poor physical appearance of their community, and
(d) anger at tobacco companies that were profiting from

44S HEaLTH PROMOTIOn PRacTIcE / September 2013

their community. One youth took a picture of a tobacco
outlet (figure 1) and described it as promoting youth
smoking via youth-targeted advertisements and sales
by stating,

a smoke shop is on PcH (Pacific coast Highway), so
when people drive by they can see the smoke shop.
There are a lot of advertisements on the window and
it is near an elementary school. To stop kids from
using drugs, we need to start a program to tell the
teens about the consequence of drugs. Someone can
buy the store and make the smoke shop move.

as shown in figure 2, another youth selected and
described a photograph depicting the poor physical
quality of the city as part of the reason why youth also
smoke. according to this youth,

Driving by the ditch, people can see all the graffiti
and all the litter. The graffiti is in a neighborhood
and it’s gang related. all the litter and graffiti make
Long beach look bad. We should make a place, so
they can tag and start a gang prevention program.

In contrast, when they went to Pasadena the youth
were struck by the lack of cigarette and other promo-
tions, as well as the general cleanliness and beauty of
the city environment. In describing figure 3, one youth
wrote,

table 1
types of Pro- and anti-tobacco locations Influencing

Youth smoking in long beach

Anti-
Tobacco

Pro-
Tobacco

Both Pro
and Anti

ads
cigarette ad 4
Shops
Liquor store 3 10 2
Smoke shop — 4 —
Gas station — 1 2
Small market — 5 2
Supermarket — 2 —
Other 1 2 2
food
fast food 1 1 2
Donut shop — 2 —
Restaurant — — 1
coffee shop 1 — —
Residential
House 1 7 —
apartment — 2 —
Schools
Elementary — 2 —
Middle — — 2
High 1 1 1
community
Park — 6 4
Recreation

center
1 — 3

Library — 1 —
faith
church — — 1
Temple — — 1
Transportation
bus stop — 2 2
Parking lot — 4 1
Health
clinic — 1 —
Hospital 1 — —
Other
alley — 9 —
Ditch — 5 —
Sidewalk — 3 —
Laundromat 1 — —
Total 10 74 27

table 2
associations between Proximity (in Miles) to Pro-

tobacco Influences and Youth smoking in long beach

Variable
Proximity to Pro-

Tobacco Influences p

Smoked in last 30 days
Yes 1.49 *
no 2.06
Smoked 100+ cigarettes

in lifetime

Yes 1.97 ns
no 1.98
Participated in leader-

ship programs

Yes 2.26 *
no 1.70

*p < .05

Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 45S

This picture shows how clean Pasadena is and the
environment around it. Pasadena is a clean place
and isn’t as dirty as Long beach. . . . not a lot of
people smoke in Pasadena and there is barely any
cigarette ads around. after looking at this picture
and how clean it is I want Long beach to be the
same, to be clean, pretty, and a great place.

Last, youth surveys indicated that perceptions of
the environment were associated with smoking status.
Of the 298 youth who participated in the survey,
93.6% were all or part cambodian, 52.9% were male,
and 83.2% were between 16 and 19 years old. The
majority were born in the united States (92.7%), were
11th or 12th graders (71.7%), and had more than $10
of discretionary spending money per week (68.9%;
data not shown). cronbach’s alpha was .83 for the
positive attitudes toward smoking scale; with possible

scores ranging from 0 to 18, the mean score was 5.8
(SD = 4.1). nearly all participants (90.2%) indicated
that at least “a few” of the same-aged peers whom they
knew smoked cigarettes or other tobacco products.
close to 1 in 4 participants indicated that their neigh-
borhoods were either “unsafe” or “very unsafe” to live
in (25.3%) and either “stressful” or “very stressful” to
live in (22.9%). nearly half (49.3%) had ever partici-
pated in a youth program within their community. Of
the entire sample of 298 participants, 138 (46.3%)
indicated that they had ever tried smoking, and 61
(20.5%) indicated that they smoked at least one ciga-
rette in the past 30 days (data not shown).

Table 3 presents multiple logistic regression results
of the two outcome variables: smoking 100 cigarettes in
lifetime and smoking in past 30 days. Smoking 100
cigarettes in lifetime was positively associated with
positive attitudes toward smoking. Past 30-day smok-
ing was associated with positive attitudes toward
smoking and perceived neighborhood safety and was
marginally associated with the number of known peers
who smoke. although preliminary bivariate analyses
indicated that males had higher rates of lifetime smok-
ing, that discretionary income was positively associ-
ated with past 3-day smoking, and lifetime participation
in a youth program within their community was nega-
tively associated with past 30-day smoking, none of
these associations were significant in the multivariate
analyses.

>dIscussIon

We found that perceived environmental factors/
features had a substantial influence on aaPI youth
smoking risk and behaviors. Data from all three mixed-
methods (survey, Photovoice, and GIS mapping) identified

FIgure 1 smoke shop in long beach

FIgure 2 community conditions in long beach

FIgure 3 environmental condition in Pasadena

46S HEaLTH PROMOTIOn PRacTIcE / September 2013

the many and diverse environmentally oriented influ-
ences on youth smoking, including not only tobacco-
related factors (e.g., cigarette advertisements) but also
community-related factors (e.g., perceived safety of the
community, which was slightly more predictive of
30-day smoking than number of smoking peers) that put
youth at risk for using tobacco products.

Perhaps more important, youth were empowered to
use the study results to postively influence their envi-
ronment. When the youth in Long beach compiled
their Photovoice and GIS mapping results in Year 3,
they were motivated to share the findings with local
stakeholders. The youth created a display that was pre-
sented to the coalition for a Smoke free Long beach,
which was working on a tobacco retailer permit (TRP)
ordinance. The coalition arranged for the youth to pre-
sent to the city councilperson of the sixth district, with
the message that there were too many smoke shops and
liquor stores selling cigarettes in their community. In
the words of one youth leader, “Though I know that
tobacco alone can be harmful . . . but growing up and
living in the ghetto part [of] Long beach is also danger-
ous. I’ll probably die from gang violence before dying
from cancer.” One month later, that city councilperson
put the TRP on the city council agenda where it was
unanimously passed, and the youth leaders were cred-
ited with helping the council recognize the importance
of promoting citywide policies for positive community
change.

although many positive processes and outcomes
arose from this study, we also faced many challenges

that limit the generalizability and replicability of our
efforts for other communities and populations. Given
the focus on youth empowerment, nonprobability sam-
pling based on youth organizational affiliation was
used throughout all data collection efforts. Thus, results
many not be applicable to the larger chamorro,
cambodian, and Laotian communities. Since the sur-
vey was only administered to cambodian youth in
Long beach, we are uncertain about the applicability of
results to the other aaPI subgroups. Given the explora-
tory nature of the study, we did not measure the valid-
ity or reliability of the scales and coding methods. Last,
we did not measure the impacts of the cbPR-informed
trainings on changes in individual knowledge and
skills. Despite these challenges, however, partnering
cbO and university institutions emerged from this pro-
cess with greater understanding of and capacities to
address larger community-level influences on aaPI
youth tobacco use.

Lessons Learned

ultimately, we hope this article describes how inno-
vative, mixed-methods approaches can not only provide
critical community assessment information to plan
future interventions but also creatively engage youth
and community members in tobacco control. from our
experience, we also found that GIS and Photovoice
yielded visually powerful information that could be
used to facilitate discussions of environmentally ori-
ented community recommendations. To the degree that

table 3
logistic regression of self-reported 100-cigarette and Past 30-day smoking (n = 298)

Smoked 100 Cigarettes During
Lifetime

Smoked in
Past 30 Days

Odds
Ratio p

Adjusted
Odds Ratio p

Predictor variables
Positive attitudes toward smoking 1.21 ** 1.47 ***
number of known peers who smoke — — 1.46 ns
Perceived neighborhood safety (not safe) — — 1.88 **
Demographic variables
Gender (female) — — 1.03 ns
Discretionary money per week — — 1.08 ns

**p < .01. ***p < .0001.

Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 47S

these assessments and recommendations are shared with
policy makers, they become advocacy tools that can con-
tribute to community-wide tobacco policy change.

furthermore, we credit the cbPR approach as essen-
tial in our efforts to develop innovative and commu-
nity-responsive research strategies and engagement
mechanisms. cbPR efforts such as daylong biannual
meetings that included trainings on research knowledge
and advocacy skills helped promote community readi-
ness to support policy opportunities as they arose, such
as Long beach’s TRP ordinance. close collaborations
between university researchers and cbO staff informed
the design, development, testing, implementation, anal-
ysis, and dissemination of all GIS and Photovoice
activities in our aaPI communities. We strongly feel
that cbPR should be a key strategy for populations that
have not been effectively reached for tobacco preven-
tion and control, and hope that future research builds
on our efforts to take a community-informed approach
in assessing and addressing the many environmental
influences on youth tobacco smoking.

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011-9537-x

SOCIO-CULTURAL FACTORS RELATED TO ALCOHOL USE

AMONG ASIAN AMERICANS

A dissertation submitted in partial fulfillment of the degree of Doctor of Philosophy
from New York University School of Social Work

So-Youn Park

September 2010

Examining Committee Members:

Dr. Jeane W. Anastas, Ph.D. (Advisor)

Dr. Tazuko Shibusawa, Ph.D.

Dr. Duy Nguyen, Ph.D

UMI Number: 342300

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a note will indicate the deletion.

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unauthorized copying under Title 17, United States Code.

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This dissertation is dedicated to my mother, who has supported me financially,
physically, and emotionally. She has always said that she would invest in the education of her
children before retiring. She truly believes in the power of education, in the importance of
women’s independence, and in the individual’s power to use knowledge gained to give back to
society. I love you, mom.

ACKNOWLEDGEMENTS

My doctoral education has been, in every sense of the word, a journey, and one that I

would not have completed without the support of many people.

I am very grateful to my dissertation committee members, who endlessly supported,
encouraged, and guided me through every step of this process.

Dr. Jeane W. Anastas my dissertation chair, allowed me the freedom to explore through
trial and error, and established an intellectually inspiring environment that challenged me to
think more deeply. She also encouraged me to stay connected with social work education.

Dr. Tazuko Shibusawa generously contributed time and her expertise in research on
Asian Americans, taught me the importance of the connection between practice and research,
and always comforted me with her wonderful smile. Dr. Duy Nguyen was enormously helpful
with methodology and patiently answered all my questions, and encouraged me to advance new
perspectives on research.

I cannot thank my friends enough. My cohorts at school: Jan Wolff Bensdorf, Maya

Dolyle, Camille Huggins, Alexis Kuerbis, Karyn Marsh, Jennifer Mills, and James Railey. I am
very lucky to have such encouraging and supportive friends.

A special thanks to Alexis Kuerbis, Camille Huggins, Soonhee Roh, Yeddi Park,
Jennifer Mills, Maya Dolyle, and Ian Ong. Alexis helped edit my paper and gave comments
filled with knowledge and wisdom. Camille Huggins, my study partner, provided insightful
reflections. Soonhee Roh was warm and generous with valuable feedback. Yeddi Park genuinely
listened to my concerns, kept my spirits up, and shared her knowledge. Jennifer Mills was a big
help who gave many valuable suggestions and feedback, especially with the CIP. Maya Dolyle
brought energy and intelligence. Ian Ong was always willing to help and encouraged me to think
critically.

I am also indebted to the doctoral program at NYU’s Silver School of Social Work. Dr.

Lynn Videka, our dean, supported my fellow doctoral students and me with warmth, intelligence,
and concern. Dr. James Martin, the doctoral program director, also provided me with the
necessary assistance and support. Tandayi Jones, Ph.D. program administrator, responded
promptly to my questions and took the time to update me on school news whenever I visited her.
Dr. Robert Yaffee, research professor, patiently answered my countless statistical questions and
contributed to my understanding of statistics. The Doctoral Student Association (DSA) organized
very informative and effective workshops and seminars.

Many thanks to my Korean mentors and colleagues. Dr. Kunsook Bernstein and Dr. Jin

Y. Shin, my mentors, believed in me and accommodated my requests in every possible way.
Haein Son, my long-time colleague, kept me connected with the Korean-American community
and shared resources generously. Dr. Jinah Shin, Dr. Eunjung Ko, and members of the Korean
American Behavioral Health Association showed interest in my research and lent encouragement
and support.

I would like to extend my sincere thanks to Data Studio Service at Bobst Library at
NYU—Frank Lopresti, Himanshu Mistry, David McGarry–my supervisors who gave me an
opportunity to work as a lab consultant. They afforded me not only some needed income, but
also a friendly environment conducive to learning and using new technology and statistics. Many
thanks to my co-student consultants, Kevin Kai Du, Yasmin Grewal, Mashfiqur Khan, Angus
Mungal, and Melissa Reese. We had interesting discussions, and they helped me better
understand statistics and statistical software. It was fun to work with them.

An infinite thanks to my family and friends: Dr. Shin-Eun Choi, my mother; Dr. Eyun

Park, my sister; and Dr. Hyung Jun Park, my brother. Thank you for your eternal confidence in
me, your unconditional support, and your encouragement in pursuing my goals. Although he has
passed away, my father, Dr. Jin-Young Park, has been an inspiration for to me, and I will always
be grateful to him for providing me with his guidance and a good education.

I would like to express my appreciation to my parents-in-law, Dr. Jaechol Chung and Dr.

Chaok Lee, who inspired me in many ways, and my sister-in-law, Myung Chung, and her
husband, Dr. Jinyoung Park, for their support. My best friends: Wonhae Koh, Jooeun Lee, and
Hakyung Sung, who have been there for me and nourished my mind and body. They are my
second family. I would also like to thank Cullen Thomas, my long-time English tutor, and Jie-
Eune Choi, Seunghee Hong, Seunghyun Son, and Jimin Kim for their continuous support,
friendship, and encouragement. Special thanks to my dearest friend, Jung Euen Choi, who
sometimes knew me better than I knew myself. She brought good ideas out of me when I
doubted myself. And thank God for giving me strength and guidance throughout my life.

Finally, I am extremely grateful to my wonderful husband, Sanghyun Chung, for his

understanding, patience, and sacrifice throughout the process. Every step of the way, he
understood me, loved unconditionally, and unwaveringly believed in my ability to succeed. At
each dissertation milestone, he brought home my favorite comfort food and movies to cheer me
up.

Park, So-Youn. Socio-cultural factors related to alcohol use among Asian Americans. New York
University, Ph.D., September 2010.

This study examines factors related to alcohol use—acculturation, acculturative stress,

religiosity, and social support—for three distinct Asian American subgroups: Chinese, Filipino,

and Vietnamese Americans. The alcohol-use model that guided the study was derived from an

acculturation and acculturative-stress model that integrated stress-buffering theories.

This study was a secondary analysis of data from the National Latino and Asian Americans

Study (NLAAS), which collected information from a nationally representative sample of Asian

Americans, 18 years of age or older, residing in the United States. Unweighted sample sizes for

Chinese, Filipino, and Vietnamese Americans were 600, 508, and 520, respectively. Separate

analyses were conducted for each subgroup; results showed different drinking patterns for each.

For Chinese Americans, higher English-language proficiency (OR=1.12) or being second

(OR=5.87) or third (OR=3.61) generation were significantly related to increased

alcohol use.

Among Filipino Americans, higher English-language proficiency (OR=1.22) and unfair treatment

(OR=1.09) were positively related to alcohol use while perceived racial/ethnic discrimination

(OR=0.48) were negatively related to alcohol use. For Vietnamese-Americans, only English-

language proficiency (OR=1.14) was significantly associated with increased drinking. Social

support and religiosity had both a positive and a negative impact on alcohol use across the three

groups depending upon which acculturative stressor was examined. The findings underscore the

importance of considering the heterogeneity of Asian Americans when designing relevant

assessments and interventions related to alcohol use.

TABLE OF CONTENTS

CHAPTER I: Introduction and Problems ………………………………………………………………………. 1

Purpose of the Study ……………………………………………………………………………………………………. 1
Problem of Statement …………………………………………………………………………………………………… 1
Significance of the Proposed Study for Social Work ……………………………………………………….. 5

CHAPTER II: Literature Review ………………………………………………………………………………….. 7

Alcohol Consumption ………………………………………………………………………………………………….. 7
Health Conseqeunces ……………………………………………………………………………………………….. 7
Measurement of alcohol Significance of Alcohol Consumption …………………………………….. 9

Description of the Asian American Population ……………………………………………………………… 10
Chinese …………………………………………………………………………………………………………………. 12

Filipinos ……………………………………………………………………………………………………………….. 12
Vietnamese ……………………………………………………………………………………………………………. 13

Prevalence of Alcohol Use among Asian Americans ………………………………………………….. 14
Relevant Contributory Factors to Alcohol Use ………………………………………………………………. 19

Biological Factors ………………………………………………………………………………………………….. 19
Socio-cultural Factors …………………………………………………………………………………………….. 20

Acculturation……………………………………………………………………………………………………… 20
Models of acculturation …………………………………………………………………………………… 21
Measuring levels of acculturation and acculturative stress ……………………………………. 22
Acculturation scale approriate for Asian Americans ……………………………………………. 24
Factors associated with acculturation ………………………………………………………………… 25
Acculturation and Alcohol Use …………………………………………………………………………….. 26
Acculutration model for alcohol use ………………………………………………………………….. 26
Acculutration stress ………………………………………………………………………………………….

Acculturative stress model for alcohol use …………………………………………………………. 35
Discrimination………………………………………………………………………………………………… 37
Family cultural conflict ……………………………………………………………………………………. 38

Stress-buffering hypotheis: The role of social support and religisoity ……………………….. 40
Social support…………………………………………………………………………………………………. 41
Religiosity ……………………………………………………………………………………………………… 42

Summary ………………………………………………………………………………………………………………….. 44

CHAPTER III: Method ……………………………………………………………………………………………….. 46

Statement of Research Questions and Explored Hypotheses …………………………………………… 46
Data Source and Sample …………………………………………………………………………………………….. 51

Method of Sampling ……………………………………………………………………………………………. 52

Study Procedure ………………………………………………………………………………………………………… 52
Measures ………………………………………………………………………………………………………………….. 53

Acculturation…………………………………………………………………………………………………….. 53
Acculturative stress ……………………………………………………………………………………………. 54

Discrimination………………………………………………………………………………………………. 54
Family cultural conflict ………………………………………………………………………………….. 55
Social support …………………………………………………………………………………………………… 55
Religiosity ………………………………………………………………………………………………………… 55

Alcohol use ……………………………………………………………………………………………………… 56
Demographic Variables ……………………………………………………………………………………… 57

Analytic Plan

……………………………………………………………………………………………………………. 57
Ethical Issues ……………………………………………………………………………………………………………. 61

CHAPTER IV: Results ………………………………………………………………………………………………… 63

Chateristics of the Sample ………………………………………………………………………………………….. 63
Alcohol use ………………………………………………………………………………………………………….. 65

Addressing Multicollinearity ………………………………………………………………………………………. 68
Factors Related to Alcohol Use among Chinese Americans ……………………………………………. 69
Factors Related to Alcohol Use among Filipon Americans ……………………………………………… 77
Factors Related to Alcohol Use among Vietnamse Americans ………………………………………… 86
Summary of Findings for Chinese, Filipino, and Vietnamse Americans …………………………… 93

CHAPTER V: Discussion …………………………………………………………………………………………….. 94

Alcohol Use ……………………………………………………………………………………………………………… 94
Acculturation…………………………………………………………………………………………………………….. 96
Acculturative Stress …………………………………………………………………………………………………… 97
Filipino Americans ……………………………………………………………………………………………….. 98
Chinese and Vietnamese Americans ……………………………………………………………………… 100
The Relationship between Acculturation and Acculturativstress ……………………………………. 100
Social Support/Religiosity ………………………………………………………………………………………… 101

Chinese Americans …………………………………………………………………………………………….. 102
Filipino Americans ……………………………………………………………………………………………… 103
Vietnamese Americans ……………………………………………………………………………………….. 104

Study Limitations

…………………………………………………………………………………………………….. 104
Implications…………………………………………………………………………………………………………….. 107

Social work practice ……………………………………………………………………………………………. 107
Social work policy ……………………………………………………………………………………………… 111
Rcommendatiosn for Future Study ……………………………………………………………………………. 113

Conclusion

……………………………………………………………………………………………………………… 115

References …………………………………………………………………………………………………………………. 117

Appendices ………………………………………………………………………………………………………………… 1

Appendix A Unfair treatment scale ……………………………………………………………………………. 148
Appendix B Perceived racial/ethnic discrimination scale ……………………………………………… 150
Appendix C Family conflict scale ………………………………………………………………………………. 151
Appendix D Statistical regression models in path analysis: Oridinal logistic and ordinary least
squares (OLS) regression……………………………………………………….152
Appendix E IRB approval notice ……………………………………………………………………………….. 153
Appendix F Charaterisitcs of Chinese, Filipino, and Vietnamse Americans in weighted sample
size………………………………………………………………………………154
Appendix G Correlation matrix among all variables among Chinese Americans ……………… 156
Appendix H Correlation matrix among all variables among Filipon Americans ………………. 158
Appendix I Correlation matrix among all variables among Vietnamese Americans …………. 160
Appendix J Direct as well as indirect paths from generation to alcohol use …………………….. 162

LIST OF TABLES

Table 1: Summary of available studies on acculturation and alcohol use ……………………………… 28

Table 2: Weighted and unweighted sample subgroup ……………………………………………………….. 63

Table 3: Characteristics of Chinese, Filipino, and Vietnamse Americans …………………………….. 66

Table 4: Ordinal logistic regression results for alcohol use among Chinese Americans ………….. 70

Table 5: OLS regression results for acculturative stressors among Chinese Americans …………. 75

Table 6: Ordinal logistic regression results for alcohol use among Filipino Americans ………….. 78

Table 7: OLS regression results for acculturative stressors among Filipino Americans …………. 84

Table 8: Ordinal logistic regression results for alcohol use among Vietnamse Americans ……… 87

Table 9: OLS regression results for acculturative stressors among Vietnamse Americans …….. 91

Table 10: Summary of results from hypothesis testing for the three groups …………………………. 93

LIST OF FIGURES

Figure 1: Proposed conceptual model for Asian Americans’ alcohol use ………………………………

Figure 2: Diagram of expected pathways among predictors of alcohol use for Asian Americans

Figure 3: Final model for Chinese Americans …………………………………………………………………… 76

Figure 4: Final model for Filipino Americans …………………………………………………………………… 85

Figure 5: Final model for Vietnamese Americans ……………………………………………………………… 92

Chapter I

Introduction and Problems

Purpose of the Study

The purpose of this current study is to explore the interrelationships among factors that

contribute to alcohol use among Asian American adults, with particular attention to the socio-

cultural variables of acculturation, acculturative stress (discrimination and family conflict),

religiosity, and social support. A path model is proposed and tested to explore and test the

interrelationships of these variables and their association with alcohol use for three distinct

cultural subgroups: Chinese, Filipinos, and Vietnamese

Americans.

Problem Statement

Alcohol is the most commonly used substance in the United States across all ethnic and

racial groups (U.S. Department of Health and Human Services [USDHHS], 2001). Alcohol use

significantly impacts society as a whole and individuals of all ethnic groups. While moderate

drinking may mitigate risk for certain diseases, including cardiovascular disease and diabetes, the

overall negative consequences of alcohol consumption far outweigh its benefits (Dufour, 1999).

According to Healthy People 2010 (USDHHS, 2010a), alcohol use contributes to a wide range of

health and social problems, including lost occupational productivity, domestic violence,

homelessness, teenage pregnancy, fetal alcohol syndrome, automobile accidents, and HIV/AIDS.

In the United States, among causes of death related to lifestyle, excessive alcohol use ranks third

(Center for Disease Control and Prevention [CDC], 2006).

While many studies have examined patterns of alcohol use and abuse among African

Americans and Hispanics, few have focused specifically on Asian Americans. Although Asian

Americans are the fastest-growing ethnic minority and suffer the same adverse health and social

consequences of alcohol use as other ethnic groups (Fong & Tsuang, 2007), research on alcohol

use within this ethnic group is scant (Ja & Aoki, 1993; Lee, Law, & Eo, 2003; Subramanian &

Takeuchi, 1999; Wong et al., 2007). The limited published data available suggest that Asian

Americans as a whole may have lower levels of alcohol abuse and related problems than other

ethnic groups (Klatsky, Seigelaub, Landy, & Friedman, 1983; Price, Risk, Wong, & Klingle,

2002; Substance Abuse and Mental Health Service Administration [SAMHSA], 1998).

To date, most research has studied Asian Americans as a single homogenous group,

without examining variability across subgroups (Kinto, Lubben, & Chi, 1989; Kuramoto, 1997;

Varma & Siris, 1996); however, the population of Asian Americans is composed of more than 30

subgroups, which differ in terms of religion, language, and other cultural features. Hence,

existing studies may not capture important variations in alcohol use among subgroups within the

Asian American population (Ja & Aoki, 1993; Lee et al., 2003; Makimoto, 1998; Subramanian &

Takeuchi, 1999; Wong et al.. 2007; Zane & Huh-Kim, 1998). Consequently, little is known

about variability in alcohol use within the Asian American population or about socio-cultural

factors that may contribute to such variability (Subramanian & Takeuchi, 1999). For a more

accurate picture of alcohol use and its determinants among Asian Americans, variability among

subgroups needs to be investigated with attention to multiple social-cultural factors that may

contribute to this variability and/or to alcohol consumption by Asian Americans as a whole.

A review of relevant literature on alcohol use among Asian Americans reveals several

weaknesses in existing data. First, few studies have addressed or compared the differential

impacts of Asian Americans’ level of acculturation and the experience of acculturative stress.

The acculturation model posits that alcohol use reflects the norms and practices of the society

into which a person is being acculturated, and some studies have demonstrated that Asian

Americans who are more acculturated to the U.S. drink more (Liu & Iwamoto, 2007; Wong et al.,

2007; Yi & Daniel, 2001). At the same time, the acculturative stress model posits that alcohol

use is associated with the stresses accompanying the process of acculturation to the mainstream

society, such as discrimination or family conflict, and studies have suggested that many

immigrant and ethnic minority populations drink alcohol as a means of coping with acculturation

stresses (Bhattacharya, 2005; D’Avanzo, Frye, & Froman, 1994; McLaughin, Raymond,

Murakami, & Goebert, 1987). However, few empirical studies have incorporated an examination

of both level of acculturation and acculturative stress in the same study, and few have taken into

account the potentially important moderating factors of social support and religiosity.

Second, most studies have focused on adolescents and college students, with few

assessing alcohol consumption and its predictors within adult populations. The more limited

ability to speak English among Asian American adults in contrast with their younger

counterparts has posed a significant barrier to their inclusion in research studies and national

surveys (Wong et al., 2007; Zane & Huh-Kim, 1998). Third, as noted above, most published

research has reported data for Asian Americans as a composite group, providing little

information on differences in alcohol-use patterns among subgroups of the population (Fong &

Tsuang, 2007; Kuramoto, 1997; Varma & Siris, 1996; Zane & Huh-Kim, 1998). “The paucity of

systematic collection of disaggregated Asian American and Pacific Islanders (AAPI) data leads

to a lack of information on the health status, treatment, and service delivery to various AAPI

subgroups” (Louise, 2001, p.176).

The current study addressed the shortcomings in prior research in a number of ways. First,

researchers argue that both level of acculturation and acculturative stress are relevant factors to

consider in relation to alcohol use. Therefore, the current study incorporated consideration of

both acculturative stress due to family cultural conflict and racial/ethnic discrimination and

acculturation as predictors of alcohol consumption, and also considered the potential for the

variables religiosity and social support to moderate these relationships. In particular, this study

built on a study by Chae et al. (2008) which examined the relationship between routine

experiences of unfair treatment and racial/ ethnic discrimination and life-time alcohol use

disorders. That study included both alcohol abuse and alcohol dependence disorders and used the

National Latino and Asian American Study (NLAAS) data. Unfair treatment was assessed as

frequency of routine experiences of unfair treatments, while racial/ethnic discrimination was

assessed as Asian Americans’ perceptions of

discrimination.

The NLAAS analyses revealed that

unfair treatment was significantly related to a history of alcohol use disorder. The current study

extended and built upon the Chae et al. (2008) findings, using the same NLAAS data set but

incorporated analyses of a greater number of relevant variables (i.e., family conflict, social

support, and religiosity) and examined more complex relationships as predictors of

alcohol use.

Second, this study used a representative adult population, rather than one limited to a

young college sample. Third, analyses were conducted separately among different ethnic

subgroups, which allowed for more accurate and targeted conclusions and enable comparisons

across ethnic subgroups. Prior studies, including Chae et al. (2008), have not examined subgroup

differences but rather have adjusted these out of the analyses. In contrast, this study conducted

separate analyses for Chinese, Vietnamese, and Filipino Americans.

In sum, this study is aimed to provide a better understanding of how the key factors of

acculturation and acculturative stress relate to alcohol use and how these relationships are

modified by social support and religiosity within subgroups of this population. Overall, the

analyses in this study aimed at filling knowledge gaps about intergroup heterogeneities among

Asian Americans. They will provide information necessary for the design of effective ethnically-

specific and culturally-tailored interventions for improving the health status of both specific

subgroups and Asian Americans on the whole.

Significance of the Proposed Study for Social Work

In 2003, 22 million Americans were identified as having substance abuse problems, but,

only 3.5 million received treatment services (SAMHSA, 2003). One explanation for this gap in

service is shortage of adequately qualified professionals and appropriate treatment options

(Kaplan, 2005). According to the National Association for Alcoholism and Drug Abuse

Counselors (NAADAC; now known as The Association for Addiction Professionals), 22% of its

members are licensed social workers (Kaplan, 2005). Expanding the number and expertise of

social workers trained to address substance abuse issues could potentially help close the gap

between need and available treatment.

While there are relatively fewer social workers specializing in addiction compared to

other mental health treatment providers, the field has made efforts to enhance the study of

addiction (Straussner, 2001). For example, in 1995, the National Association of Social Workers

(NASW) recognized the importance of treating addiction by establishing a specialty section

focusing on the study of alcohol, tobacco, and other drug use, and the association now offers a

clinical credential in the specialty (Straussner, 2001). This development, in turn, has fostered

interest in related topics within the social work field including the relationship between ethnicity

and substance abuse. While this is an important development, much remains to be done to bring

the field of social work in line with the needs of the Asian American community. The current

study will contribute empirically-based knowledge about alcohol use among Asian Americans

and will promote sensitivity to cultural and ethnic diversity in the field of social work and

substance abuse treatment.

Moreover, social work has a distinguished history of working to address the needs of

immigrant populations, ethnic minorities, and people affected by alcohol use and abuse. As the

number of Asian Americans in the United States continues to increase, social workers need to be

prepared to address increased use of alcohol in this population. By testing a comprehensive

model of alcohol use that incorporates both protective and risk factors, the study will provide

knowledge to improve the understanding of the lives of ethnic minority groups who are

acculturating to the mainstream society and will potentially contribute to improved assessment

and treatment of Asian Americans.

In addition, Asian Americans tend to underutilize and prematurely terminate mental

health services (Lin & Cheung, 1999; Yu, Clark, Chandra, Dias, & Lai, 2009), a trend that

reflects in part a lack of appropriate culturally-sensitive services. The results of the study with

Asian Americans can inform social work interventions at individual, family, and community

levels for this rapidly growing population. Furthermore, the comparative study of ethnic

subgroups will provide information to inform culturally relevant assessments and interventions

for members of specific subgroups. Overall, this study will provide much needed data to improve

understanding of the experiences and needs of the rapidly growing but understudied Asian

American population.

Chapter II

Literature Review

Relevant literature is summarized pertaining to alcohol use among Asian Americans and

to this current study exploring factors that contribute to alcohol consumption within three ethnic

subgroups of this population. First, alcohol consumption is discussed, both in relation to

associated health consequences and in regard to measurement approaches relevant to the

proposed research. Second, the Asian American population is characterized as a whole and the

three ethnic subgroups that are the focus of this study are described with respect to cultural and

historical differences. What is known about alcohol consumption among Asian Americans is also

be summarized. Third, the literature on some factors that may contribute to or moderate alcohol

consumption is reviewed, with attention to acculturation, acculturative stress (discrimination,

family conflict), social support, and religiosity. Lastly, the conceptual framework for

understanding alcohol use that emerges from the reviewed studies is introduced.

Alcohol Consumption

Health consequences. Alcohol consumption contributes to a range of acute and chronic

health problems, including injuries from auto and other accidents, alcohol abuse and dependence

disorders, cancer, and cardiovascular disease (Dawson, Grant, & Hartford, 1995; Midanik, Tam,

Greenfield, & Caetano, 1996; Rehm, Gmel, Sempos, & Trevisan, 2003; Room, Barbor, & Rehm,

2005). The Epidemiological Catchment Area Study (ECAS) reported the rate for lifetime

occurrence of alcohol abuse or dependence as 13.5 % (Kessler et al., 1994). Overall, research

supports the expected positive relationship between alcohol use and alcohol use disorders

(Archer, Dawson, & Grant, 1995; Caetano, Tam, Greenfield, Cherpitel, & Midanik, 1997;

Kessler et al., 1994). Caetano, Tam, Greenfield, Cherpitel, and Midanik (1997) found that the

consumption of five or more drinks in one day during the previous 12 months translated into a

six-fold risk of being alcohol dependent.

In addition, Russell and colleagues (2004) reported a liner relationship between increased

quantity and frequency of alcohol consumption and number of self-reported problems. For

example, binge drinking and heavy drinking have been associated with increased health

problems among drinkers, especially fatal and nonfatal injuries (CDC, 2006). Similarly, Rehm,

Room, Graham, et al. (2003) conducted a meta-analysis of the relationship between alcohol

consumption and a variety of diseases and found volume of alcohol intake to be associated with

increased risk for most diseases, including cancers of the mouth, oropharynx, esophagus, liver,

and breast as well as epilepsy, hypertensive diseases, hemorrhagic stroke, and cirrhosis.

In contrast, light to moderate alcohol consumption has been shown to have a beneficial

effect on the cardiovascular system compared to lifetime abstention or heavy drinking (Rehm,

Gmel, Sempos, & Trevisan, 2003). However, Rehm, Gmel, Sempos and Trevisan (2003) caution

that longitudinal analysis has failed to confirm this beneficial effect. Moreover, Puddey, Rakic,

Dimmitt, and Beilin (1999) state that the conclusion of a beneficial effect of alcohol is not

“clear-cut” (p. 650) and suggest that the pattern of consumption needs to be evaluated and

considered more carefully to better understand the overall impact of alcohol on cardiovascular

risk.

Recently increased attention had been given to the alleged benefits of moderate drinking.

The definition of moderate drinking is highly subjective and depends on individuals and cultures,

and no universal definition exists (DuFour, 1999). In the United States, according to the Dietary

Guidelines (USDHHS, 2005), moderate drinking is defined as “no more than one drink per day

for women and no more than two drinks per day for men” (p. 44). However, since individuals

react differently to alcohol consumption depending on body weight, age, and other variables

(DuFour, 1999), even this definition is questionable. Thus, physiological differences need to be

taken into account when discussing the effects of alcohol on drinkers.

Certain biological characteristics make some people more susceptible to health problems

arising from alcohol use than others. Brooks, Enoch, Goldman, Li, and Yokoyama (2009)

recently reported that individuals who have a deficiency in the enzyme aldehyde dehydrogenases

2 (ALDH-2) carry a much higher risk of esophageal cancer from alcohol consumption than those

with fully active ALDH-2 and that even moderate drinking increased the risk for esophageal

cancer among those with the deficiency. In non-drinkers, ALDH-2 deficiency by itself did not

have an effect on risk of esophageal cancer. Importantly, it appears that an inherited ALDH-2

deficiency is common among Asian Americans, manifesting most often as a flushing response

when consuming alcohol. Therefore, even a moderate consumption of alcohol may pose a higher

risk of esophageal cancer for this population.

In addition, liver cancer is prevalent among Asian Americans (USDHHS, 2009). While

hepatitis B is the factor most strongly associated with liver cancer, alcohol consumption is

another important predictor. This suggests that alcohol use may be implicated in the high

incidence of liver cancer in this population.

In brief, along with other health problems, the higher prevalence of liver cancer and the

increased risk of esophageal cancer among Asian Americans who drink support the critical

importance of examining alcohol consumption patterns and contributing factors to alcohol use

within this population.

Measurement of alcohol consumption. Alcohol consumption can be measured in many

ways (Breslow, Guenther, & Smothers, 2006). Five types are commonly used: (1) frequency

measures; (2) quantity-frequency measures (QF); (3) graduated frequency measures; (4) short-

term recall methods; and (5) diary methods (Dufour, 1999). Reviewing all approaches to

measurement is beyond the scope of this review, but frequency and QF measures are discussed

briefly as they pertain directly to the current study. Frequency measures query respondents in

regard to how much they typically drink within a specified timeframe (e.g., the past year), giving

them predetermined categories from which to choose. Since the actual amount of alcohol

consumed on each drinking occasion is not assessed, a frequency measure alone cannot capture

the total volume or average amount consumed (Rhem, 1998).

In contrast to the frequency measure, a QF measure queries the amount of alcohol

consumed in addition to frequency (Breslow et al., 2006; DuFour 1999), allowing calculation of

total volume of alcohol consumption and providing information on drinking patterns. Because of

these merits, QF measures are the most widely used instruments for measuring drinking in most

countries, including the United States (Breslow et al., 2006; DuFour, 1999), and will be used in

this study.

Description of the Asian American Population

This section includes three parts: a brief description of the Asian American population as

whole, a summary of Chinese, Filipino, and Vietnamese subgroups in terms of distinct history

and cultural features, and a synopsis of what is known about the prevalence of alcohol use

among Asian Americans.

Asian Americans are the fastest-growing ethnic minority in the United States (Hahm,

Lahiff, & Guterman, 2003). From 1990 to 2000, this population increased by 46 %, as compared

to 13 % for the general population as a whole (Wong et al., 2007). This growth is expected to

continue. While Asian Americans comprised just 4.2 % of the total U.S. population in 2000

(Reeves & Bennett, 2004), by 2050 it is projected that they will comprise 11 %, about 41 million

people (Arliss, 2007).

In general, Asian cultures are considered to be more collective in orientation in

comparison to more individualistic western cultures, and, at the most general level, the Asian

American population can be expected to reflect this distinction. Collective values include an

emphasis on maintaining harmonious relationships with others and exerting pressures on

individuals to subordinate satisfaction of individual needs to the needs of family and community.

Nevertheless, while this characterization may generally hold across Asian cultures and Asian

American immigrants, considering the Asian American population as a whole without taking

into account subgroup distinctions risks missing important cultural differences of potential

relevance to alcohol consumption.

Asian Americans are a heterogeneous group encompassing more than 30 ethnic

subgroups (Loue, 2003; Uba, 1994). The six dominant subgroups in order of their prevalence

are: Chinese (23.8%), Filipino (18.3%), Asian Indian (16.1%), Vietnamese (10.8%), Korean

(10.5%), and Japanese (7.8%) (Asian American Federation of New York [AAFNY], 2004).

These subgroups vary greatly with respect to socioeconomic status, migration patterns, language,

and political inclinations (Lee, 1997; Loue, 2003). About 70% of Asian Americans living in the

United States were born abroad and continue to be influenced by the cultural norms and values

of their native countries (Lai & Arguelles, 2003). Nearly two thirds of all Asian Americans still

speak an Asian language at home (USDHHS, 2001).

Helms and Cook (1999) defined ethnicity as “the national, regional, or tribal origins of

one’s oldest remembered ancestors and the customs, traditions, and rituals (i.e., subjective

culture) handed down by these ancestors, which among the ethnic group’s members, are assumed

to their culture” (p. 19). Further, according to Yancey, Aneshensel, and Driscoll (2001), ethnicity

distinguishes individuals based on their inclusion in groups whose members have common social,

cultural, and historical heritage. In line with the aforementioned definition of ethnicity,

subgroups of Asian Americans have distinct cultures. Those of Chinese, Filipino, and

Vietnamese American subgroups are described

below.

Chinese. According to the U.S. census, 2.7 million Chinese Americans represent 23% of

the total Asian American population in this country (Barnes & Bennett, 2002). The Chinese were

the first group of Asian Americans to come to the United States in large numbers (Lee & Mock,

2005). Most of them came as manual labor for the construction of railroads in the mid 1800s

(Lee, 1997). Racial and ethnic antagonism and xenophobia against these early immigrants led to

the passage of the Chinese Exclusion Act of 1882, which barred Chinese laborers and their

relatives from entering the United States (Lee, 1997).

Currently, most Chinese Americans reside in California, with the next largest populations

in New York and Hawaii (Lee & Mock, 2005). As of 2000, about 47% of Chinese Americans

were foreign born (Lai & Arguelles, 2003) and about 50 % did not speak English well (Reeves &

Bennett, 2004). While no single native language is shared by all Chinese immigrants, the most

commonly spoken dialects are Cantonese and Mandarin.

Traditional Chinese culture places strong emphasis on harmonious interpersonal

relationships and interdependence. Interactions among family members are governed by

hierarchy, obligation, and duty (Lee, 1997). Families are patriarchal, with males filling the

dominant roles and wives subservient to their husbands. Among Chinese Americans, the most

common religions are Buddhism and Christianity (Lee & Mok, 2005), although Confucianism

and Taoism also represent important influences on people’s behavior.

Filipinos. Filipinos are a multicultural people with elements of Chinese, Spanish,

Malayan, Indonesian, and South Asian heritage. The Philippines were at various times colonized

by the Americans, the Spanish, and other Asian powers (Nadal, 2000). This history has

contributed to a kind of “colonial mentality” (p. 102) that includes a sense of inferiority and

suspiciousness in relation to the colonizer (Sustento-Senriches, 1997).

Filipinos began migrating to the Unites States in the late 1880s. Compared to other Asian

Americans, they have the highest rate of English proficiency, largely due to their colonization by

the United States (Root, 2005). This, along with such factors as multigenerational households,

sharing of resources, and education, has helped Filipinos achieve one of the highest median

family incomes and lowest poverty levels of immigrant groups. Also, due to four hundred years

of Spanish colonization, over 80% of the Filipino population is Roman Catholic (Nadal, 2000).

The Filipino concept of family extends beyond the nuclear to include the clan and the

community (Sustento-Senriches, 1997). The family structure is hierarchical, based on respect and

responsibilities, and Filipino culture places great value on harmonious relationships (Sustento-

Senriches, 1997).

Vietnamese. Compared to Chinese and Filipino Americans, Vietnamese are relatively

recent immigrants (Wong et al., 2007). As a result of U.S. military involvement in Vietnam in

the 1960s and 70s, many came as involuntary immigrants (Wong et al., 2007), and large numbers

arrived after the end of the Vietnam War in 1975 (Sodowsky, Lai, & Plake, 1991). The growth

rate in the Vietnamese population from 1990 to 2000 was 82.7% (Xu, Ross, Ryan, & Wang,

2005). By 2002, there were about 1.2 million Vietnamese Americans in the U.S., representing

11% of the U.S. Asian population (Barnes & Bennett, 2002). This number is expected to grow to

nearly 4 million by the year 2030. A large portion of the Vietnamese American population is

foreign born, although there is now a generation that was born in the United States (Wong et al.,

2007). Still, according to the 2000 U.S. census data, 62.4% of Vietnamese Americans do not

speak English very well and/or at home (Barnes & Bennett, 2002).

China has had strong and extensive influence on Vietnamese culture and history (Leng &

Boehnlein, 2005). Chinese Confucianism, adopted by Vietnam, has governed Vietnamese society

for centuries (Leng & Boehnlein, 2005). Currently the Vietnamese most commonly practice

Buddhism and Catholicism, the latter a result of French colonialism (Lee & Mok, 2005). With

respect to family culture, more importance is placed on the family group than the individual.

Maintaining relationships of harmony with the environment and other people is also important.

In sum, while there are cultural similarities across these three ethnic subgroups of Asian

Americans including shared hierarchical family structure, and an emphasis on family-

centeredness, each group represents a different combination of history, geography, language, or

religion. As such, the experiences of these ethnic subgroups are likely to differ too in regard to

acculturation, acculturative stresses (family conflict and discrimination experience), social

support, and other factors that potentially contribute to or moderate drinking behavior. This

current study takes into account this cultural diversity within the Asian American population by

separately examining the how such variables interrelate in predicting alcohol consumption for

three distinct subgroups of Chinese, Filipino, and Vietnamese Americans. Studying alcohol

patterns in disaggregated Asian Americans samples will allow more precise testing of the

applicability of the proposed model of alcohol use.

Prevalence of alcohol use among Asian Americans. Estimates about the prevalence of

alcohol use among Asian Americans vary, depending in part on how the population has been

defined and sampled and on whether subgroups have been queried separately. In general,

epidemiological studies that treat Asian Americans as one group report lower rates of alcohol use

in this population compared with other ethnic groups (Caetano, Clark, & Tam, 1998; Lee et al.,

2003; Loue, 2003; Price et al., 2002). However, the few studies that have examined patterns of

alcohol use in different ethnic subgroups reveal a more complex picture (Lee et al., 2003; Griffin,

Mosher, Rotolo, & Drapela, 2004; Wong et al., 2007).

Most past research on racially or ethnically based differences in alcohol use has focused

on Hispanic Americans, African Americans, and Whites, while either excluding Asians or

relegating them to a category of “others” (Lee et al., 2003). However, recent national studies on

alcohol use have reported data for Asian Americans, treating them as a single group. For

example, a 1998 National Household Survey on Drug Abuse (NHSDA) study reported that,

based on frequency analyses, Asian Americans as a group had lower rates of alcohol

consumption than the general United States population; 53 % of Asian Americans consumed

alcohol compared to 56 % of non-Asian Americans (Griffin at al., 2004). A 2003 SAMHSA

publication provides a more complex picture of substance use among Asian Americans with

analyses by ethnic subgroup. That study reported dramatic differences among groups in alcohol

and other drug use; lifetime prevalence of alcohol use among adults ranged from 51.5% for

Asian Indians to 83.9% for the Japanese, and past-30-day alcohol use ranged from 23.4% for

Filipinos to 45.3% for the Japanese (Griffin et al., 2004). The fact that the same study found that

Asian Americans as a group consumed less alcohol than the U.S. population in general

underscores the importance of more nuanced subgroup analyses.

Clinical and anecdotal evidence further suggests that alcohol abuse is a significant

problem within the Asian American community (Zane & Sasso, 1992). Alcohol abuse and

dependence disorders have been reported as the most common psychiatric disorders affecting

Asian Americans (Chang, 2002). According to the National Asian Pacific American Families

Against Substance Abuse (NAPAFASA, 2005), alcohol use is both prevalent and increasing

within this population, and those Asian Americans who do drink typically drink more per day

than any other racial/ethnic group. The implications of these patterns are potentially serious since

Asian Americans with alcohol dependence appear to be at a greater risk for alcohol-related

illness such as cancers and alcohol-induced asthma (Sakai, Ho, Shore, Risk, & Price, 2005). In

addition, it appears to be important to examine the changing nature of alcohol use among the

Asian American population over time: Longitudinal data indicate that the prevalence of alcohol

use disorders among Asian Americans doubled from 1990-1991 to 2000-2001 (Grant et al.,

2004).

Community-based studies of alcohol use have reported less consistent findings in rates of

alcohol use among Asian Americans than have broader national studies (Chi, Lubben, & Kitano,

1989; Wong et al., 2007). For example, a study by Chi, Lubben, and Kitano (1989) showed that

heavy drinking among Asian Americans—defined as at least five drinks during a single drinking

occasion— was similar to that of the general U.S. population with rates of heavy drinking among

Japanese and Korean Americans at 28.9% and 25.8%, respectively. In contrast, a 2007 National

Survey on Drug Use and Health (NSDUH) study reported that the rate of heavy drinking among

Asian Americans as a single group was 12.6% (SAMHSA, 2007). In another study, which used a

community-based methodology, Wong et al. (2007) reported that the current alcohol-use rate

(defined as at least one drink in the past 30 days) for Vietnamese Americans was 60.3%,

considerably higher than the 56.1% for Whites found in a 2007 NSUDH report.

There are numerous reasons why results of epidemiological studies may not accurately

reflect the full scope of alcohol use among Asian Americans. These include (1) inappropriately

treating Asian Americans as a homogenous group, (2) the underrepresentation of Asian

Americans in treatment facilities from which research samples are drawn, (3) biases introduced

by self-report methodologies, (4) lack of culturally appropriate measurement, and (5) the myth of

‘model minority’ (Ja & Aoki, 1993; Subramanian & Takeuchi, 1999; Zane & Huh-Kim, 1998).

Each of these reasons is elaborated below.

First, differences in rates of alcohol use may be the result of reporting data on Asian

Americans as if they represented a homogenous group (Caetano et al., 1998; Kuramoto, 1997;

Makimoto, 1998; Subramanian & Takeuchi, 1999; Varma & Siris, 1996; Wong et al., 2007). A

report by the Surgeon General (USDHHS, 2001) noted that categorizing all Asian American

groups under one heading has resulted in misconceptions of lower rates of alcohol use, and a

lack of research devoted to or resources provided for this population. However, as mentioned

earlier, rates of alcohol use vary within subgroups of Asian Americans (Price et al., 2002; Wong

et al., 2007).

Second, many epidemiological studies have been conducted in substance abuse treatment

settings where few if any Asian Americans are located. The underrepresentation of Asian

Americans in such centers has been well-documented (Caetano et al., 1998; Ja & Aoki, 1993).

For, example, while Asian Americans represented 4.2% of the total U.S. population (Reeves &

Bennett, 2004), in 2003 they constitute just 1.1 % of the nearly 1.7 million admissions to

publicly funded alcohol-abuse treatment program (National Institute on Drug Abuse [NIDA],

2005). The underrepresentation probably results from the reluctance of Asian Americans to seek

treatment for alcohol-related problems because of fatalistic views of having no personal control

over outcomes (Zane & Kim, 1994), cultural stigmas (e.g., losing face), and language barriers

(Catetano et al., 1998; Ja & Aoki, 1993; Ja & Yeun, 1997; Mercado, 2000).

Moreover, many research studies have relied on self-report measures or interviews that

may lead to underreporting of alcohol consumption because of a strong culturally-based stigma

against substance use (Ja & Aoki, 1993; Subramanian & Takeuchi, 1999; Zane & Kim, 1994).

Furthermore, many of the studies have failed to use culturally-appropriate measurement tools

and/or provide translation of the items or questions (Zane & Huh-Kim, 1999). Even when

translated measures are available, few studies evaluate the conceptual equivalence of the

translated measures with the originals (Zane & Huh-Kim, 1999). Finally, the stereotypical notion

of Asian Americans as reserved, successfully assimilating into the dominant culture, and high

achieving model minority members, may contribute to erroneous perceptions of their alcohol use

(Ja & Aoki, 1993; Loue, 2003; Mercado, 2000; Subramanian & Takeuchi, 1999).

Taken as a whole, the literature suggests that problems of alcohol use in the Asian

American community have probably been underestimated. Because of the misconception of

Asian Americans as a “model minority” and the lower prevalence rates of alcohol use for the

Asian American population as a whole, little attention has been given to the study of alcohol

consumption and its determinants among Asian American groups. The limited available

literature nonetheless highlights the potential importance of disaggregating the Asian American

population into subgroups for research purposes. Finally, this population is no more immune to

alcohol use than any other (Chi et al., 1989; Fong & Tsuang, 2007); Asian Americans share the

same negative consequences of drinking alcohol with other ethnic groups and, as elaborated

earlier, may be at greater risk for certain diseases. Clearly, a focus on alcohol use within this

population is overdue. It is time to move beyond debating about rates of alcohol use and to

examine underlying factors contributing to alcohol use and related problems within various

segments of the Asian American population.

Relevant Contributory Factors to

Alcohol Use

Research has focused on several potential contributory factors in relation to alcohol use.

Some researchers have emphasized the role of biological factors (Matsyuoshi, 2001; Wall &

Ehlers, 1995). Others have pointed to psychological triggers such as trauma, while still others

have asserted the importance of socio-cultural factors, such as a person’s cultural background

and degree of acculturation (Caetano et al., 1998; Chen, 2003; Johnson & Nagoshi, 1990;

Makimoto, 1998). Overall, alcohol consumption appears to be multi-determined—the combined

result of biological, socio-cultural, and psychological influences (Straussner, 2001). Biological

and socio-cultural factors that pertain to an understanding of alcohol consumption in Asian

American population and to the conceptual model developed for this current study are reviewed

below.

Biological factors. Many studies have explored the role of biological factors in Asian

Americans’ alcohol use (Luczak, Elvine-Kreis, Shea, Carr, & Wall, 2002; Matsuyoshi, 2001;

Wall & Ehlers, 1995), suggesting the prevalence of ALDH-2 deficiency may account for their

apparently lower rate of alcohol consumption. The deficiency gives rise to a flushing response

when alcohol is consumed, characterized by a reddening of the face and torso and an increase in

skin temperature (Caetano et al., 1998; Matsuyoshi, 2001). ALDH2 is a liver enzyme involved in

the breakdown of alcohol, without which the oxidation of acetaldehyde occurs more slowly,

causing a higher blood acetaldehyde level and consequently flushing when alcohol is consumed

(Wall & Ehlers, 1995). People of Asian heritage are more susceptible to this negative

physiological reaction to alcohol compared to other ethnic groups (Luczak et al., 2002).

Not all Asian Americans experience the flushing reaction, and the prevalence of flushing

differs from one Asian group to another (Austin, Prendergast, & Lee, 1989). Although the

response may mitigate alcohol consumption, it is inadequate to explain the lower rates of alcohol

consumption in Asian Americans compared to other ethnic groups (Au & Donaldson, 2000;

Johnson & Nagoshi, 1990). For example, although in some studies Asian Indians have higher

levels of flushing compared with other Asian groups, they also consume more alcohol (Stewart,

1964, cited in Peele 1986). Hence other contributory factors must also be considered to

understand alcohol use among Asian Americans (Johnson, Nagoshi, Ahern, Wilson, & Yuen,

1987; Sue, Zane, & Ito, 1979; Zane & Huh-Kim, 1998).

Socio-cultural factors. There are several socio-cultural factors that may contribute to

alcohol use among Asian Americans of any subgroup. Only some of these factors are the focus

of this review: acculturation, acculturative stress (including discrimination and family conflict),

social support, and religiosity.

Acculturation. Acculturation has emerged as an important construct to explain health

behavior of ethnic minorities (Cabassa, 2003; Trimble, 2003), and many studies have examined

the relationship between acculturation and alcohol use. In this section, acculturation is defined,

conceptual and methodological approaches to measurement of acculturation are described, and

available literature on the relationship between acculturation and alcohol use among Asian

Americans is summarized. The review focuses on acculturation and acculturative stress models

with particular attention to acculturative stressors of discrimination and family conflict.

Acculturation is an important variable in studies of the well-being of ethnic minorities

and immigrants (Trimble, 2003; Zane & Mak, 2003). Specifically, acculturation refers to the

process by which the social, psychological, and cultural lives of ethnic minorities and

immigrants including their beliefs and behaviors, are affected and changed by the mainstream

culture in which they live (Berry, 1997). The construct describes the impact on beliefs and

behaviors that results from continuous contact between individuals from different cultures

(Caetano & Clark, 2003; Zane & Mak, 2003).

The pressure to accommodate to the larger culture is a complex and powerful force in the

lives of all ethnic minority individuals (Berry, 2003; Caetano & Clark, 2003). The acculturation

experience of new immigrants is shaped by their country of origin and the circumstances of

migration (Cabassa, 2003). The process of acculturation, however, is not confined to immigrants

alone; second and third generations born into families whose cultures are different from the

dominant one also face ongoing acculturation pressures (Zimmerman, Vega, Gil, Warheit,

Apospori, & Biafora, 1994).

A comprehensive literature review conducted by Gilbert and Cervantes (1986) gave raise

to two related models of the relationship between alcohol use and acculturation: an acculturation

model and an acculturative stress model. The acculturation model predicts that the drinking

pattern of an individual will resemble that of the general U.S population as the individual adopts

mainstream society’s norms and culture. The acculturative stress model, on the other hand,

predicts more alcohol consumption by an individual as he or she is exposed to stressors which

occur during the acculturation process.

Models of acculturation. Whether acculturation is best understood and measured on a

uni- or multi-dimensional basis has been debated over time, reflecting shifting definitions of the

construct (Trimble, 2003). When viewed as a one-dimensional process, an individual’s

acculturation is seen as moving along a single continuum from conformity to the ethnic culture

of origin to adaption of the dominant culture (Gordon, 1964). Proximity to one cultural pole

implies distance from the other.

An alternative model proposes that acculturation is a bi- or multi-dimensional process,

best understood with reference to two distinct and independent dimensions (Berry, 2003). The

first dimension reflects the individual’s relationship to his or her culture of origin, ranging from

strong adherence to total rejection. The second dimension reflects the adaption by the individual

of the values, attitudes, and behaviors of the dominant culture, and similarly ranges from full

participation to complete rejection.

Berry’s multi-dimensional model defines four quadrants that representing distinct

acculturation styles: assimilation, integration, separation, and marginalization (Berry, 2003).

Assimilation refers to the complete absorption of the new culture and relinquishment of the

culture of origin. Integration refers to embracing and valuing both the original and the new

culture. Separation refers to adhering to the original culture while rejecting and avoiding the

dominant one. Finally, marginalization refers to the acculturation style of those who neither

adopt the new culture nor maintain their culture of origin.

Measuring levels of acculturation and acculturative stress. Acculturation measures vary

in terms of whether they are based on uni- or multi-dimensional models and on the domains of

cultural change they assess. Uni-dimensional measure includes proxy measures and uni-

dimensional scales. The proxy measurement approach is based on the assumption that degree of

acculturation can be approximated by assessing the cultural minority member’s amount of

exposure to the dominant culture. A proxy measure typically consists of a response to a single

question, such as duration of residence in the host country, generational status, English-language

proficiency, and age at time of immigration (Salant & Lauderable, 2003). Proxy variables and

their measures assume a uni-dimensional model of acculturation.

Unlike individual proxy measurements, uni-dimensional scales of acculturation typically

include multiple items that tap a variety of cultural domains (Zane & Mak, 2003). These scales

allow classification of individuals along a continuum ranging from low to high levels of

acculturation, depending on the degree to which they have adopted values, beliefs, or behaviors

of the mainstream culture. An example is the Suinn-Lew Asian Self-Identity Acculturation scale

(SL-ASIA) which contains items about language use, ethnic identity, and personal preference for

one culture or the other.

In contrast to uni-dimensional measures, multi-dimensional measures allow for separate

assessments of an individual’s adherence to both their ethnic culture and the dominant one

(Berry, 2003; Cabassa, 2003). Separate scores for each culture are then used to classify the

individual into one of the four acculturation categories described above: assimilation, integration,

separation, and marginalization. Examples of multi-dimensional measurements include the

Acculturation Rating Scale for Mexican-Americans-II (ARSMA-II; Cuellar, Arnold, &

Maldonado, 1995) and the Bi-dimensional Acculturation Scale (BAS; Marin & Gamba, 1996).

In one example of research using multi-dimensional measures to study Mexican

Americans, Cuellar, Arnold, and Maldonado (1995) found a significant link between

acculturation and generational status: Mexican orientation scores decreased in a linear trend with

each sequential generation, whereas Anglo orientation scores increased with each generation. In

addition, language use, a uni-dimensional measure, has been shown to correlate highly with more

comprehensive acculturation measures (Epstien, Botvin, Dusenbury, & Diaz, 1996; Gallagher-

Thompson et al., 1997), thus researchers may still find a uni-dimensional measure of

acculturation to be useful. Indeed, many researchers continue to conceptualize and measure

individual acculturation in a uni-dimensional way in their empirical studies (Gong, Takeuchi,

Agbayani-Siewert, & Tacata, 2003; Su & Wong, 2007; Takeuchi, Zane, Hong, et al., 2007;

Wong et al., 2007).

Researchers have made efforts to improve measurement of acculturation to better capture

the complexity of the process (Trimble, 2003), and many have suggested using multi-

dimensional models rather than uni-dimensional ones (Berry, 1997). Still, not even multi-

dimensional scales capture the dynamic nature of the acculturation process (Trimble, 2003). An

important component of acculturation may be the stress inherent in the process, for example, the

need to cope with discrimination and family conflict generated by cultural change.

Measures of acculturation stress are based on the assumption that stress is an inherent

part of acculturation (Berry, 2003). For example, such tasks as learning a new language or

finding a job inevitably challenge adaptive capabilities. Relative to the multitude of available

measures of acculturation, there are relatively few measures of acculturative stress, although

several researchers have made efforts to develop such measures (Chavez, Moran, Reid, & Lopez,

1997; Mena, Padilla, & Maldonado, 1987). Overall, a review of the literature leads one to

conclude that no definitively superior approach to measure either the acculturation or

acculturative stress has yet been demonstrated.

Acculturation scales appropriate for Asian Americans. Despite the availability of

measures of acculturation, those appropriate for use with Asian American are in short supply.

Zane and Mak (2003) conducted a content analysis of 23 acculturation scales. Of these, most

were designed for use with Hispanic Americans and only three were specifically designed for use

with Asian Americans: 1) the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA;

Suinn, Rickard-Figueros, Lew, & Vigil, 1987); 2) the Acculturation Scale for Southeast Asians

(AS-SEA; Anderson et al., 1993); and 3) the Asian Value Scale (AVS; Kim, Atkinson, & Yang,

1999). The SL-ASIA has been used with a broad array of Asian Americans including Chinese,

Japanese, and Korean Americans. The AS-SEA measures acculturation among Southeast Asian

Americans, including Cambodians, Laotians, and Vietnamese, while the AVS assesses value

orientations associated with East Asian societies. A review of the content of these three scales

revealed that standard measures applicable to all subgroups of Asian Americans were limited.

Zane and Mak (2003) reported that language use in one or more contexts (e.g., at home, with

friends, at work) was the most frequently assessed acculturation dimension with both Asian and

non-Asian ethnic minorities, consistent with the preponderance of language use and language

preference as core component of both uni- and multi-dimensional acculturation measures. The

general conclusion aptly applies to the specific study of Asian Americans, “no one measure

adequately samples the major behavioral and attitudinal domains related to acculturative change”

(p. 54).

Factors associated with acculturation. Language is a critical factor in the acculturation

process. The role of language is made apparent when considering outcomes for Filipino

Americans in comparison with other Asian American groups. Due to their history of American

colonization, Filipinos are more English proficient than other Asian American subgroups upon

immigration (Root, 2005) and tend to be more highly acculturated as well. Asian American

groups who have less exposure to English prior to coming to American tend to encounter serious

language barriers in the acculturation process. Such has been the case with Vietnamese

Americans, most of whom are recent immigrants (Wong et al., 2007), who arrived in the U.S.

after the Vietnam War (Sodowsky et al., 1991). Similarly, although the Chinese have migrated to

the U.S over the past 150 years, most in the current U.S. population are recent immigrants,

making language an important factor in their acculturation. In sum, differences in language

acquisition are crucially important in understanding the complex relationship between ethnicity

and acculturation.

Overall, it appears that the most important contributions to the rate and success of the

acculturation process are language acquisition and generational status, factors which interact

with ethnicity to produce a variety of trajectories for Asian Americans.

Acculturation and alcohol use. Acculturation may also play an important role in the

patterns of alcohol use among ethnic minorities. Both the acculturation and the acculturative

stress model have been proposed to address this relationship. The acculturation model posits that

alcohol use reflects the norms and practices of the society into which a person is being

acculturated, whereas the acculturative stress model posits that alcohol use increases in response

to the stresses accompanying the process of acculturation into a new society (Gilbert &

Cervantes, 1986). Research is summarized below relevant to the application of these models to

alcohol use.

Acculturation model for alcohol use. The acculturation model is based on the idea that

there is an ethnic culture that exists within the mainstream culture. Cultural transition occurs

between ethnic and mainstream cultures. According to the acculturation model, drinking

behavior of recent immigrants would be expected to mimic the drinking pattern in their home

country, but as they become more acculturate into the mainstream society, their drinking

behavior would come to resemble that culture. In Asian culture, drinking is generally social

rather than solitary, occurs in moderation and in prescribed settings, and, is usually accompanied

by eating (Matsyuoshi, 2001; Wall & Ehlers, 1995). With acculturation Asian Americans adopt

the more lenient and permissive drinking norms of the mainstream society.

Studies on the relationship between acculturation and alcohol use among Asian

Americans are summarized in Table 1. Although results have been inconsistent, the acculturation

model as a predictor of alcohol use has been generally supported. Some studies documented a

direct and positive relationship between acculturation and use of alcohol and alcohol-related

disorders (Gong et al., 2003; Liu & Iwamoto, 2007; Sue et al., 1979; Yi & Daniel, 2001) while

others fail to do so (Akutsu, Sue, Zane, & Nakamura, 1989; Kitano, Lubben, & Chi, 1988; Su &

Wong, 2006). These inconsistencies may reflect both methodological differences among studies

and a reliance on correlational and multiple regression analyses. For example, many have used

correlational and regression analyses but have not examined a complex path model of

determinants of alcohol use in relation to multiple acculturative factors among Asian Americans.

Table 1: Summary of available studies on acculturation and alcohol use among Asian Americans (in reverse chronological order)

Authors

Acculturation

measure
Alcohol use measure Sample/design Findings Statistical Model

Liu &
Iwamoto
(2007)

 Asian Value Scale-
Revised (AVS-R:
Kim & Hong,
2004)

 Substance use
(alcohol use,
binge drinking
behavior,
marijuana use,
cocaine, other
illicit drug use) in
the last month

 Asian American male
college students.
 Convenience sampling
 Sample size=154

Chinese(n=40)
Vietnamese (n=31)
Filipino (n=23)
Korean (n=17)
Asian Indian (n=14)
Japanese (n=12)
other Asians (n=17)

 Asian Americans
with higher
adherence to Asian
values drank less
alcohol

 Logistic regression

Despuses &
Friedman
(2007)

 Modified version
of Marin, Sabogal,
Marin, Otero-
Sabogal, & Perez-
Stable(1987)
 Three subscales:

language use,
media, and ethnic
social relations

 Alcohol per day
 Alcohol per week
 Binge drinking

 College students
 Asian (n=153)

European (n=110)
African (n=69)
Hispanic (n=138)
other (n=51)
 Sample size=521

 Asian Americans
with high
acculturation
reported to drink
more than those with
lower acculturation

 MANCOVA

Wong et al.
(2007)

 Place of birth (US
born vs. Foreign
Born)
 English-language

proficiency

 Use of alcohol in
the past month

 Cambodian, Laotian,
& Vietnamese Adults
in Washington D.C.
metropolitan area
 Sample size=4

 Those who were
born in U.S. were
more likely than
those who were
foreign born drink
alcohol

 Logistic Regression

Su & Wong
(2006)

 Language spoken
at home
 Preference for

 Substance Use
Checklist (19
items)

 College students in a
private university in
East Coast city.

 Those who preferred
watching American
TV/Movie were

 Correlation testing

eating American
food and watching
American
TV/movie
 Place of birth (US

born vs. Foreign
born)

 use of substance
in lifetime and in
the past 30 days

 Sample size= 248
Asian American and
Pacific Islanders.

more likely to drink
alcohol
 Foreign born Asians

were more likely to
drink beer than U.S.
born.
 No association

between language at
home and current
drinker

Hendershot,
MacPherson,
Myers, Carr,
& Tamara
(2005)

 Suinn-Lew Asian
Self-Identity
Acculturation (SL-
ASIA)

 Ever used alcohol
in lifetime
 Used alcohol in

past 30 days
 Heavy drinking in

the past 2 weeks

 College students in
Southern California
 Sample size=428
 Korean (n=205)

Chinese (n=223)
 Longitudinal study

 Highly-acculturated
Asian Americans
were more likely to
drink heavily.

 ANOVA

Gong,
Takeuchi,
Agbayabi-
Siewert, &
Tacata
(2003)

 Length of time in
US
 Age at immigration
 English

proficiency

 Alcohol
dependence (Short
form of the
University of
Michigan’s
version of the
Composite
International
Diagnostic
Interview)

 Secondary data – the
Filipino American
Epidemiological Study
in San Francisco or
Honolulu.
 Sample size= 1,818

Filipino immigrants.
 Probability sampling

 Those who
immigrated at early
age were more likely
to have alcohol
dependence disorder
than those who
immigrated at older
age.

 Multiple regression

Chung
(2002)

 Generation status
(U.S born vs.
Foreign born)

 Alcohol
consumption –
average daily
ethanol intake
(current drinker,
ex-drinker, &
Abstainer)

 Adults
 Chinese-, Japanese-,

Korean-Americans
 Sample size=704
 Secondary data –

National Longitudinal
Alcohol

 U.S. born Asians
consumed more
alcohol than foreign
born Asians.

 Multiple regression

 Alcohol
dependence
(lifetime)
 Alcohol

abuse(lifetime)
 Binge drinking
 Socially

hazardous
drinking

Epidemiological Study
(NLAES) data of 1992

Yi & Daniel
(2001)

 Modified version
of the Suinn-Lew
Asian Self-Identity
Acculturation
Scale

 Use of alcohol-
current uses or
nonuse

 College student at the
University of Houston
 Vietnamese
 Sample size=412
 Cross-sectional design

 Students who were
more acculturated
were more likely to
drink than those with
less acculturation

 Logistic regression

Akutsu, Sue,
Zane, &
Nakamura
(1989)

 Contrasting Value
Survey (60-items)
(Conner, 1977)

 Frequency &
Quantity of

alcohol use
(Abstainer,
infrequent drinker,
light drinker,
moderate drinker,
and heavy
drinker)

 University students
 Chinese (n=49)

Japanese (n=34)
Caucasian (n=96)

 Acculturation was
not related to
alcohol consumption

 Hierarchical multiple
regression

Johnson,
Nagoshil,
Ahern,
Wislon, &
Yuen (1987)

 Place of birth (US
born vs. Foreign
born)
 Number of years of

residence in
Hawaii

 Frequency &
Quantity of
alcohol use
(Abstainer, former
drinkers, and
current drinkers)

 Chinese, Japanese,
Filipino, Hawaiian,
Hapa- Haoles, and
Caucasian
 Sample size=3,714
 Cross-sectional design

 Chinese, Japanese,
and Filipinos who
were born in Hawaii
were more likely to
drink alcohol
compared to those
who were born in
their home country.

 T-test and ANOVA

Sue, Zane,
& Ito (1979)

 English-language
proficiency

 Frequency &
Quantity of

 College students
 Chinese (n=23)

 Acculturation was
related to increase

 MANOVA

 Socialization with
American friends
 Generation

(Parents/
grandparents – U.S
born vs. Foreign
born)

alcohol use
(5 categories:
abstainer/light,
mild, moderate,
heavy, and very
heavy)

Korean (n=24)
Caucasian (n=77)
 Cross-sectional design

drinking levels.

Acculturation has been associated in some studies with increases in risky health-related

behaviors including alcohol use and drug use (Despues & Friedman, 2007; Gong et al., 2003;

Hahm et al., 2003; Liu & Iwamoto, 2007; Yi & Daniel, 2001), changes attributable to

incorporation of the values of the dominant culture through the acculturative process (Marin &

Gamba, 2002). Consistent with this reasoning, recent immigrants would be expected to show

rates of alcohol use similar to the rates in their home countries, with time shifting toward the

drinking patterns of the new dominant culture (Chung, 1990-1991; Gilbert, 1989; Kim, McLeod,

& Shantzis, 1995; Sue et al., 1979). Drinking patterns of subsequent generations of a particular

ethnic group would come to more closely resemble those of the general U.S. population (Chung,

1990-1991; Gilbert, 1989).

Research by Sue, Zane, and Ito (1979) supports these predictions: highly acculturated

Asian college students consumed more alcohol than their less assimilated counterparts. In their

study, acculturation was measured using three components: 1) socialization, based on the

percentage of an individual’s friends who were fellow Asian Americans; 2) level of proficiency

in the native language (Japanese or Chinese); and 3) the number of generations of family

residence in the United States. Not speaking one’s parents’ native language and longer familial

residence in the United States were significantly associated with increased alcohol consumption.

Similarly, Price et al. (2002), using the 1999 NHSDA and the 1992 National Longitudinal

Alcohol Epidemiologic Survey (NLAES), reported a positive relationship between acculturation

and alcohol use. Japanese Americans, who came from families that arrived as immigrants in the

early 20th century had the highest levels of acculturation among the ethnic subgroups in the study

and reported the highest rate of alcohol use (37.5%), closest to the rate among Whites (46.9%).

Conversely, Vietnamese Americans, the most recent immigrant group, were the least

acculturated and had the lowest rate of alcohol use (18.1%). Although sample sizes were too

small to allow definitive conclusions, the results support the link between acculturation and

alcohol use. Takeuchi, Zane, Hong, et al. (2007) also found that acculturation, as assessed via

English proficiency was positively associated with alcohol use disorders including both alcohol

use and alcohol dependences (DSM-IV diagnoses) among Asian Americans. The authors suggest

that English proficiency facilitate the expansion of social networks, increasing exposure to social

situations where drinking is involved.

Some studies report that ethnic minority individuals born in the United States, and

therefore assumed to be more acculturated, are more likely to use alcohol than those born

elsewhere (Brown, Council, Penne, & Gfroerer., 2005; Canino, Burman, & Caetano, 1992; Vega

& Gill, 1999; Wong et al., 2007). In their analysis of data from the 1999–2001 NSDUH, for

example, Brown, Council, Penne, and Gfroerer (2005) found that overall alcohol consumption,

past month alcohol use (defined as at least one drink in the past 30 days), and past month heavy

drinking (defined as five or more drinks on the same occasion on 5 or more days in the past 30

days) were lower for immigrants from China, Vietnam, and the Philippines in comparison with

their counterparts born in the United States. Chung’s dissertation (2002) similarly corroborates

the relationship between acculturation and alcohol use across Chinese, Japanese, and Korean

Americans. In this study, alcohol consumption was measured by average daily ethanol intake in

the previous month. Finally, Wong et al. (2007), using a community survey, found that U.S.-born

Southeast Asian Americans reported consuming three times more alcohol in the previous month

than their foreign-born counterparts.

Not all studies, however, have confirmed a relationship between acculturation and

alcohol use. Akutsu Sue, Zane, and Nakamura (1989) compared alcohol consumption,

acculturation, and physiological reactions to alcohol among Asians and Caucasians. When

demographic (i.e., age, gender, & body weight) and physiological factors were controlled, there

were no significant relationships between acculturation and alcohol use. Alcohol use was

measured by frequency and quantity of drinking; acculturation, by differences between Asian

and Western cultural values. Su and Wong (2006) also investigated the relationship between

alcohol use and acculturation, using three proxy measures of acculturation: place of birth,

preference for both American food and watching American television, and length of residence in

the U.S. The foreign-born Asian college students were more likely to be current drinkers than

their American-born counterparts.

As Sue and Nakamura (1984) have argued, acculturation reflects a complex set of

interactions between an individual’s native culture, mainstream American culture, and

generational status. Various factors may contribute to inconsistencies in research results. The

findings of any particular study are affected by how acculturation is defined and operationalized

(Caetano et al., 1998; Chen, 2003; Varma, & Siris, 1996). In addition, alcohol use measures vary

across studies, making comparisons difficult. In spite of inconsistencies related at least in part to

methodological differences, the acculturation model that proposes a direct association between

acculturation and alcohol use is generally supported.

Acculturative stress. As mentioned earlier, a concept closely related to that of

acculturation is acculturative stress (Caetano et al., 2008). Acculturative stress is defined “as a

stress reaction in response to life events that are rooted in the experience of acculturation” (Wei,

Heppner, Mallen, Ku, Liao, & Wu, 2007). Similarly, Castillo, Conoley, Brossart, and Quiros

(2007) defined acculturative stress as “the difficulties and stressors that arise during the

acculturative process” (p. 233). This reasoning suggests that acculturative stress is a part of the

acculturation process (Berry, 2006).

Caetano, Ramisetty-Mikler, and Vaeth (2007) assumed that levels of acculturation would

lead to acculturation stress and confirmed this relationship. More specifically, people with a

lower level of acculturation reported more stress. To explain this finding, the authors posited that

being less acculturated is more stressful because the individual experiences stronger tensions

between the ethnic culture and the host culture. In contrast, those who are more acculturated to

the host country have successfully adapted to values of mainstream society and, as a result, do

not experience as much acculturative stress. In that study, level of acculturation was indicated

by: daily use of and ability to speak, read, and write English and Spanish; preference for media

in English or Spanish; ethnicity of persons with whom individuals interacted (p. 1436). The

acculturative stress instrument covered topics such as conflicts with family because of changes in

values and adjustment problems.

Acculturative stress model for alcohol use. Alcohol use can be seen as one manifestation

of acculturation stress and the acculturative stress model posits that alcohol consumption is the

result of acculturative stress (Gilvert & Cervantes, 1986). According to this model, alcohol

consumption would be expected to increase among those struggling with cultural family conflicts,

discrimination, and other problems of cultural adjustment.

This acculturative stress model represents an adaption of the stress-coping model of

Lazarus and Folkman (1984) to the problems of cultural transition. In the stress-coping model,

stress occurs as a function of the relationship between an individual and an environment. An

individual’s encounter with environmental demands or a stressor causes the person to appraise

the situation. During the appraisal, an individual evaluates the stressor and available resources

for coping. Within this framework, alcohol use is seen as a coping strategy. Substantial empirical

studies have documented the relationship between stress and alcohol use (Horwitz & Davies,

1994; Sayette, 1999; Wills & Shiffman, 1985). In a comprehensive review of the research, Wills

(1990) concluded that a positive relationship between stress and alcohol use had been fairly

consistently demonstrated. Given the prevalence of stress in the process of adapting to a new

culture, the acculturative stress model has obvious relevance to potential alcohol abuse among

Asian Americans.

Like other ethnic groups, Asians in the United States often contend with challenges to

their economic survival, experiences of racism and discrimination, loss of extended family

support, cultural and family conflicts, marginalization, job dissatisfaction, and minority status. In

a review article, Subramanian and Takeuchi (1999) suggested that Asian Americans may use

alcohol to relieve psychological distress related to such stressors. Asian Americans tend to

underutilize mental health services due to the stigma attached to mental illness, a fact that may

further contribute to their vulnerability to using alcohol and drugs to relieve stress and manage

pain (Bhattacharya, 2005; D’Avanzo et al., 1994; McLaughin et al., 1987).

In spite of the logic and appeal of the acculturation stress model in regards to alcohol use,

few studies on the effects of acculturation on health behaviors have actually measured

acculturative stress (Caetano, Ramisetty-Mikler, Vaeth, & Harris, 2007). Studies that reported

acculturation as a risk factor for use of alcohol often assume that the relationship is based on the

stress of acculturation, without testing this assumption directly and empirically (Caetano et al.,

2007). In particular, several researchers have posited, based on their findings, that alcohol use is

associated with the stresses of coping with new cultural realities (D’Avanzo et al., 1994; Liu &

Iwamoto, 2007; Su & Wong, 2006; Vega & Gil, 1999). For example, D’Avanzo, Frye, and

Froman (1994) reported that Cambodian immigrant women used substances to relieve stress and

anxiety, but they did not assess acculturative stress in general or responses to specific stressors. It

is important to directly test rather than assume the underlying role of acculturative stress,

especially since according to the acculturation model an increase in drinking may be part of the

acculturation process itself, rather than a response to stresses encountered along the way (Black

& Markides, 1993; Caetano & Medina Mora, 1988).

In addition to not directly measuring acculturative stress as a construct, very few studies

to date have focused on specific acculturative stressors that may contribute to alcohol use,

although researchers, such as Recio Adrados (1993) have argued that the development of the

acculturative stress model would benefit from assessment of specific stressors. Among the most

important sources of acculturative stress are discrimination and family conflict (Castillo, Cano,

Chen, Blucker, & Olds, 2008; Salgado de Snyder, 1987; Yip, Gee, & Takeuchi, 2008), both of

which have been identified in the literatures as highly relevant to Asian Americans. The

following review explores these two important acculturative stressors as they pertain to the Asian

American population.

Discrimination. Asian Americans continue to experience discrimination due to their

ethnic group membership, although the topic has been overlooked in most research. Realistic

appraisal of the effects of discrimination has been impeded by perception of this group as a

“model minority” with Asian Americans viewed as having frequent educational and professional

success (Lee, 2003; Young & Takeuchi, 1998). Despite this stereotype, Asian Americans face

discrimination even when they are not recent immigrants (Liang, Li, & Kim, 2004). The

mainstream perception of Asian Americans as “perpetual foreigners” and “permanent aliens”

promulgates a view of Asian Americans as not “real” Americans (Liang et al., 2004). Members

of families who have been in the United States for several generations may still be seen as not

fully American.

Discrimination is a stressor and, as such, a risk factor for psychological distress and

alcohol use among racially and ethnically diverse populations (Jackson et al., 1996; Lee, 2003;

Noh, Kaspar, Hou, & Rummens, 1999; Yip et al., 2008). Whereas a number of studies have

examined the relationship between discrimination and alcohol use among African Americans and

Hispanic Americans, only a few have done so with Asian American samples (Gee, Delva, &

Takeuchi, 2007; Chae et al., 2008). One study by Gee, Delva and Takeuchi (2007) found that

everyday experiences of unfair treatment were associated with substance use among Filipino

Americans. In their study, unfair treatment was defined as “discriminatory behavior on the part

of institutions and individuals directed toward individuals with less power and the groups to

which they belong” (Gee et al., 2007, p.933). In another study, Chae et al. (2008), using data

from NLAAS, confirmed that Asian Americans who experience discrimination are more likely to

have alcohol disorders. These authors stated that substance use may be a means for ethnic

minority group members to attempt to cope with the psychosocial stressor associated with

discrimination.

Family cultural conflict. As the most proximal social environment, family has

increasingly been recognized as an important factor affecting individuals’ health status (Syme &

Yen, 2000). In traditional Asian cultures, the family is considered the central and most important

domain of one’s life. In such collectivist cultures, the strength of the family rests on the strength

of the individual members (Buki, Ma, Strom, & Strom, 2003). However, the needs of the family

are seen as more important than the needs of the individual. Family members are expected to

make sacrifices and decisions that are in the best interest of the family (Lee, 1997; Mercado,

2000; Uba, 1994).

Research indicates that many Asian American families experience and struggle with

intergenerational and cultural conflicts (Buki et al., 2003). In particular, it appears that greater

acculturation leads to more family conflict (Harachi, Catalano, Kim, & Choi, 2001), as family

members attempt to integrate disparate Asian and American cultural values and practices

(Bhattacharya, 2002; Buki et al., 2003). For example, when children become interpreters for their

parents who are struggling with English, this may threaten the hierarchical relationship of parent

and children and cause family discord.

In addition, Asian tradition emphasizes role differences between husbands and wives

(Lee, 1997; Uba, 1994), with the husband as the sole wage earner and the wife responsible for

housework and supporting her husband. However, economic realities often require women to

work outside the home causing gender role conflicts and potentially creating an imbalance in the

traditional structure of the family.

With respect to alcohol use, the few studies that have explored the role of family conflict

have focused on substance use among Asian American youth and young adults (Bhattacharya,

2002; Harachi et al., 2001). These studies found a positive relationship between intergenerational

conflicts between parents and their children and use of alcohol. For example, in two studies of

Asian Indian adolescents, Bhattacharya (1998 & 2002) found that family conflict was

experienced as stressful and was associated with increased substance use. In sum, it appears that

acculturation is often accompanied by experiences of discrimination and conflicts within the

family, stresses which may give rise to alcohol use as a means of coping.

Stress-buffering hypothesis: the role of social support and religiosity. There are factors

which mitigate the impact of stressors and which may lessen the risk of increased alcohol

consumption in the face of difficulties. According to the stress-buffering hypothesis, the

availability of social resources such as having supportive, close relationships will lessen the

impact of stressful events (Cohen & Pressman, 2004). In a seminal study, Cohen and Wills

(1985) performed a comprehensive review of the research on the relationship between stress and

social support and subsequently proposed two models of the protective effects of social support

in the context of stress. The simpler model, referred to as the main effect model, proposes that

social support is beneficial irrespective of the degree of stress that individuals are experiencing.

In other words, individuals exposed to both high and low levels of stress should benefit from

receiving social support which has been shown to enhance health and well-being. There is no

interaction between social support and stress proposed in this model. This prediction is in line

with Cohen and Wills’ (1985) general proposition that lack of positive social relationships is

psychologically detrimental.

The second model, referred to as the buffering model, proposes that social support

moderates the effect of stress on a person. According to the buffering model, social support is

beneficial for individuals experiencing stress because support reduces the effect of stressors

either by reducing the stress or by helping individuals to respond more adaptively. In other words,

this model proposes an interaction between stress and social support.

Recently, researchers using the framework of the stress-buffering model have identified

religion as a contributing source of social support (Ellison, Boardman, Williams, & Jackson,

2001; Ellison & Levin, 1998). Using the date from the 1995 Detroit Area study, Ellison,

Boardman, Williams, and Jackson (2001) found that frequent church attendance as one aspect of

religious involvement was related to mental health and conclude that religious involvement can

be a source of support, buffering the effects of stress and promoting well-being. Building on

these considerations, the current study examines both the main and buffering (moderating)

effects of social support and religiosity on alcohol use. The subsequent section provides further

review of the topic by focusing on the relationship between social support and stress and

between religiosity and stress.

Social support. Much research has provided evidence that social support mitigates the

effects of stress and decreases harmful health behaviors in a variety of populations (Brown,

Brady, Lent, Wolfert, & Hall, 1987; Cohen & Wills, 1985), including ethnic minorities (Chen,

Mallinckrodt & Mobley, 2002; Finch & Vega, 2003; Lee, Koeske, & Sales, 2004; Shen &

Takeuchi, 2002; Yoshikawa, Wilson, Chae, & Cheng, 2004). Individuals who have strong social

support networks tend to adapt more effectively and with less distress than those who have

weaker social support (Thomson, Flood, & Goodvin, 2006), and are less likely to engage in risky

health behaviors (Gottlieb, 1983; St. Lawrence, Brasfield, Jefferson, Allyene, & Shirley, 1994).

In addition, some studies have found an inverse relationship between social support and the use

of alcohol (Berkman & Breslow, 1983; Cohen & Lemany, 2007; Green, Freeborn, & Polen,

2001).

With respect to the relationship of acculturative stress and social support among Asian

Americans, Bhattacharya (2005) conducted a qualitative study of acculturative stress and risky

behavior among Indian Americans and found that social support was an influential contributor to

coping with acculturative stress. In another qualitative study, Chin, Lai, and Rouse (1991) found

that feeling isolated and lacking social support were associated with increased alcohol use.

However, these studies did not examine the effects of specific acculturative stressors. In a

quantitative study design, Noh and Kaspar (2003) examined whether racial/ethnic discrimination,

different types of coping strategies, and social support were associated with depression among

Korean Americans. The study revealed an interaction between racial/ethnic discrimination,

coping strategies, and social support in predicting depression.

Gee et al. (2006) examined whether social support could moderate the association

between discrimination and health condition among 2,241 Filipino Americans. Health condition

was measured using a composite score created from a check list of aliments including

hypertension, high blood pressure, and other heart disease. Discrimination was measured by

recording everyday experiences of unfair treatment due to participants’ ethnicity. Social support

assessed included access to both emotional and instrumental support. However, in contrast to the

above-mentioned research, this study did not find demonstrate an impact of discrimination-

related stress and health.

Finally, little research has been conducted on the relationship among specific

acculturative stressors, social support, and alcohol use among Asian Americans. Existing studies

of the relationship between social support and acculturative stress have yielded mixed results.

Religiosity. A growing body of studies has shown that religion and religiosity have both

direct and indirect protective effects against alcohol use (Chawla, Neighbors, Lewis, Lee, &

Larimer, 2007; Gong et al., 2003; Kerr-Correa, Igami, Hiroce, & Tucchi, 2007; Lubben, Chi, &

Kitano, 1988; Mullen, Blaxter, & Dyer, 1986; Yi & Daniel, 2001). This protective function has

been attributed to the fact that religion may serve as a resource in time of need and mitigate the

effects of life stressors. In addition, participation in religious activities can be an important

means of developing social networks (Garcia, 2005).

There is growing empirical evidence for the protective effects of religion in regard to

substance abuse in the Asian American population. Lubben, Chi, and Kitano (1988) found that

female Filipinos who were abstinent from alcohol frequently attended religious services.

Similarly, Yi and Daniel (2001) reported that religion had a beneficial influence on the drinking

patterns of Vietnamese Americans. However, these studies measured religion affiliation not

religiosity. A study by Gong et al. (2003) based on data from the Filipino American

Epidemiological Study (FACES) found that greater religious involvement was associated with

reduced risk for alcohol dependence among Filipinos Americans. Religious involvement was

operationalized as attending religious services, participating in activities of a religious nature,

and participating in private religious activities. Other empirical research has also demonstrated

that religiosity buffers the relationship between stress and alcohol use (Siegel, Anderman, &

Schrimshaw, 2001; Wills, Yaeger, & Sandy, 2003).

Overall, an important premise in regard to the link between social support/religiosity and

stress is that stressors are harmful only when coping resources are inadequate. For immigrants

and ethnic minorities, one key stressor is acculturative stress, and therefore it is important to

understand how it interacts with the social support and religiosity variables discussed above.

Despite the demonstrated links between stress and social support and stress and religiosity, few

empirical studies have examined the role of social support and religiosity in coping with

acculturative stress. Rather, most studies on stress have focused on traumatic stressors. In order

to understand how acculturative stress and social support and religiosity influence alcohol use in

the Asian American population it is important to consider that demands must exceed resources to

produce a negative outcome. As mentioned earlier, alcohol use can become a coping strategy

when social resources are inadequate to reduce stress (Vega, Zimmerman, Warheit, & Gil, 2003).

Thus, research is needed to develop an understanding of how acculturative stress and social

support and religiosity influence alcohol use in this population so as to inform future prevention

and intervention efforts.

Summary

The literature review presented identified social factors of acculturation, acculturative

stress (discrimination and family conflict), social support, and religiosity as associated with

alcohol use. On the one hand, it appears that greater levels of acculturation are positively

associated with alcohol use among some Asian American populations. On the other hand, other

studies suggest that Asian Americans drink alcohol to cope with the stress they encounter during

the acculturative process. Substantial research findings have identified discrimination and family

conflict as relevant acculturative stressors. However, currently there is limited research that takes

into consideration the effects of both acculturation and acculturative stress and examines role of

protective factors such as social support and religiosity. Most studies have typically examined a

simple direct relationship between acculturation and alcohol use and few have explored the

relationship of acculturation and acculturative stress as they may interact to affect drinking

behavior. This absence underscores the importance of developing a comprehensive model to

explain alcohol use among Asian Americans.

The current study proposes and then tests a model of how crucial variables of

acculturation, discrimination, family conflict, social support, and religiosity interact to affect

alcohol use within three subgroups of the Asian American population.

The conceptual framework for this study is shown in Figure1. This model is derived from

acculturation and acculturative stress model as applied to an investigation of how socio-cultural

factors may contribute to alcohol use among Asian Americans.

Figure 1. Proposed conceptual model for Asian Americans’ alcohol use

Chapter III

Method

This chapter presents the research questions, hypotheses and then the methodology for

the study, including date source and sample, method of sampling, study procedures, measures,

analytic plan, and ethical issues.

Statement of Research Questions and Explored Hypotheses

This current study has two research aims. Each aim is elaborated below in terms of

general questions and specific hypotheses. The first aim of this study is to describe patterns of

alcohol use within the Asian American subgroups. The second aim is to explore predictors of

alcohol use for three separate Asian subgroups: Chinese, Filipino, and Vietnamese Americans.

Questions and hypothesis to be addressed include:

1. What drinking patterns are found among subgroups of Asian Americans?

2. Is acculturation associated with alcohol

use?

Hypothesis 2.1: Acculturation has a direct effect on alcohol use. It is hypothesized that

Asian Americans who are more acculturated drink more than Asian Americans who are

less

acculturated.

3. Are acculturative stressors (unfair treatment, perceived racial/ethnic discrimination and

family cultural conflict) associated with alcohol use?

Hypothesis 3.1: Unfair treatment and racial/ethnic discrimination have a direct effect on

alcohol use. It is hypothesized that Asian Americans who experience more unfair

treatment and perceive more racial/ethnic discrimination drink more than Asian

Americans who experience less unfair treatment and perceive less racial/ethnic

discrimination.

Hypothesis 3.2: Family conflict has a direct effect on alcohol use. It is hypothesized that

Asian Americans who experience more family conflict drink more than Asian Americans

who experience less family conflict.

4. Are there relationships among degree of acculturation, acculturative stress (unfair

treatment, perceived racial/ethnic discrimination and family conflict), and alcohol use?

Hypothesis 4.1: Acculturation has an indirect effect on alcohol use through unfair

treatment and perceived racial/ethnic discrimination. It is hypothesized that Asian

Americans who are less acculturated drink more because they experience more unfair

treatment and perceive more

racial/ethnic discrimination.

Hypothesis 4.2: Acculturation has an indirect effect on alcohol use through family

conflict. It is hypothesized that Asian Americans who are less acculturated drink more

because they experience more family conflict.

5. Does social support from friends and family moderate the relationship between

acculturative stress (specifically, unfair treatment, perceived racial/ethnic discrimination,

and family conflict) and alcohol use?

Social support is expected to exert both an indirect and direct effect on alcohol use.

Hypothesis 5.1: Higher levels of social support are predicted to be directly related to

lower alcohol use.

Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair

treatment and perceived racial/ethnic discrimination on alcohol use. It is hypothesized

that Asian Americans who receive a greater amount of social support are better able to

cope with unfair treatment and perceived racial/ethnic discrimination and, as a result,

drink less than Asian Americans who receive less social support.

Hypothesis 5.3: Social support will also moderate the impact of family conflict on

alcohol use. It is hypothesized that Asian Americans who receive a greater amount of

social support are better able to cope with family conflict and, as a result, drink less than

Asian Americans who receive less social support.

6. Does religiosity moderate the relationship between acculturative stress (specifically,

unfair treatment, perceived racial/ethnic discrimination, and family conflict) and alcohol

use?

Religiosity is expected to both directly and indirectly impact alcohol use.

Hypothesis 6.1: Stronger religiosity is predicted to be directly related to lower alcohol use.

Hypothesis 6.2: Religiosity is expected to moderate the impact of unfair treatment and

perceived racial/ethnic discrimination on alcohol use. It is hypothesized that Asian

Americans with a higher level of religiosity are better able to cope with unfair treatment

and perceived racial/ethnic discrimination and, as a result, drink less than Asian

Americans with weaker religiosity.

Hypothesis 6.3: Religiosity moderates the impact of family conflict on alcohol use. It is

hypothesized that Asian Americans with stronger religiosity are better able to cope with

family conflict and, as a result, drink less than Asian Americans with weaker religiosity.

7. Is acculturation related to unfair treatment, perceived racial/ethnic discrimination, and

family conflict, respectively?

Hypothesis 7.1: Acculturation has a direct effect on discrimination. It is hypothesized that

Asian Americans who are less acculturated experience more unfair treatment and

perceive more racial/ethnic discrimination than Asian Americans who are less

acculturated.

Hypothesis 7.2: Acculturation has a direct effect on family conflict. It is hypothesized

that Asian Americans who are less acculturated experience more family conflict than

Asian Americans who are more acculturated.

Figure 2 presents the expected pathways among variables.

Figure 2. Diagram of expected pathways among predictors of alcohol use for Asian
Americans

Data Source and Sample

This study used Asian population data from the National Latino and Asian American

Study (NLAAS). NLAAS is part of the Collaborative Psychiatric Epidemiology Study (CPES),

which was designed to provide psychiatric epidemiological information on different U.S. ethnic

populations (Alegria et al., 2004). It is the first national study to use probability sampling and

translation services to obtain comprehensive mental health data, including substance use

disorders, among Asian Americans. Previous national surveys of Asian American were primarily

conducted in English, excluding a significant number of Asian Americans who lack English-

language skills from these studies (Nemoto, Huang, & Aoki, 1998) and thus biasing the sample;

however, NLAAS conducted interviews in each respondent’s preferred language eliminating

these potential biases. In addition, most epidemiological studies have been conducted in

locations where there is a sparse population of Asian Americans, and as such the data could not

be used to accurately estimate Asian Americans’ health behaviors (Nemoto et al., 1998). Instead,

NLAAS used high-density sampling supplemental strategies. Consequently, NLAAS increased

the likelihood that the sample and the content of the interviews were of improved quality and

equivalent to standard epidemiological studies (Alegria et al., 2006).

The NLAAS collected information between May 2002 and December 2003 from a

nationally representative sample of noninstitutionalized Asian Americans who were 18 years of

age or older and resided in any of the 50 states or Washington D.C. (Pennell et al., 2004). There

were a total of 2,095 Asian-American respondents. Target groups were Chinese, Filipinos,

Vietnamese, and persons with “other” Asian ancestry. Asian ethnic groups such as Korean,

Cambodian, and Indian were included in the “other Asian ancestry” category because sample

sizes for these ethnic groups were too small to conduct a detailed analysis on each of them

individually (Takeuchi, Hong, Gile, & Alegria, 2007). This study chose to analyze data on

Chinese, Filipino, and Vietnamese Americans but not the category of other Asian. This category

was excluded in consideration of the heterogeneity of Asian-American subgroups, as an analysis

of the other Asian category would mask differences within subgroups. This current study was

designed to take this diversity into account.

Method of sampling. NLAAS used three sampling strategies to recruit participants.

First, the core sample was recruited through multistage stratified probability sampling. Primary

sampling units (PSUs) were metropolitan statistical areas (MSAs) or county units; secondary

sampling units (SSUs) were census block groups. Once PSUs were selected, SSUs were

sampled. From the block group, households were sampled according to probability proportionate

to size (PPS) (Takeuchi, Hong, Gile, et al., 2007). Second, a high-density supplemental sampling

strategy was utilized to oversample Asian Americans in census block groups where target groups

made up more than 5% of the total households. Third, NLAAS used second-respondent sampling

to increase sample size by recruiting second respondents from households in which one

participant had already been interviewed (Takeuchi, Hong, Gile, et al., 2007).

Study Procedure

The NLAAS interviewers were selected by an independent agent and were matched by

ethnicity to the respondents. Interviewers had to be bilingual and undergo extensive interviewer

training. Respondents were contacted initially by an introductory letter and study brochure,

followed by screening either over the phone or in person. For those eligible and willing to

participate, they then participated in a full interview. Respondents chose their preferred language

for the interview, whether Chinese, Tagalog, Vietnamese, or English. Interviewers used laptop

and computer-assisted interviewing software to guide and record the interview. In the core and

high-density samples, interviews were conducted face-to-face, unless a respondent specifically

requested a telephone interview, while second respondents were interviewed via telephone. The

mean interview time was 2.6 hours. Respondents were initially compensated $50.00 for

participating in interviews, but later the compensation was increased to $150.00 to reduce

nonresponse rates.

Measures

Acculturation. Acculturation was assessed using two independent indicators: English

proficiency and generational status. English-language proficiency was assessed using three

items: “How well do you speak English”; “How well do you write English”; and “How well do

you read English.” For each item, responses were given on a 4-point, Likert-type scale: (1) Poor,

(2) Fair, (3) Good, and (4) Excellent. Scores for each of these three items were summed to create

an English proficiency scale ranging from 0 to 12. Higher scores indicated higher English

proficiency. Cronbach’s Coefficient alphas for Chinese, Filipino, and Vietnamese Americans

were 0.97, 0.91, and 0.97, respectively.

Generational status was determined from two general items obtaining information

regarding: (1) whether a participant’s parents were born in the U.S. and (2) whether a participant

was born in the U.S. Based on Takeuchi, Zane, Hong, et al.’s (2007) definition, the following

categories of generational status were created: (1) “First generation” (respondents were not born

in the U.S. and had both parents not born in the U.S.), (2) “Second generation” (respondents

were born in the U.S and had at least one parent born outside the U.S.), and (3) “Third

generation” (respondents were born in the U.S and both of their parents were born in the U.S).

The reference group for the analysis was the first generation.

Acculturative stress. Acculturative stress was measured by examining three constructs:

unfair treatment, perceived racial/ethnic discrimination, and family cultural conflict.

Discrimination. NLAAS measured two aspects of discrimination: unfair treatment and

perceived racial/ethnic discrimination. These two constructs differ because unfair treatment is a

measure of routine experiences of unfair treatment while perceived racial/ethnic discrimination is

a measure of the degree to which an individual perceives that they have been discriminated

against. Chae et al. (2008) conducted an analysis of these two variables and found that unfair

treatment and perceived racial/ethnic discrimination measures captured different experiences.

Thus, in the current study, these two constructs were examined separately.

Unfair treatment was measured using a set of nine items (see Appendix A for a detailed

description). Items assessed how often respondents may have experienced several possible

scenarios, such as “You received poorer service than other people at restaurants or stores” or

“You are treated with less respect than other people.” Respondents used a 5-point response scale

to rate the frequency of discriminatory experiences, ranging from 0 (Never) to 5 (Almost every

day). Responses to the nine items were summed to create a score ranging from 0 to 45, with

higher scores indicating greater incidences of unfair treatment. Cronbach’s Coefficient alphas for

Chinese, Filipino, and Vietnamese Americans were 0.88, 0.91, and 0.92

respectively.

Perceived racial/ethnic discrimination was determined by creating a scale from three

specific items (see Appendix B for a detailed description). Respondents were asked to rate how

often: (1) other people dislike them because of their race/ethnicity; (2) people treat them unfairly

because of their race/ethnicity; or (3) they have seen friends treated unfairly because of their

race/ethnicity. Responses to the three items ranged from 0 (Never) to 3 (Often), and scores from

each item were summed to make a total score. The total score ranged from 0 to 9, with higher

scores indicating greater incidences of perceived racial/ethnic discrimination. Cronbach’s

Coefficient alphas for Chinese, Filipino, and Vietnamese Americans were 0.84, 0.84, and 0.90

respectively.

Family cultural conflict. The Family Cultural Conflict scale was a self-report, 5-item

instrument that assessed issues of cultural and intergenerational conflict between the respondents

and their families (see Appendix C for a detailed description). The five items were drawn from a

subscale of the Hispanic Stress Inventory (HIS, Cervantes, Padilla, & de Synder, 1991) and used

a 5-point response format ranging from 1 (Almost never) to 5 (Almost always). Each of the five

items was summed to create a total score, and higher scores indicated greater family conflict.

The Cronbach’s Coefficient alphas for Chinese, Filipino, and Vietnamese Americans were 0.74,

0.76, and 0.80 respectively.

Social support. The NLAAS study assessed two facets of social support: (1) family and

(2) friends. In the current study, these two constructs were used separately. Family support was

measured using the question, “How much can you open up to relatives who do not live with you

if you need to talk about your worries?” Friend support was measured using the question, “How

much can you open up to your friends who do not live with you if you need to talk about your

worries?” In NLAAS, four responses were given to these questions: (1) not at all, (2) little, (3)

some; and (4) a lot. For the present study, categories of “no” versus “yes” were created to

indicate presence or absence of social support: “no” included the response not at all (coded as 0)

and “yes” including all remaining responses, ranging from little to a lot (coded as 1). The

reference group was those who did not receive support.

Religiosity. Religiosity was determined by the self reported frequency of attendance of

religious services. Respondents were asked how often they attended religious services; responses

ranged from 1 (More than once a week) to 5 (Never). For the current study, these five categories

were combined into three categories: (1) never, (2) one to three times a month, and (3) once or

more a month. The reference group was those who never attended religious services.

Alcohol use. The NLAAS had two questions that assessed alcohol consumption: (1)

frequency of alcohol use and (2) quantity of alcohol use. Frequency of alcohol use was measured

by asking “In the past 12 months, how often did you usually have at least one drink?” Responses

to this question were coded into 6 categories: (1) nearly every day, (2) three to four days a week,

(3) one to two days a week, (4) one to three days a month, (5) less than once a month, or (6) do

not drink. Quantity of alcohol use was measured by asking in an open-ended format “On the

days you drank in the past 12 months, about how many drinks did you usually have per day?”

Dawson et al. (1996) defined an abstainer as someone who had less than 12 drinks or

never drank in the previous year. Having five or more drinks per occasion was considered

hazardous drinking because consuming five or more drinks on any one occasion is associated

with an increased risk of alcohol-related problems (Archer, Grant, & Dawson, 1995). Moderate

drinking was defined as occasions during which fewer than five or more drinks were consumed

(Archer et al., 1995). Based on these definitions, this current study developed an alcohol-use

variable that consisted of the following three categories;

1). Abstaining: drank less than once a year or not at all.

2). Light-to-moderate drinking: drank less than once a month but at least once a month;

or drank one to three times a month but never has five or more drinks per occasion, or

drank once a week or more often but never drank five or more drinks per occasion.

3). Risky drinking: drank one to three times a month and had five or more drinks per

occasion; or drank once a week or more often and had five or more drinks per occasion.

Demographic variables. Demographic variables included ethnicity, gender, age, marital

status, household income, educational attainment, and religion. Participants reported their

ethnicity by responding to the question, “Which group best describes your race?” The NLAAS

offered four categories: Chinese, Filipino, Vietnamese, and other Asian. Gender was coded into

two categories: male (coded as 1) and female (coded as 0). Age was assessed by asking

respondents “How old are you?” For marital status, respondents were given five response

options: (1) married, (2) separated, (3) divorced, (4) widowed, and (5) never married; for

regression analysis, marital status was coded into a dummy variable; married (coded as 0) and

non-married (coded as 1), which included separated, divorced, widowed, and never married.

Education was measured by asking respondents to indicate the highest level of education

they had completed. Categories ranged from 1 (completed first grade) to 17 (some graduate

school education). Respondents with a high school or equivalent diploma were coded as 12.

Overall, higher numbers indicated higher education. Income was measured as a continuous

variable. Participants were also asked about religious preferences. In the NLAAS, 14 response

options were provided, and this current study recoded these options into four different categories

using the NLAAS’s guidelines. Protestantism included Protestantism with no denomination,

Baptist, Lutheran, Methodist, Presbyterian, other Protestant, and Pentecostal. Catholicism

included Catholicism with no denomination and Roman Catholic. No religion included being

agnostic/atheists, reporting no religious preference and no religion. Those reporting other

religions were identified in the category “other religion.” For the purposes of analysis and

subsequent interpretation, each of the categories of religion was transformed into a dummy

variable. The reference group for the analysis was no religion.

Analytic Plan

In order to examine the hypotheses proposed in this study, data analysis was conducted in

four phases. First, descriptive statistics of the sample and variables were generated. Bivariate

analyses were performed to test for significant differences on all variables in this study among

the three ethnic groups. Research question one was answered by using bivariate tests to find

significant differences in alcohol use across the three ethnic groups. For categorical variables, a

chi-square test was used to assess the relationship between two variables. ANOVA was

conducted to test the relationship between continuous variables and categorical variables, and

Bonferroni corrected post-hoc tests were calculated to allow for inter-group comparisons.

Second, Pearson correlation analyses were conducted to evaluate the strength of the

relationship between variables in order to address a potential problem of multicollinearity. All

categorical variables (gender, marital status, religion, family support, and friend support) were

dummy coded and entered into the correlation analysis. All scales (English-language proficiency,

unfair treatment, perceived racial/ethnic discrimination, and family conflict) and income were

considered

continuous variables.

Ordinal variables (education, generational status, and

religiosity) were included in the analyses as continuous measures.

Third, to test hypotheses, multivariate analyses were performed with ordinal logistic

regression or ordinary least squares (OLS) regression, depending upon the level of measurement

of the endogenous variable (see Appendix D). With respect to hypotheses two through six, the

endogenous variable was alcohol use, which was an ordinal variable. Therefore, an ordinal

logistic regression was performed. To test hypothesis seven, which pertained to the relationship

between acculturation and acculturative stressors, OLS was used because the endogenous

variables (unfair treatment, perceived racial/ethnic discrimination, and family conflict) were

continuous variables.

Ordinal logistic regression was used to analyze the endogenous variable, alcohol use,

with three ordered levels; abstaining (coded 1), light-to-moderate drinking (coded 2), and risky

drinking (coded 3). According to the parallel regression assumption (otherwise known as the

proportional odds assumption), in ordinal logistic regression, the coefficient of the linear

predictor is the same for each category of the ordinal endogenous variable. The only change is a

choice of ‘cut-points,’ and the constant in the model is the cut-point used to distinguish the two

probabilities that are comprised of odds for the endogenous variable of the regression model.

When there are m levels of the endogenous variable, there are m-1 cut-points (Long & Freese,

2006). In this study, there were two cut-points at which the endogenous variable was

dichotomized for the purpose of formulating a logistic equation. Cut-point one was found

between the probability of abstaining and the probability of a combination of light-to-moderate

and risky drinking. Cut-point two was found between the probability of a combination of

abstaining and light-to-moderate drinking and the probability of risky drinking. Whether using

cut-point one or cut-point two, it was assumed that the values of the odd ratios remains the same

(Long & Freese, 2006).

To combine two different types of regression (OLS and logistic regression) in the same

path model, there has to be a comparable method to obtain goodness-of-fit in the both types of

regression models. This current study used pseudo R2 and R2 for comparable path coefficients.

The reasoning proceeds as follows. Proportional reduction of deviance in logistic regression is

comparable to R2 in OLS regression. Deviance is equal to the sum of squared errors. Deviance is

measured by -2 times natural log likelihood of the model. Therefore, R2 is equal to 1- deviance.

Because logistic regression generates pseudo-R2, OLS R2 and, logistic R2 can be compared.

Consequently, there is comparable goodness-of-fit measure in both types of regression models.

A proportional reduction of error due to a particular variable in a logistic regression

yields a path coefficient comparable to that of the R2 change due to a variable in an OLS

regression. Reduction of the deviance in a logistic regression is measured by a proportion that

indicates the decrease in total error. In that proportion, the denominator represents the amount of

error (deviance) prior to the addition of the new variable to the model. The numerator in the

proportion is equal to the error (deviance) after the introduction of the new variable. Therefore,

the proportion represents the reduction of deviance is due to introduction of the new variable.

This proportional reduction of deviance is the same as a partial pseudo-R2 . The path coefficients

in the both types of regression are comparable and can be used to integrate these two types of

path coefficients into a unified path model.

Lastly, a diagram was created to illustrate the different, both the relationships between

the predictors of alcohol use and their relationship directly to alcohol use. As mentioned above,

because of each of the types of regression use different metrics for their respective coefficients,

each were transformed to a comparable metric. The path coefficients of logistic and OLS

regression were calculated respectively in changes of pseudo-R2 and change of R2. In order to

calculate R2 change, after all other covariates are placed in the model, an initial R2 was computed.

Then, the variable being examined was added, and the second R2 was computed. The difference

between the two R2 was an R2 change (ΔR2) was caused by the addition of the variable under

consideration. Therefore, the path coefficient represented the effect of this variable in the model.

The direction of the path of a variable was determined by the sign of the regression coefficients.

The significance of the coefficient was determined by the p-value of variable in the model. A

significant level was determined at the usual p-value of .05. In regards to calculation of an

indirect effect to test hypothesis five, two significant direct path coefficients were multiplied.

Each hypothesis was tested separately. Because of the level of measurement of a variable

in the model could be either continuous or ordinal, the necessity for different types of regression

models precluded simultaneous estimation of all coefficients in one model. Therefore, the path

coefficients of a model were estimated sequentially. In addition, this procedure was followed for

Chinese, Filipino, and Vietnamese Americans separately.

Sample size for the current study is consistent with the generally accepted practice N ≥ 50

+8 m (where m is the number of independent variables) (Tabachnick & Fidell, 2007). Since there

were 30 independent variables including interaction variables, a minimum of 290 cases were

needed to appropriately use regression analysis. The sample size for Chinese, Filipino, and

Vietnamese Americans were 600, 508, and 520 respectively. Therefore, the sample size for this

study was considered sufficient for data analyses.

The statistical software used to analyze the study data was Stata 10 (StataCorp, 2007).

Stata 10 is capable of analyzing complex survey data. In this case, the complex sample included

the sampling weight, a clustering as well as stratification variable. Subpopulation syntax was

used to isolate subgroups for separate analysis. In addition, standard errors of estimates were

produced in Stata 10 using Taylor linearization, a method of robust variance estimation with the

sample weights that corrects for heteroskedasticity as the sample size becomes large (White,

1980). A level of statistical significance of p < .05 was applied for all tests.

Ethical Issues

The original study was conducted by multiple investigators from different institutions;

the NLAAS required approvals from each Institutional Review Board (IRB). The IRB

Committees of Cambridge Health Alliance, the Harvard School of Public Health, the University

of Washington, and the University of Michigan approved all recruitment, consent, and

interviewing procedures (Center for Multicultural Mental Health Research, 2009). All study

procedures, as well as a written consent form, were translated and explained in each respondent’s

preferred language, consistent with recommended ethical procedures.

As noted earlier, this study used a subset of data from the NLAAS. Because this study

involved secondary analysis of a pre-existing, de-identified, and publicly available dataset, no

participants were recruited for this current study and there was no potential for harm to

participants. Research involving the study of existing publicly available de-identified data is one

of categories of human subjects’ research exempt from continuing review under federal

regulations. This current study design was submitted to University Committee on Activities

Involving Human Subjects (UCAIHS) at New York University, with a request for exempt status

based on conducting a secondary analysis. The Exempt Certification Form-Category was

approved on January 21, 2010 (see Appendix E for detailed description).

Chapter VI

Results

This chapter presents the results of the data analyses. First, descriptive statistics of the

sample as a whole are presented. Second, descriptive statistics of all variables are broken down

and presented by Asian subgroup for Chinese, Filipino, and Vietnamese Americans. Also, results

of bivariate analyses are presented to compare the subgroups on all variables. Third, after a brief

discussion of the problem of multicollinearity, the results of ordinal logistic regression and OLS

regression and the final path diagram illustrating relationships between variables are presented

for each ethnic subgroup. The diagram for each subgroup shows paths between variables based

on testing hypothesized relationships one at a time, rather than simultaneously.

Characteristics of the Sample

Table 2 summarizes sample and population sizes of Chinese, Filipino, and Vietnamese

Americans. Chinese Americans were the largest of the three populations.

Table 2: Weighted and unweighted sample subgroups sizes

Sample/Population
Size

Chinese
Americans

Filipino
Americans

Vietnamese
Americans

Unweighted N 600 508 520
Weighted N 2,234,825 1,681,420 1,007,086

Table 3 describes socio-demographic characteristics of the sample of Chinese, Filipino,

and Vietnamese Americans in unweighted sample size (see Appendix F for details in weighted

sample size). No statistical differences among the three groups were found for age, gender,

marital status, or family cultural conflict. The mean age for the three groups combined were

approximately 42 years old. Slightly more than half of the entire sample was female (52.5%) and

approximately two thirds were currently married. The mean family conflict score across the three

groups was approximately 6 and ranged from 5 to 15.

Significant differences were found between subgroups for education, income, English-

language proficiency, generation, unfair treatment, perceived racial/ethnic discrimination, family

and friend support, and religiosity. A chi-square analysis found a significant difference in

education among three groups (χ2 = 9.41, df = 6, p < .001). Overall, Vietnamese Americans were

the least educated, as they had the highest proportion of respondents (31.7%) with the lowest

level of education. In contrast, Chinese Americans were the most well educated, as they had the

largest proportion of respondents (45.6%) reporting some graduate education.

Filipino Americans reported the highest mean income, while Vietnamese Americans

were the most impoverished group with the lowest mean income. The most common religion

among Filipinos was Catholicism, and this is consistent with their cultural and historical

background. The majority of Chinese Americans (49.4%) and Vietnamese Americans (54.7%)

reported having no religion or “other religion,” respectively.

Of the three groups, Filipino Americans were the most proficient in English, as reflected

in the highest mean score of English language proficiency. Given their historical background and

the U.S. occupation of the Philippines, this is not surprising, even among first generation

Filipinos. All three groups were overwhelmingly comprised of first generation respondents, with

Vietnamese Americans having a significantly larger proportion than the other two groups at

97.8%.

From the self report measures, Filipino Americans reported the highest level of unfair

treatment whereas Chinese Americans reported the greatest level of perceived racial/ethnic

discrimination. Self-reported family and friend support were highest among Filipino Americans

and lowest among Vietnamese Americans. Filipino Americans reported attending religious

services more often than Vietnamese or Chinese Americans.

Alcohol use. Descriptive statistics (Table 3) were generated to answer the first research

question “What drinking patterns are found among subgroups of Asian Americans?” The

relationship between alcohol use and ethnicity was statistically significant (χ2 = 72.92, df = 4, p

< .001). Vietnamese Americans (71.9%) had the largest proportion of abstainers from alcohol.

Filipino Americans reported the highest rates of light to moderate drinking (49.8%) and risky

drinking (5.6%). The levels of risky drinking reported among Chinese (3.0%) and Vietnamese

(1.4%) respondents were relatively low in comparison with other ethnic groups. The number of

risky drinkers in the three groups was small in unweighted sample size. When this number was

weighted for total population, the number of risky drinkers was considerably large enough to pay

attention. The number of risky drinkers in total population for Chinese and Filipino were 67,147

and 93,901. The total number of risky drinkers for Vietnamese Americans and 136, 668.

In the 2007 SAMHSA study, 8.3% of Whites, 6.1% of Hispanics, 4.7% of African

Americans, and 12.1% of Native Americans reported risky drinking patterns. However, these

subgroup rates are high when compared to the Asian population as an aggregate group who, in

the same study, had a rate of only 2.7% of risky drinkers.

Table 3. Characteristics of Chinese, Filipino, and Vietnamese Americans

Chinese Filipino Vietnamese sig. test

n (%)/mean n (%)/mean n (%)/mean

Agea n.s.

Mean 41.6 41.9 43.0

SD 14.02 16.1 14.73

Range 18-85 18-89 18-95

Genderb n.s.

Female 316 (52.5) 273 (52.5) 277 (52.5)

Male 284 (47.5) 235 (47.5) 243 (47.5)

Marital statusb

Married 414 (65.9) 346 (68.2) 384 (71.7) n.s.

Divorced 61(10.1) 50 (9.7) 38 (6.9)

Never married 125 (24.0) 112 (22.1) 98 (21.4)

Educationb χ2=9.41***,

Less than high school 85 (17.4) 53 (10.9) 152 (31.7) df=6

High school graduate 96 (16.2) 97 (20.3) 116 (21.1)

College 117 (20.8) 168 (32.0) 129 (23.5)

Graduate school 302 (45.6) 190 (36.8) 123 (23.7)

Incomea F (2, 40)=20.57*

Mean 76,675.0 81612.6 53,100.5

SD 63,051.4 57466.7 51,323.6

Range 0-200,000 0-200,000 0-200,000

Median 59,999.50 72,499.00 37,499.50

Religionb χ2=111.80***,

Protestantism 134 (20.5) 84 (15.5) 25 (5.5) df=6

Catholic 45 (7.9) 358 (71.9) 177 (32.9)

Other religion 128 (22.2) 35 (6.8) 280 (54.7)

No religion 287 (49.4) 25 (5.8) 36 (6.8)

English proficiencya F (2, 40)=121.74***

Mean 7.84 10.05 6.11

SD 3.11 2.15 2.84

Range 3-12 3-12 3-12

Generationb χ2 =51.88**,

First generation 518 (88.1) 416 (83.1) 509 (97.8) df=4

Second generation 24 (4.16) 44 (8.8) 10 (2.17)

Third generation 56 (7.74) 48 (8.1) 0

Unfair treatmenta F (2, 40)=42.68***

Mean 7.09 8.97 4.19 df=2

SD 5.98 7.08 5.85

Range 0-37 0-43 0-45

Perceived racial/ethnic
discriminationa F (2, 40)=15.98***

Mean 2.53 2.02 1.87 df=2

SD 2.06 2.12 2.21

Range 0-9 0-9 0-9

Family cultural conflicta n.s.

Mean 6.51 6.6 6.14

SD 1.83 1.89 1.73

Range 5-15 5-15 5-15

Family support χ2=22.10***,

Yes 506 (85.7) 439 (86.1) 389 (75.2) df=2

No 91 (14.3) 68 (13.9) 127 (24.8)

Friend support

Yes 535 (89.1) 457 (88.6) 381 (74.4) χ2=27.19***,

No 64 (10.1) 49 (11.4) 135 (25.6) df=2

Religiosityb χ2=49.87***,

Never 349 (60.5) 75 (16.8) 121 (23.6) df=4

One to three times a month 145 (18.9) 179 (34.6) 216 (44.7)

Once a week or more 100 (13.6) 248 (48.6) 181 (31.6)

Alcohol usea χ2=72.92***,

Abstaining 369 (61.3) 232 (44.6) 380 (71.9) df=4

Light-to-moderate drinking 215 (17.8) 248 (49.8) 130 (26.7)

Risky drinking 16 (3.0) 26 (5.6) 9 (1.4)

a: ANOVA test
b: chi-square test
df=degrees of freedom

*p < .05, **p < .01, ***p < .001

n.s.: not significant

Addressing Multicollinearity

Before proceeding to the multiple regression analyses for each subgroup, bivariate

correlations among the all variables were calculated in order to assess their degree of

interrelatedness. These correlations matrices are presented in Appendix G, H, and I. Among

Chinese Americans, significant correlations ranged from 0.08 to 0.52. No variables yielded a

relationship greater than +.70; thus, these results suggested the absence of multicollinearity

(Tabachnick & Fidell, 2007).

Issues of multicollinearity were evident for the other two ethnic subgroups with reference

to the religion variable, at least in part as result of how the variable was constructed for the

research project. For the purposes of ease of interpretation, four dummy variables were created

from the categorical religion variable–Protestantism, Catholicism, No religion, Other religion—

one for each potential response. While it was necessary to check for potential association among

the dummy variables in order to avoid problems of multicollinearity, there was also the risk of

artificial conflation of the correlation coefficients because of the nature of their construction. The

dummy variables were clearly not mutually exclusive and were expected to be related. Indeed,

among Filipino Americans, the correlation between Protestantism and Catholicism was highly

negatively correlated (r = -.71, p < .001), and among Vietnamese Americans, the correlation

between Catholicism and other religion yielded r = -.78. These correlations of + .70 or higher in

the same analysis indicate a potential problem with multicollinearity (Tabachnick & Fidell,

2007). One way to solve multicollinearity is to omit one of the two highly related variables

(Tabachnick & Fidell, 2007). Given both the potential problem of multicollinearity among the

religion dummy variables and the potential for artificial conflation, this current study did not

exclude variables that were merely highly correlated with one another. The decision not to

exclude variables that were merely highly correlated with one another was made based on the

conceptualization underlying the religion dummy variable and on the need to balance the

disadvantage of multicollinearity with bias that would be introduced by omitting a variable

(Ericsson, Campos, & Tran, 1991, p.21-p.22).

Factors Related to Alcohol Use among Chinese Americans

Table 4 provides results of ordinal logistic regression related to alcohol use to assess

support for hypotheses two through six. Table 5 shows results of OLS regression related to

acculturative stressors to test hypothesis seven. The final path coefficients are presented in

Figure 3. This study found that several factors—acculturation, friend support, and religiosity—

were significantly related to alcohol use among Chinese Americans.

Hypothesis 2.1: Acculturation has a direct effect on alcohol use. It is hypothesized that Asian

Americans who are more acculturated drink more than Asian Americans who are less

acculturated.

Acculturation, defined here by English-language proficiency and generational status, was

significantly related to alcohol use for Chinese Americans. Both English-language proficiency

and generational status were significantly positively associated with alcohol use after controlling

for age, gender, income, education, marital status, and religion. For a one unit increase in

English-language proficiency, the odds of an increase in drinking level was 1.12 times greater,

given all other variables constant. Generation had even more of an impact on alcohol use. Being

second generation Chinese American greatly increased the likelihood of being a light-to-

moderate or risky drinker by over five times compared to their first generation counterparts; and

being third generation Chinese American significantly increased the likelihood of increase in

alcohol use over three times that of being first generation.

Table 4. Ordinal logistic regression results for alcohol use among Chinese Americans

Variable Odds ratio P-value 95% CI

Controlling variables

Age 0.98** 0.007 0.96-0.99

Gendera 4.68*** 0.000 3.05-7.19

Income 1.00 0.122 1.00-1.00

Education 0.98 0.612 0.89-1.07

Marital statusb 1.00 0.997 0.62-1.60

Protestantismc 0.61 0.387 0.19-1.92

Catholicismc 2.24 0.063 0.95-5.26

Other religionc 1.51 0.34 0.64-3.57

Acculturation

English proficiencyd 1.12* 0.046 1.00-1.26

Second generatione 5.87** 0.018 1.37-25.07

Third generatione 3.61*** 0.000 2.04-6.37

Acculturative stressors

Unfair treatmentf 0.98 0.841 0.84-1.15

Perceived racial/ethnic discriminationg 1.37 0.085 0.96-1.96

Family conflicth 0.97 0.902 0.61-1.54

Social support/religiosity

Family supporti 6.27 0.132 0.56-70.27

Friend supporti 0.09 0.064 0.01-1.15

Religiosity-one to three time a month or lessj 4.46 0.17 0.51-38.68

Religiosity-once a week or morej 0.63 0.757 0.03-12.22

Interaction of support/religiosity

Unfair treatment * religiosity (1 to 3 a month or less) 1.08 0.192 0.96-1.22

Unfair treatment * religiosity (once a week or more) 1.18* 0.021 1.03-1.36

Perceived racial/ethnic disc* religiosity (1 to 3 a month or less) 0.87 0.528 0.57-1.34

Perceived racial/ethnic disc * religiosity (once a week or more) 1.22 0.32 0.82-1.84

Family conflict* religiosity (1 to 3 a month or less) 0.70** 0.008 0.55-0.91

Family conflict * religiosity (once a week or more) 0.86 0.366 0.62-1.20

Unfair treatment * family support 0.92 0.219 0.80-1.05

Racial/ethnic disc * family support 0.90 0.576 0.61-1.33

Family conflict * family support 0.88 0.416 0.64-1.20

Unfair treatment * friend support 1.09 0.308 0.92-1.30

Racial/ethnic disc * friend support 0.80 0.22 0.57-1.15

Family conflict * friend support 1.46 0.107 0.92-2.33

Cut1 2.00 -.47-4.48

Cut2 5.99 3.46-8.52

*p < .05, **p < .01, ***p < .001 95% CI = 95% Confidence Interval disc: discrimination a Reference group is female (Male = 1; Female= 0). b Reference group is being married (Married = 0; Not married = 1). c Reference group is no religion. d Higher numbers indicate greater English-language proficiency. e Reference group is first generation immigrants. f Higher numbers are associated with more unfair treatment. g Higher numbers are associated with more perceived racial/ethnic discrimination. h Higher numbers are associated with greater family conflict. i Reference group is receiving no support (Yes = 1; No = 0). j Reference group is attending no religious services.

Hypothesis 3.1: Unfair treatment and perceived racial/ethnic discrimination have a direct effect

on alcohol use. It is hypothesized that Asian Americans who experience more unfair treatment

and perceive more racial/ethnic discrimination drink more than Asian Americans who experience

less unfair

treatment and perceive less racial/ethnic discrimination.

Hypothesis 3.2: Family conflict has a direct effect on alcohol use. It is hypothesized that Asian

Americans who experience more family conflict drink more than Asian Americans who

experience less family conflict.

As shown in Table 4, reported unfair treatment and perceived racial/ethnic discrimination

and family conflict were not directly related to alcohol use for Chinese Americans. Therefore,

this data did not support hypothesis 3.1 and 3.2.

Hypothesis 4.1: Acculturation has an indirect effect on alcohol use through unfair treatment and

perceived racial/ethnic discrimination. It is hypothesized that Asian Americans who are less

acculturated drink more because they experience more unfair treatment and perceive more

racial/ethnic discrimination.

Hypothesis 4.2: Acculturation has an indirect effect on alcohol use through family conflict. It is

hypothesized that Asian Americans who are less acculturated drink more because they

experience more family conflict.

This analysis did not support Hypotheses 4.1 and 4.2 for Chinese Americans (see Figure

3 for dotted line).

Hypothesis 5.1: Higher levels of social support are predicted to be directly related to lower

alcohol use.

Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair treatment

and perceived racial/ethnic discrimination on alcohol use. It is hypothesized that Asian

Americans who receive a greater amount of social support are better able to cope with unfair

treatment and perceived racial/ethnic discrimination and, as a result, drink less than Asian

Americans who

receive less social support.

Hypothesis 5.3: Social support will also moderate the impact of family conflict on alcohol use. It

is hypothesized that Asian Americans who receive a greater amount of social support are better

able to cope with family conflict and, as a result, drink less than Asian Americans who receive

less social support.

Social support, both as a main and an interaction effect, was not related to alcohol use,

therefore this analysis did not support hypotheses 5.1, 5.2, and 5.3 for Chinese Americans.

Hypothesis 6.1: Stronger religiosity is predicted to be directly related to lower alcohol use.

Hypothesis 6.2: Religiosity is expected to moderate the impact of unfair treatment and perceived

racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans with a higher

level of religiosity are better able to cope with unfair treatment and perceived racial/ethnic

discrimination and, as a result, drink less than Asian Americans with weaker religiosity.

Hypothesis 6.3: Religiosity also moderates the impact of family conflict on alcohol use. It is

hypothesized that Asian Americans with stronger religiosity are better able to cope with family

conflict and, as a result, drink less than Asian Americans with weaker religiosity.

Religiosity as a main effect was not negatively, directly related to alcohol use, thus

hypothesis 6.1 was not supported for Chinese Americans. The interaction of religiosity and

unfair treatment was statistically significant (p < .05); however, the direction was the opposite of

that predicted by hypothesis 6.2. Those Chinese Americans who experienced unfair treatment

and attended religious service one or more times a week had a greater likelihood of being light-

to-moderate or risky drinkers as compared to those who attended no religious services. In

addition, there was no statistically significant relationship between the interaction of perceived

racial/ethnic discrimination and religiosity and alcohol use. Therefore, this analysis did not

support hypothesis 6.2.

The interaction of religiosity and family conflict was related to alcohol consumption for

Chinese Americans. With higher family conflict, Chinese Americans who attended religious

services one or more times a week were less likely to be light-to-moderate or risky drinkers than

those who attended no religious services. This study found that religiosity had a negative joint

(interaction) effect over and above the individual main effects on the relationship between family

conflict and alcohol use for Chinese Americans. When the interaction effect was modeled, the

main effect of family conflict was not significant. Thus, this analysis did not support hypothesis

6.2.

Hypothesis 7.1: Acculturation has a direct effect on discrimination. It is hypothesized that Asian

Americans who are less acculturated experience more unfair treatment and perceive more

racial/ethnic discrimination than Asian Americans who are more acculturated.

Hypothesis 7.2: Acculturation has a direct effect on family conflict. It is hypothesized that Asian

Americans who are less acculturated experience more family conflict than Asian Americans who

are more acculturated.

As shown Table 5, English-language proficiency and generational status as indicators of

acculturation were not directly associated with unfair treatment and family conflict for Chinese

Americans. With respect to perceived racial/ethnic discrimination, first generation Chinese

Americans perceived greater discrimination than did second and third generation Chinese

Americans. In other words, Chinese Americans who were less acculturated to the mainstream

society and experienced more acculturative stress. This analysis supported hypothesis 7.1.

However, hypothesis 7.2 was not supported.

Table 5. OLS regression results for acculturative stressors among Chinese Americans

Variables Acculturative stressors

Unfair
treatment

Perceived Racial/ethnic
discrimination

Family
cultural conflict

Controlling variables Beta Beta Beta

Age -0.06** -0.02** 0.00

Gendera 1.28** 0.22 -0.16

Income 0.00* 0.00 0.00

Education 0.07 0.01 0.07*

Marital statusb 1.50* -0.08 0.70**

Protestantismc -0.21 -0.21 0.11

Catholicismc -0.03 -0.20 0.72**

Other religionc 0.48 -0.14 0.47*

Acculturation

English proficiencyd 0.22 -0.02 0.00

Second generatione 0.34 -1.65** -0.24

Third generatione -0.38 -0.68* -0.06

*p < .05, **p < .01, ***p < .001 a Reference group is female (Male = 1; Female= 0). b Reference group is being married (Married = 0; Not married = 1). c Reference group is no religion. d Higher numbers indicate greater English-language proficiency. e Reference group is first generation immigrants. f Higher numbers are associated with more unfair treatment. g Higher numbers are associated with more perceived racial/ethnic discrimination. h Higher numbers are associated with greater family conflict.

The overall path diagram results are presented in Figure 3. Although statistical

significance was found for some R2 estimates, the amount of variance accounted for by each

variable was typically small.

Figure 3: Final Model for Chinese Americans

B: logistic regression unstandardized coefficients. b: OLS Regression unstandardized coefficients.
R2: changes of pseudo-R2 to make coefficients comparable.

Factors Related to Alcohol Use among Filipino Americans

Tables 6 and 7 present results of the ordinal logistic regression in relation to alcohol use

(hypotheses two through six) and OLS regression related to acculturative stressors (hypothesis

seven) for Filipino Americans. The final model for Filipino Americans is presented in Figure 4.

Some factors, such as English proficiency, unfair treatment, perceived racial/ethnic

discrimination, family support, and friend support were significantly associated with alcohol use,

some positively and others negatively.

Hypothesis 2.1: Acculturation has a direct effect on alcohol use. It is hypothesized that Asian

Americans who are more acculturated drink more than Asian Americans who are less

acculturated.

Of the two acculturation indicators, English-language proficiency was directly and

positively related to alcohol use after controlling for age, gender, income, education, marital

status, and religion for Filipino Americans. Having higher English-language proficiency

increased the likelihood of being a light-to-moderate or risky drinker as compared to having

lower English-language proficiency. In other words, the odds of being light-to-moderate or risky

drinker were increased by 1.22 for each unit increase in the level of English-language

proficiency. Generational status was not significantly associated with alcohol use. Therefore, this

analysis partially supported hypothesis 2.1.

Table 6. Ordinal logistic regression results for alcohol use among Filipino Americans

Variable Odds ratio P-value 95% CI
Controlling variables

Age 0.96*** 0.000 0.94-0.98

Gendera 7.68*** 0.000 5.21-11.31

Income 1.00 0.534 1.00-1.00

Education 1.06 0.071 0.99-1.13

Marital statusb 1.03 0.931 0.55-1.94

Protestantismc 1.17 0.742 0.46-3.00

Catholicismc 1.20 0.706 0.45-3.23

Other religionc 1.48 0.162 0.85-2.58

Acculturation

English proficiencyd 1.22* 0.031 1.02-1.45

Second generatione 1.22 0.52 0.65-2.29

Third generatione 2.30 0.159 0.71-7.46

Acculturative stressors

Unfair treatmentf 1.09* 0.014 1.02-1.17

Perceived racial/ethnic discriminationg 0.48** 0.009 0.29-0.83

Family conflicth 1.16 0.465 0.77-1.76

Social support/religiosity

Family supporti 0.02** 0.002 0.00-0.21

Friend supporti 5.71 0.246 0.25-128.51

Religiosity-one to three time a month or lessj 4.76 0.11 0.69-32.60

Religiosity-once a week or morej 0.89 0.873 0.21-3.71

Interaction of support/religiosity

Unfair treatment * religiosity (1 to 3 a month or less) 1.00 0.984 0.90-1.11

Unfair treatment * religiosity (once a week or more) 1.00 0.979 0.87-1.15

Perceived racial/ethnic disc* religiosity (1 to 3 a month or less) 0.88 0.330 0.68-1.14

Perceived racial/ethnic disc * religiosity (once a week or more) 0.76 0.177 0.51-1.14

Family conflict* religiosity (1 to 3 a month or less) 0.75 0.075 0.54-1.03

Family conflict * religiosity (once a week or more) 0.93 0.460 0.77-1.13

Unfair treatment * family support 0.89* 0.031 0.80-0.99

Racial/ethnic disc * family support 2.12*** 0.000 1.44-3.13

Family conflict * family support 1.91*** 0.000 1.43-2.54

Unfair treatment * friend support 1.05 0.119 0.99-1.11

Racial/ethnic disc * friend support 1.10 0.642 0.73-1.66

Family conflict * friend support 0.61*** 0.024 0.40-0.93

Cut1 1.344 -2.22-4.91

Cut2 5.68 1.87-9.49

Hypothesis 3.1: Unfair treatment and racial/ethnic discrimination have a direct effect on alcohol

use. It is hypothesized that Asian Americans who experience more unfair treatment and perceive

more racial/ethnic discrimination drink more than Asian Americans who experience less unfair

treatment and perceive less racial/ethnic discrimination.

Hypothesis 3.2: Family conflict has a direct effect on alcohol use. It is hypothesized that Asian

Americans who experience more family conflict drink more than Asian Americans who

experience less family conflict.

After controlling for age, gender, income, education, marital status, and religion, among

Filipino Americans, the odds of being a light-to-moderate or risky drinker were associated with

an increase in experiencing unfair treatment. Contrary to the hypothesis, this study found that

those with lower perceived racial/ethnic discrimination were significantly more likely to drink

than those with greater perceived racial/ethnic discrimination. Taken together, these findings

offer partial support for hypothesis 3.1. Family conflict was not significant predictor of drinking

for Filipino Americans, and hypothesis 3.2 was not supported.

Hypothesis 4.1: Acculturation has an indirect effect on alcohol use through unfair treatment and

racial/ethnic discrimination. It is hypothesized that Asian Americans who are less acculturated

drink more because they experience more unfair treatment and perceive more racial/ethnic

discrimination.

Hypothesis 4.2: Acculturation has an indirect effect on alcohol use through family conflict. It is

hypothesized that Asian Americans who are less acculturated drink more because they

experience more family conflict.

This study found that being third generation Filipino American as an indicator of

acculturation had an indirect effect on alcohol use through unfair treatment (Figure 4 for the

solid line among generational status, unfair treatment, and alcohol use). The indirect effect of the

third generation status through unfair treatment explained 0.006% of the variance of alcohol use

(see Appendix J for a detailed description). Because of estimation of the total subpopulation of

Filipino Americans, this effect was statistically significant. The product of two positive direct

effects was also a positive indirect effect. In other words, compared to first generation Filipino

Americans, third generation Filipino Americans who experienced unfair treatment tended to

increase levels of alcohol use by being light-to moderate or risky drinkers. This finding turns out

to be in the opposite direction of hypothesis 4.1. Therefore, hypothesis 4.1 was inconsistent with

this study finding for Filipino Americans.

Neither second generation status nor English-language proficiency had an indirect effect

on alcohol use through unfair treatment, racial/ethnic discrimination, or family cultural conflict

for Filipino Americans. Therefore, this analysis did not support hypotheses 4.1 or 4.2.

Hypothesis 5.1: Higher levels of social support are predicted to be directly related to lower

alcohol use.
Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair treatment

and racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans who

receive a greater amount of social support are better able to cope with unfair treatment and

perceived racial/ethnic discrimination and, as a result, drink less than Asian Americans who

receive less social support.

Hypothesis 5.3: Social support will moderate the impact of family conflict on alcohol use. It is

hypothesized that Asian Americans who receive a greater amount of social support are better

able to cope with family conflict and, as a result, drink less than Asian Americans who receive

less social support.

No consistent significant results were found for social support among Filipino Americans.

Family support as a main effect was significantly associated with alcohol use. Filipino

Americans who reported family support were less likely to be light-to-moderate or risky drinkers

compared to those who did not. Interactions of family support and unfair treatment and

racial/ethnic discrimination and family conflict were statistically significant. With respect to this

interaction effect, Filipino Americans who reported unfair treatment and reported the presence of

family support were less likely to drink than those who reported no family support.

However, family support did not function as a buffer on the relationship between

perceived racial/ethnic discrimination and drinking or between family cultural conflict and

drinking. Those who perceived racial/ethnic discrimination and received family support were

more likely to report drinking than those who received no family support. In addition, Filipino

Americans who experienced family conflict and received more family support were more likely

to be light-to-moderate or risky drinkers than abstinent.

Friend support as a main effect was not associated with drinking for Filipino Americans.

The interaction between friend support and family conflict was statistically significant. Filipino

Americans who experienced family conflict and received friend support were less likely to be

light-to-moderate or risky drinkers than those who received no friend support. The odds of

increase in alcohol use were 0.61 times lower for each one unit increase in the interaction of

friend support and family conflict. Therefore, this analysis partially supported hypotheses 5.1,

5.2, and 5.3.

Hypothesis 6.1: Stronger religiosity is predicted to be directly related to lower alcohol use.

Hypothesis 6.2: Religiosity is expected to moderate the impact of unfair treatment and perceived
racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans with a higher

level of religiosity are better able to cope with unfair treatment and perceived racial/ethnic
discrimination and, as a result, drink less than Asian Americans with weaker religiosity.

Hypothesis 6.3: Religiosity moderates the impact of family conflict on alcohol use. It is

hypothesized that Asian Americans with stronger religiosity are better able to cope with family

conflict and, as a result, drink less than Asian Americans with weaker religiosity.

Religiosity as both a main and an interactive effect was not related to alcohol use for

Filipino Americans. Therefore, this analysis did not support hypotheses 6.1, 6.2, and 6.3.

As was the case for Chinese Americans, among Filipino Americans, there were many

significant R2 estimates in the relevant path diagram (Figure 4), but the amount of variance

explained by those variables was small, indicating weak relationships within this data.

Hypothesis 7.1: Acculturation has a direct effect on discrimination. It is hypothesized that Asian
Americans who are less acculturated experience more unfair treatment and perceive more
racial/ethnic discrimination than Asian Americans who are more acculturated.

Hypothesis 7.2: Acculturation has a direct effect on family conflict. It is hypothesized that Asian

Americans who are less acculturated experience more family conflict than Asian Americans

who are more acculturated.

Being third generation rather than first generation Filipino American was a statistically

significant factor in relation to unfair treatment (b = 3.98, p < .002) (see Table 7). Those who

were more acculturated to the dominant society reported more unfair treatment. This finding was

in the opposite direction of the proposed hypothesis. In addition, no statistically significant

differences in unfair treatment were found between the first and the second generation Filipino

Americans. Furthermore, acculturation (as indicated by English-language proficiency and

generational status) was not directly associated with perceived racial/ethnic discrimination and

family conflict. Therefore, hypotheses 7.1 and 7.2 were not supported for Filipino Americans.

Table 7. OLS regression results for acculturative stressors among Filipino Americans

Variable Acculturative stressors

Unfair
treatment
Perceived Racial/ethnic
discrimination
Family
cultural conflict
Controlling variables Beta Beta Beta

Age -0.07** 0.00 -0.02*

Gendera 2.29** 0.19 -0.36

Income 0.00 0.00 0.00

Education 0.26 0.14*** 0.04

Marital statusb 0.33 -0.07 -0.13

Protestantismc 1.90* 0.22 0.48

Catholicismc 0.32 0.06 0.02

Other religionc 1.21 -0.36 0.47

Acculturation

English proficiencyd -0.29 -0.08 -0.03

Second generatione -0.28 0.19 -0.36

Third generatione 3.98** -0.04 -0.35

Figure 4. Final Model for Filipino Americans

B: logistic regression unstandardized coefficients. b: OLS regression unstandardized coefficients.
R2: changes of pseudo-R2 to make coefficients comparable.

Factors Related to Alcohol Use among Vietnamese Americans

Tables 8 and 9 show results of ordinal logistic regression related to alcohol use

(hypotheses two through six) and of OLS regression related to acculturative stressors (hypothesis

seven), respectively for Vietnamese Americans. Figure 5 presents the final model. Overall, fewer

factors–English proficiency, religiosity, and interaction of religiosity and unfair treatment–were

identified that related to alcohol use in this subsample than in the other two Asian American

groups studied.

Hypothesis 2.1: Acculturation has a direct effect on alcohol use. It is hypothesized that Asian

Americans who are more acculturated drink more than Asian Americans who are less

acculturated.

English-language proficiency as one acculturation indicator was directly and positively

related to alcohol use among Vietnamese Americans, after controlling for age, gender, income,

education, marital status, and religion (Table 8). Higher English-language proficiency was

positively associated with increased likelihood of light-to-moderate or risky drinking compared

to lower English-language proficiency. However, generational status was not significantly

associated with alcohol use for Vietnamese Americans. Hence, this analysis partially supported

hypothesis 2.1.

Table 8. Ordinal logistic regression results for alcohol use among Vietnamese Americans

Variable Odds ratio P-value 95% CI
Controlling variables

Age 1.01 0.368 0.99-1.03

Gendera 5.25*** 0.000 2.62-10.5

Income 1.00 0.491 1.00-1.00

Education 0.98 0.583 0.89-1.07

Marital statusb 0.89 0.747 0.43-1.85

Protestantismc 0.64 0.665 0.78-5.23

Catholicismc 5.33* 0.032 1.17-24.31

Other religionc 3.20* 0.030 1.13-9.08

Acculturation

English proficiencyd 1.14** 0.016 1.03-1.27

Second generatione 2.69 0.207 0.56-12.85

Third generatione

Acculturative stressors

Unfair treatmentf 1.10 0.240 0.93-1.30

Perceived racial/ethnic discriminationg 1.12 0.565 0.76-1.65

Family conflicth 0.71 0.274 0.39-1.32

Social support/religiosity

Family supporti 0.32 0.345 0.03-3.60

Friend supporti 0.84 0.895 0.06-12.03

Religiosity-one to three time a month or lessj 0.86 0.899 0.07-9.94

Religiosity-once a week or morej 0.04* 0.049 0.00-0.98

Interaction of support/religiosity

Unfair treatment * religiosity (1 to 3 a month or less) 0.93 0.382 0.79-1.10

Unfair treatment * religiosity (once a week or more) 0.82* 0.040 0.68-0.99

Perceived racial/ethnic disc* religiosity (1 to 3 a month or less) 1.04 0.864 0.69-1.56

Perceived racial/ethnic disc * religiosity (once a week or more) 0.89 0.533 0.60-1.30

Family conflict* religiosity (1 to 3 a month or less) 0.94 0.776 0.60-1.46

Family conflict * religiosity (once a week or more) 1.55 0.089 0.93-2.57

Unfair treatment * family support 0.96 0.660 0.79-1.16

Racial/ethnic disc * family support 1.04 0.857 0.68-1.58

Family conflict * family support 1.24 0.263 0.84-1.81

Unfair treatment * friend support 1.11 0.245 0.93-1.32

Racial/ethnic disc * friend support 1.03 0.884 0.65-1.64

Family conflict * friend support 1.11 0.665 0.68-1.80

Cut1 2.89 -1.22-7.00

Cut2 7.04 2.87-11.20

*p < .05, **p < .01, *** p< .001 95% CI = 95% Confidence Interval disc: discrimination a Reference group is female (Male = 1; Female= 0). b Reference group is being married (Married = 0; Not married = 1). c Reference group is no religion. d Higher numbers indicate greater English-language proficiency. e Reference group is first generation immigrants. f Higher numbers are associated with more unfair treatment. g Higher numbers are associated with more perceived racial/ethnic discrimination. h Higher numbers are associated with greater family conflict. i Reference group is receiving no support (Yes = 1; No = 0). j Reference group is attending no religious services.

Hypothesis 3.1: Unfair treatment and perceived racial/ethnic discrimination have a direct effect

on alcohol use. It is hypothesized that Asian Americans who experience more unfair treatment

and perceive racial/ethnic discrimination drink more than Asian Americans who experience less

unfair treatment and perceive less racial/ethnic discrimination.

Hypothesis 3.2: Family conflict has a direct effect on alcohol use. It is hypothesized that Asian

Americans who experience more family conflict drink more than Asian Americans who

experience less family conflict.

As shown Table 8, after controlling for age, gender, income, education, marital status,

and religion, the variables of unfair treatment, perceived racial/ethnic discrimination and family

conflict were not significantly associated with alcohol use. Therefore, this analysis did not

support hypotheses 3.1 and 3.2 for Vietnamese Americans.

Hypothesis 4.1: Acculturation has an indirect effect on alcohol use through unfair treatment and
racial/ethnic discrimination. It is hypothesized that Asian Americans who are less acculturated
drink more because they experience more unfair treatment and perceive more racial/ethnic
discrimination.

Hypothesis 4.2: Acculturation has an indirect effect on alcohol use through family conflict. It is
hypothesized that Asian Americans who are less acculturated drink more because they

experience more family conflict.

Acculturation did not have an indirect effect on alcohol use through unfair treatment and

perceived racial/ethnic discrimination or through family conflict for Vietnamese Americans (see

Figure 5 for dotted line). Thus, hypotheses 4.1 and 4.2 were not supported.

Hypothesis 5.1: Higher levels of social support are predicted to be directly related to lower
alcohol use.
Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair treatment
and racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans who
receive a greater amount of social support are better able to cope with unfair treatment and
perceived racial/ethnic discrimination and, as a result, drink less than Asian Americans who
receive less social support.

Hypothesis 5.3: Social support will moderate the impact of family conflict on alcohol use. It is

hypothesized that Asian Americans who receive a greater amount of social support are better

able to cope with family conflict and, as a result, drink less than Asian Americans who receive

less social support.

The results showed that family and friend support as both main and interactive effects

were not associated with alcohol use for Vietnamese Americans (Table 8). Therefore this

analysis did not support hypotheses 5.1 through 5.3.

Hypothesis 6.1: Stronger religiosity is predicted to be directly related to lower alcohol use.
Hypothesis 6.2: Religiosity is expected to moderate the impact of unfair treatment and
racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans with a higher

level of religiosity are better able to cope with unfair treatment and perceived racial/ethnic
discrimination and, as a result, drink less than Asian Americans with weaker religiosity.
Hypothesis 6.3: Religiosity moderates the impact of family conflict on alcohol use. It is

hypothesized that Asian Americans with stronger religiosity are better able to cope with family

conflict and, as a result, drink less than Asian Americans with weaker religiosity.

As shown in Table 8, attending religious services was associated with decreased levels of

alcohol use for Vietnamese Americans, supporting hypothesis 6.1.

The interaction of religiosity and unfair treatment was statistically significant. Attending

religious services was associated with decreased drinking when Vietnamese Americans

experienced unfair treatment. When the interaction was specified, the main effect of unfair

treatment was not significant. Therefore, this analysis did not support hypothesis 6.2. The

interaction of religiosity and perceived racial/ethnic discrimination and interaction of religiosity

and family conflict were not statistically significant in relation to alcohol use. Therefore, this

analysis did not support hypothesis 6.3.

Hypothesis 7.2: Acculturation has a direct effect on family conflict. It is hypothesized that Asian

Americans who are less acculturated experience more family conflict than Asian Americans who

are more acculturated.

As Table 9 shows, English-language proficiency was positively associated with unfair

treatment. Vietnamese Americans with high English-language proficiency reported more unfair

treatment. However, generational status was not directly associated with either discrimination or

family conflict for Vietnamese Americans. Therefore, this analysis partially support hypothesis

7.1 but did not support hypothesis 7.2.

Table 9. OLS regression results for acculturative stressors among Vietnamese Americans

Variable Acculturative stressors

Unfair
treatment
Perceived Racial/ethnic
discrimination
Family
cultural conflict
Controlling variables Beta Beta Beta

Age -0.03 0.00 -0.01

Gendera 1.19 -0.11 0.10

Income 0.00 0.00** 0.00

Education 0.06 0.13** 0.02

Marital statusb 2.61* 0.95*** 1.12***

Protestantismc -0.06 -0.68 0.00

Catholicismc -1.96 -0.77 -0.23

Other religionc -1.88* -1.40* -0.48

Acculturation

English proficiencyd 0.32* -0.03 0.04

Second generatione -1.55 -0.36 -0.25

Third generatione

Figure 5. Final Model for Vietnamese Americans

B: logistic regression unstandardized coefficients. b: OLS regression unstandardized coefficients.
R2: changes of pseudo-R2 to make coefficients comparable

Summary of Findings for Chinese, Filipino, and Vietnamese Americans

A summary of hypotheses tests for the three groups is presented in Table 10. Different

drinking patterns were found for Chinese, Filipino, and Vietnamese Americans. English-

language proficiency was the only common predictor for alcohol use across the three subgroups.

Generational status was a predictor for Chinese and Filipino but not Vietnamese Americans. A

significant relationship between acculturative stressors and alcohol use was found only for

Filipino Americans. The effects of social support and religiosity yielded mixed findings.

Depending on the type of acculturative stressor and the specific subgroup, social support and

religiosity had positive or negative effects on alcohol consumption. Overall, these findings

underscore the need to examine variation across different groups of Asian Americans, both

because alcohol use rates differ and because factors associated with risk and protection seem to

differ as well.

Table 10. Summary of results from hypothesis testing for the three groups.

Chinese Filipino Vietnamese
Hypothesis 2.1 Yes Partially Partially
Hypothesis 3.1
Hypothesis 3.2

No
No

Partially
No

No
No

Hypothesis 4.1
Hypothesis 4.2

No
No
No
No
No
No

Hypothesis 5.1
Hypothesis 5.2
Hypothesis 5.3

No
No
No

Partially
Partially
Partially

No
No
No

Hypothesis 6.1
Hypothesis 6.2
Hypothesis 6.3

No
No
Yes

No
No
No

Yes
Partially

No
Hypothesis 7.1
Hypothesis 7.2

Yes
No

No
No
Partially
No

Chapter V

Discussion

The current study had two aims: (1) to examine levels of alcohol use among Chinese,

Filipino, and Vietnamese Americans; and (2) to examine the interrelationships between socio-

cultural factors and alcohol use using acculturation and acculturative stress models. Most of the

literature on alcohol use among Asian Americans employs either an acculturation model alone or

an acculturative stress model alone. This study brought together the two models and thus was

better able to determine relevant socio-cultural factors associated with alcohol consumption. The

discussion section addresses (1) the differences in levels of alcohol use among the three ethnic

subgroups, (2) the study’s findings with respect to acculturation, acculturative stress, and stress

moderators and the study’s limitations, (3) the implications of the study’s findings for social

work practice and policy, and (4) recommendations for future research.

Alcohol Use

Differences in alcohol use for subgroups of Asian Americans were found in this study;

Filipino Americans (5.6%) reported the highest levels of risky-drinking behaviors, followed by

Chinese Americans (3.0%), and Vietnamese Americans (1.4%). This finding of variations in

alcohol use across subgroups is consistent with findings of previous studies (Price et al., 2002;

Wong et al., 2007) and reinforces the importance of considering diversity in alcohol

consumption across the Asian American population, as well as within specific ethnic subgroups.

The particularly high rate of drinking among Filipino Americans may be due to several

factors. This subgroup was the most acculturated of the three groups in terms of English-

language proficiency. Although detailed exploration of the role of English-language proficiency

was beyond the scope of the current study, overall Filipino Americans obtained the highest level

of English-language proficiency (10.07), followed by Chinese Americans (7.71) and by

Vietnamese Americans (6.62). Compared with their Chinese and Vietnamese American

counterparts, Filipino Americans have been more influenced by American culture from

colonization by the U.S., acquiring language proficiency as a result. In addition, Filipino

Americans in the current study reported higher mean income and higher education compared

with either Chinese or Vietnamese Americans. Some studies have reported higher income and

education to relate to higher levels of alcohol consumption (Adler et al., 1994; Chi et al., 1988;

Platt, Sloan, & Costanzo, 2010). A combination of these factors may account for why Filipino

Americans report drinking more than the other two groups.

The rate of risky-drinking reported by Chinese Americans was greater than that of

Vietnamese Americans but not as great as among Filipino Americans. In terms of immigration

history, Chinese Americans came to U.S. earlier than Vietnamese Americans and thus have been

more exposed to American culture. Although cultural attitudes toward drinking were not

examined in this study, Chinese Americans emphasize moderation and discourage heavy

drinking (Zane & Huh-Kim, 1998) in comparison with Filipino Americans, a factor that may

have contributed to these group differences.

In this study, lowest rates of reported alcohol consumption were found for the

Vietnamese. Inconsistent findings have been previously reported regarding alcohol consumption

rates for this population. One study reported that Vietnamese Americans had the lowest rate of

alcohol use among other Asian subgroups (Fong, 2007). Wong et al. (2007), however, found that

alcohol consumption among Vietnamese Americans was equivalent to that of the U.S. general

population. Wong et al. (2007) claimed that national surveys do not accurately reflect practices

within specific communities and that the type of alcoholic beverage needs to be queried, since

Vietnamese Americans do not classify beer or rice wine as alcohol. The NLAAS data analyzed

in this study do not capture such nuances in alcohol use and are thus likely to underestimate

alcohol use. Further, as Wong et al. (2007) noted, Vietnamese Americans who have experienced

forced migration are often unfamiliar with research and distrustful of authority figures, factors

that may further contribute to discrepancies between self-reported and actual prevalence of

alcohol use.
Acculturation

In line with other studies (Despuses & Friedman, 2007; Gong et al., 2003; Hahm et al.,

2003; Liu & Iwamoto, 2007; Yi & Daniel, 2001), the present research confirms the predictive

relevance of the acculturation model in relation to alcohol use among Asian Americans. This

study revealed that greater English proficiency, an indicator of greater acculturation, was related

to alcohol use among Chinese, Filipino, and Vietnamese Americans. Taken together, these

results suggest that greater exposure to U.S. cultural influences leads to more drinking. As

Takeuchi, Zane, Hong, et al. suggest (2007), Asian Americans with greater English proficiency

may have more opportunities to interact with people from the mainstream society and may learn

American drinking norms and behavior as a result.

Another indicator of acculturation, generational status, was found to predict increased

drinking among Chinese Americans, but not among Filipino or Vietnamese Americans. This

finding supports the acculturation model for Chinese Americans, consistent with previous studies

(Brown et al., 2005; Price et al., 2002). The second and the third generations of Chinese

Americans appear to adopt the dominant cultural attitudes and norms toward alcohol use which

become apparent in their drinking behavior. The fact that no significant relationship was found

between generational status and alcohol use for Vietnamese Americans may well be an artifact of

the sample, since the vast majority of Vietnamese Americans in the study (97.2%) were first

generation immigrants and none reported being third generation. The disproportionate

distribution of generational status across the three ethnic subgroups precludes meaningful

comparisons in regard to the relationship between generational status and alcohol consumption.

Acculturative Stress

Whereas the acculturation model emphasizes the gradual adoption of the norms and

behaviors of the dominant culture, the acculturative stress model posits that drinking behavior

may result from the need to relieve anxiety and tension related to acculturation. Some studies

suggest that Asian Americans use alcohol to mitigate acculturative stress (D’Avanzo et al., 1994;

Liu & Iwamoto, 2007; Su & Wong, 2006; Vega & Gil, 1999). The current study examined three

facets of acculturative stress: unfair treatment, perceived racial/ethnic discrimination, and family

cultural conflict, and found support for the acculturative stress model only among Filipino

Americans. These findings suggest that Chinese and Vietnamese Americans do not use alcohol

in a way that is associated with acculturative stress; however, the three acculturative stressors

assessed in this study are not the only possible sources of acculturative stress and may not tap the

most challenging experiences associated with acculturation for Chinese and Vietnamese

Americans.

The current study hypothesized that living with family members who have varying

degrees of acculturation would increase family discord and cause family members to turn to

drinking. This hypothesis was not supported. The fact that most Asian Americans in the study

sample were first generation adults may have contributed to the absence of findings. For first

generation families, dynamics may just be beginning to change compared to families with second

or third generation family members, and therefore conflicts generated by varying degrees of

acculturation among family members may not yet have emerged.

In this study, unfair treatment referred to subtle, routine experience of injustice, not to

major events affected by discrimination, such as job loss, financial strain, being harassed by the

police, or being discriminated against in housing. This measure of unfair treatment is of more

subtle discrimination; for example, respondents were asked the frequency of occurrence whether

they were threatened or harassed. Asian Americans in this current study may not recognize many

of these more subtle experiences as acts as unfair treatment. Many Asian Americans are first

generation immigrants and may attribute this unfair treatment to their own unfamiliarity with the

U.S. culture and are less likely to recognize it (Gee & Ro, 2009). Major event discrimination, of

possible relevance to drinking behavior, may not be tapped by the methodology that was used for

this current study.

Failure to find support for the acculturative stress model may also have resulted from

inadequacies of the measure of subtle discrimination. Additionally, some studies (e.g., Chae et

al., 2009) measured whether unfair treatment had been experienced but not the frequency of

unfair treatment, while the current study measured only frequency of discriminatory experience.

The frequencies of items in unfair treatment in this current study may reflect that few Asian

Americans experienced unfair treatment. It may also be that experiences of unfair treatment do

not appear to happen with frequency (Gee & Ro, 2009). Keeping in mind the above speculations

in regard to the failure to find general support for the acculturative stress model, the relationship

between acculturative stress and alcohol use is discussed below for each ethnic subgroup.

Filipino Americans. Among Filipino Americans, both unfair treatment and perceived

racial/ethnic discrimination were found to be related to alcohol use, though not consistently in

the expected direction. As was also found in the Gee et al. (2007) study, Filipino Americans who

reported more unfair treatment also reported more drinking. However, contrary to expectation,

those who perceived less racial/ethnic discrimination reported drinking more. These

contradictory findings deserve further attention, taking into account the differences between

subtle experiences of unfair treatment and perceptions of major racial/ethnic discrimination.

In this study, Filipino Americans reported higher average income and higher levels of

education than the two other groups. It is possible therefore that they may have more exposure to

the dominant culture, be educated about the notion of equality and have more opportunity to

socialize with non-Asian Americans. The upward mobility associated with income and education

may bring with it increased pressures to minimize or deny frank racial/ethnic discrimination.

Economically successful Filipino Americans in this study may frame their experiences as would

members of the dominant white culture, acknowledging unfair treatment but not framing their

experience in terms of racial/ethnic discrimination.

Fatalism may also be a factor, with Filipino Americans accepting racial discrimination as

an aspect of life that they cannot control and must therefore accept. Holding a fatalistic view,

however, may not contribute to using drinking as a coping mechanism. Such an interpretation is

consistent with the findings of Noh, Kaspar, Hou, and Rummens (1999) that Asian Americans

tended to use coping strategies of forbearance or avoidance when dealing with the uncontrollable

stressor of perceived discrimination. Noh et al. (1999) stated that when ethnic minority group

members encounter discrimination they face a no-win situation (p. 203) and, to save face, tend

not to confront, but rather avoid, the uncomfortable situation.

These conflicting results may indicate that there is indeed no association between either

unfair treatment or perceived racial/ethnic discrimination and alcohol use for Filipino Americans.

100

As Yoo, Gee, Lowthrop, and Robertson (2009) reported, different forms of racial discrimination

may have greater or less impact on alcohol use. Alternatively, the current study’s inconsistent

findings may result from the specific, and limited, ways of measuring unfair treatment and

perceived racial/ethnic discrimination incorporated in the original study.

Chinese and Vietnamese Americans. With respect to Chinese and Vietnamese

Americans, this study did not find support for the proposed hypothesis; none of the acculturative

stressors investigated were associated with drinking. One likely explanation for this finding is

that the effects of acculturative stressors may not be clearly pronounced among first generation

immigrants. The effects of discrimination accumulate over lifetimes and may not become

manifest until the second or third generation (Harrell, 2000).

The Relationship between Acculturation and Acculturative Stress

This research was based on the assumption that the acculturation process produces

acculturative stress and that those who are less acculturated would experience greater

acculturative stress. In the current study, the relationship between acculturation and acculturative

stress was significant for Chinese Americans and Filipino Americans. However, the direction of

relationship was inconsistent for Chinese Americans and Filipino Americans; therefore, only

partially supporting the assumptions mentioned.

With respect to Chinese Americans, the first generation perceived more racial/ethnic

discrimination compared to the second and third generation, in line with previous research

(Caetano et al., 2008). It is likely that, in comparison with later generations, first generation

Chinese Americans experience more tension generated by the incongruence between their own

culture and the new culture of the U.S.

101

In contrast to Chinese Americans, the present data show that second and third generation

Filipino Americans reported greater unfair treatment in comparison to their first generation

counterparts, in the line with a previous study (Gee, 2008). A possible explanation is that more

exposure to the new culture enables ethnic minorities and immigrants to discern subtle nuances

of unfair treatment. Also, first generation immigrants typically migrate to where their own ethnic

community already exists (Lai & Arguelles, 2003), whereas subsequent generations may be less

likely to remain in geographically and ethnically defined communities. Second and third

generation Filipino Americans may be less likely to live in ethnic enclaves and may therefore

have more contact with people from other ethnic backgrounds. Greater contact with ethnically

heterogeneous communities may contribute to increased awareness of the variability of treatment

experienced by members of different ethnic minorities in their daily lives. The current study fails

to demonstrate a consistent association between acculturation and acculturative stress or that

acculturation per se leads to stress.

Social Support and Religiosity

The current study explored the buffering effects of social support and religiosity and

hypothesized that the presence of social support and more frequent attendance at religious

services would moderate the relationship between acculturative stress and alcohol use. Findings

indicated that social support and religiosity both potentiated and weakened the relationship

between acculturative stressors and alcohol use. Across the three subgroups, different types of

social support emerged as significant contributors to alcohol consumption. Thus, findings

partially support the role of social support and religiosity in buffering against the negative effects

of different types of acculturative stressors for different subgroups, but each subgroup requires

individual consideration.

102

Without more specific information about drinking habits and patterns, such as with

whom respondents drank, under what circumstances, why from their perspective they drank, or

more information about the kind and extent of social support and religiosity, one can only begin

to surmise the reasons for why these different patterns of alcohol use emerged in the context of

social support/religiosity. Additionally, the heterogeneity of Asian subgroups in terms of

immigration history, religion, and culture may provide different explanations for different

subgroups. In fact, there may be seemingly contradictory explanations for the predictors and

patterns of alcohol use across subgroups. Potential explanations proposed here are generated by

considering the unique cultural contexts of each group.

It should be noted that limitations in the measurement of social support may have

contributed to inconsistent and nonsignificant findings. The indicator for social support was a

single question, which cannot capture the complexity of the social support construct.

Furthermore, the four potential responses were re-categorized into only two: received versus not-

received support. Taken together, these variable attributes constrained the ability of the measure

to detect variation in social support and limited the interpretation of the construct by the

respondent. Understanding these inconsistencies in the roles of social support and religiosity in

regards to alcohol use requires considering the context of each individual subgroup (e.g., the

specific make up of the subgroup community, their historical and cultural background, and the

values within each subgroup) and how this moderation changes across context within each

subgroup (Gee & Ro, 2009).

Chinese Americans. For Chinese Americans, only the interactions of religiosity with

unfair treatment and with family conflict were associated with alcohol use, yet in different

directions. Those who reported greater unfair treatment and attended religious services more

103

frequently were more likely to drink, whereas those who experienced family conflict and

attended religious service more frequently were less likely to drink. Religious services are a key

site of socialization among immigrants and ethnic minority groups, and it was expected that the

interactions with religious service involvement would have only yielded a negative relationship

with alcohol use. One possible explanation for these discrepant findings is that attending services

and being exposed to religious doctrine may reduce one’s negative response to family conflict,

thereby reducing motivation to drink. Religious doctrine may encourage tolerance of family

discord and working through private matters at home. When the stressor is more public, such as

unfair treatment, adherence to religious doctrine may be more difficult or stressful in the face of

injustice. This may in turn contribute to increased drinking. While religiosity appears to play an

important role in predicting alcohol use, it appears only to do so in certain contexts.

Filipino Americans. For Filipino Americans, family support was found to be the most

associated with alcohol use. Main and interaction effects were found for family support on

alcohol use, which is consistent with previous studies that have demonstrated the protective

influence family support has on alcohol consumption (Finch & Vega, 2003; Lee, Koeske, &

Sales, 2004; Yoshikawa, Wilson, Chae, & Cheng, 2004). Generally, those who received family

support drank less; and in the face of specific stressors, such as the experience of unfair

treatment, presence of family support had a buffering effect by preventing alcohol use from

increasing, as demonstrated by the interaction with unfair treatment. This buffering effect did not

remain in the presence of other stressors, such as perceived racial/ethnic discrimination or family

conflict. Those Filipino Americans who perceived racial/ethnic discrimination as well as family

conflict and received family support reported greater levels of alcohol use than those who

received no family support. It is possible that Filipino Americans share their negative

104

experiences in the family setting, which may prompt other family members to express similar

perceptions. This may increase the amount of experienced stress among the group, which may

then contribute to increased drinking. Similarly, those who experience both conflict in and

support from family (with whom they do not live) may experience pressure from the family to

maintain harmonious family relationships by sacrificing their individual needs for the sake of the

family’s needs. This may result in greater stress and more drinking. It is apparent when

comparing Chinese and Filipino Americans that type of buffer (i.e, religiosity versus family

support) has a unique impact on each in terms of their effect on alcohol use. This is a point for

future investigation.

While there was no main effect for friend support, its interaction with family conflict was

associated with alcohol use, perhaps demonstrating the importance of friend support when there

is reported discord in the family. There was no relationship between alcohol use and religiosity.

For Filipino Americans, other sources of social support did have an association with alcohol use.

Vietnamese Americans. Similar to the Chinese Americans yet different from Filipino

Americans, family and friend social support were not predictive of alcohol use among

Vietnamese Americans. Instead, religiosity was a significant independent predictor of lower

alcohol consumption, consistent with findings from previous research on this group (Yi & Daniel,

2001). In addition, there was an interaction between religiosity and experience of unfair

treatment in predicting alcohol use. Participants who experienced more unfair treatment and

attended religious services more frequently were less likely to drink that those who attended less

often. Attending religious services may help Vietnamese Americans cope with stress associated

with unfair treatment without resorting to alcohol.

Study Limitations

105

The findings of the present study should be considered in light of the strengths and

limitations of the methodology. Using the NLAAS data set offered several notable strengths. The

NLAAS data set is a large, representative national sample of non-institutionalized adults, aged

18 and older, drawn from the general population. This provided sufficient statistical power for

the current analyses. In addition, the NLAAS data set oversampled participants of Asian descent

thereby assuring an ample number of Asian American participants for this original research. The

size and scope of the NLAAS data set and the heterogeneity of Asian population sample made it

possible to conduct separate analyses for the three ethnic subgroups in the current study.

Nevertheless, the methodology of the NLAAS data set also introduced problems for these

secondary analyses. The first methodological concern about using the NLAAS data set is that

recruitment procedures required the inclusion of second respondents in the same household as

first respondents in order to increase the sample size of Asian Americans. This approach may

have introduced bias into the findings. Rather than capturing more respondents from more

households, the findings are based on more respondents who are likely to share the same

perspective. The nature and extent of bias brought about by this approach and its effects on the

generalizability of results is unknown.

Second, as is the nature of secondary analysis, the current study was limited by the

specific variables and scales used by the original study. The NLAAS data were not originally

collected for assessing alcohol-related problems but for estimating prevalence of mental illness.

Consequently, the measures of alcohol consumption were limited in number and scope. In

comparison, national studies focusing on alcohol use have included more comprehensive

questionnaires that query details of amount, frequency, and type of alcoholic beverage consumed.

Because the NLAAS assessed quantity and frequency of alcohol use and required the

106

participants to average their alcohol consumption over the entire year, this quantity-frequency

measure is not able to provide informative data for people with irregular drinking patterns

(DeFour, 1999). In addition, patterns of alcohol consumption vary culturally and therefore the

meaning of any measure of drinking has to be interpreted in a specific population with care.

As mentioned previously, another limitation of the data set is the use of single questions

to assess the complex constructs of social support and religiosity. Family and friend support was

assessed simply with questions about how openly the respondent could talk about their worries,

which may or may not have been an indicator of experienced support (i.e., someone may still

feel supported by someone with whom they may not be able to speak openly). No questions

tapped the helpfulness of social support received. Nor was there any assessment of family

support received by relatives with whom the participant lived, although family members in the

same household may provide the most immediate and crucial sources of support. Moreover, for

analysis purposes a dichotomous dummy variable (yes versus no) was created from the four

ordinal responses to social support questions. Such aggregation of responses may reduce the

variability available for analysis. These methodological limitations may be responsible for the

failure to find a significant relationship between social support/religiosity and acculturative stress

in this study. A fuller assessment of the role of social support would require multidimensional

measures and the inclusion of same-household individuals as potential sources of support.

Third, the NLAAS uses exclusively self-report measures that are subject to potentially

distorting influences such as self-presentation concerns, interviewer effects, and

misunderstanding. Most interviews were conducted face-to-face with an interviewer, which may

particularly predispose participants to minimize their negative response due to social desirability.

More importantly, cultural stigma associated with alcohol abuse is prominent in the Asian

107

American population. Hence self-reported alcohol use behavior may be inaccurate and

underestimate actual rates.

Lastly, this current study did not test all hypotheses simultaneously. As a result, causal

relationships among variables cannot be inferred from this study. In order to utilize available

variables, each of which had different levels of measurement, this study used different types of

regression analyses to assess the various relationships of interest. Despite an attempt to make the

coefficients from these different types of regression analyses comparable, the final path models

presented here are not the same as a conventional path model and should therefore not be

interpreted as such.

Implications

Social work practice. Findings from the current study suggest that a single model of

alcohol use does not fit all Asian American subgroups and underscores the importance of

understanding heterogeneity within this population. Culturally competent practice requires that

social workers continue to study patterns of alcohol use for each Asian ethnic group separately,

taking into consideration the different social, cultural, and contextual factors that may underlie

each group’s behavior. Knowing the unique protective and risk factors across Asian subgroups

may dictate different approaches to intervention in substance abuse and mental health treatment

settings.

The results of this study provide support for the role of acculturation in shaping drinking

patterns. The association of acculturation with alcohol use implies that greater cultural exposure

results in the adoption of the relevant norms, practices, and values of the dominant society in

regard to drinking. If this is the case, less acculturated individuals and recent immigrants may

have certain protective factors, such as cultural practices and family cohesion, which may

108

diminish with each successive generation of acculturation. To reduce drinking, social workers

need to assess such potentially protective resources as well as risk factors, by considering level

of acculturation and identification with the dominant society of for each individual and group

with which they work.

In the present study, English proficiency is a common factor associated with drinking

among the three Asian subgroups. Although immigrants need to learn English to adjust to

mainstream society in the United States, acquiring language facility may also increase potentially

harmful behavior in the form of increased alcohol consumption. In addition, drinking behavior

appears to differ as a function of immigrant generation. Among Chinese Americans, in particular,

generational status may be an important factor in alcohol use. Because of the high proportion of

first generation immigrants among Vietnamese Americans, more time will likely be needed to

determine how drinking patterns in this group in particular may change over time.

More generally, social workers need to understand how life experiences differ among

subsequent generations of immigrants. As acculturation increases with each generation, there

may be more opportunities and pressures for alcohol use. This calls for an emphasis on primary

prevention and health promotion: new immigrants should be educated about the potential impact

of acculturation on their children and programs need to be developed to help immigrant families

navigate acculturation across generations in culturally sensitive ways. Furthermore, other studies

suggest that prevention programs should consider the benefits of encouraging retention of

protective aspects of the culture of origin while simultaneously acculturating to the U.S., thereby

encouraging and obtaining biculturalism (Berry, 2003; Smokowski, David-Ferdon, & Stroupe,

2009). The current study provides support for the idea that biculturalism has the potential to

lower risk for increased alcohol use.

109

The current findings can be interpreted using Shannon’s (1989) model of biopsychosocial

assessment that mandates consideration of environmental, physical, behavioral, psychological,

and social factors in working with health issues of social work clients. The present data suggest

that the acculturation-related factors of English-language proficiency and generational status be

routinely included in assessments of social factors related to drinking.

The finding that Asian Americans with higher acculturation were at greater risk of

unhealthy drinking behaviors contradicts the common expectation that recent immigrants are at

greater risk because of greater adjustment, language, and economic problems. Social workers

need to identify and acknowledge the diversity of difficulties that accompany various stages of

acculturation and develop tailored approaches to prevention and treatment. For example, alcohol

awareness and education efforts aimed at Asian Americans with higher levels of acculturation

should reinforce the importance of using alcohol in moderation and emphasize adverse

consequences of excessive use. Furthermore, social workers need to pay special attention to the

needs of children of immigrants—the second or third generation—since they are at greater risk

for increased alcohol consumption.

Although this study has not supported the hypothesized model of acculturative stressors

contributing to drinking for Chinese Americans and Vietnamese Americans, social workers

would do well to examine elements of acculturative stress pertaining to Asian subgroups not

assessed within the current study. For example, Vietnamese Americans may have experienced

trauma related to the Vietnam War and may drink in order to relieve related symptoms. Thus,

social work practitioners need to understand the unique immigration histories and norms of

Asian subgroups. Based on that knowledge, social workers carefully and comprehensively need

to assess stressors relevant to specific individuals.

110

For instance, acculturation and experiences of unfair treatment are risk factors in drinking

behavior among Filipino Americans. Social workers could create a safe space for discussion of

relevant issues related to race and ethnicity and help clients develop more constructive skills for

coping with discrimination. Social workers can encourage individuals to explore how personal

characteristics and environmental contexts affect their exposure to discrimination. In addition,

they could develop workshops in the community to discuss acculturation processes and strategies

how to address barriers pertaining to discrimination and unfair treatment. Such discussions and

awareness-building activities might promote positive mental health and enhance skills for

navigating complex social environments. In addition, the present data show that Filipino

Americans drink less when they perceive more racial/ethnic discrimination, which suggests the

use of different coping skills to deal with this stressor. To explore this relationship further it is

important to assess which coping behaviors are activated in response to particular stressors, and

to explore how alternative coping strategies can be generated to manage the stress of

discrimination.

While family and friends, as well as religiosity, are important sources of support, findings

from the current study suggest that assessing and enhancing protective factors, including family

and friend support and religiosity, may require different approaches to be effective in reducing

alcohol use. Social workers need to carefully assess social support factors and the presence of

various types of stressors within the specific cultural context in which they occur. For example,

talking about family conflict in the Asian American community may bring disgrace to the family.

Since in Asian culture maintaining the integrity of family is given great value, Asian Americans

tend to keep difficulties with their family secret. Overall, studies related to social support,

religiosity, and alcohol use are scarce, and more research is needed to better understand the role

111

of social support and religiosity as potential buffers against the negative effects of stress on

alcohol use.

Social work policy. Findings from the current study suggest four implications for social

work policy. The first entails addressing the needs of the fast-growing population of Asian

Americans. Although findings indicate that Asian Americans drink less than the general U.S.

population, increased alcohol consumption can be expected as they become acculturated to the

U.S. Furthermore, although in national studies Asian Americans generally have a lower rate of

drinking than the U.S. population as a whole, a recent study reported that the highest rates of

alcohol-related motor vehicle fatalities per 100,000 population were found among Asians (19.6),

while Whites (6.2) reported the lowest rates (USDHHS, 2010a). The high accident rate for Asian

Americans suggests that adequate primary and secondary prevention programs are not in place

for this segment of the population. The overarching goal of Healthy People 2010 is to reduce

health disparities among racial and ethnic groups (USDHHS, 2010b). The lack of appropriate

prevention and intervention programs for Asian Americans may be one such disparity. Given the

expanding population of Asian Americans and the increased risk of alcohol consumption in

younger generations, accessible culturally appropriate programs are urgently needed to educate

Asian Americans about the negative consequences of alcohol use.

A more diverse social work and health care workforce is needed to ensure access to

culturally and linguistically competent services (Ro, 2009). Currently, there are few Asian

American social workers suitable to provide such a service. One study reported that of a

representative sample of NASW members (N = 1,407), 86% were white, 5% were African

Americans, while only 2% were Asian Americans (NASW, 2003). Given 4.2% of total Asian

Americans in U.S. (Reeves & Bennett, 2004), Asian Americans are relatively underrepresented

112

in the social work workforce. Recruiting bilingual and bicultural Asian individuals to enter the

field of social workers would be an important step to addressing the needs of Asian Americans

elaborated above.

Recruitment to social work, however, is only a first step. Although there are no data on

numbers of Asian American social workers who work in the addictions field, it can be inferred

from studies of social workers at large that few have practices that involve direct work in the

addictions. Of the social work sample described above, only 16 % reported addictions as a

primary, secondary, or tertiary focus of their practice (Smith, 2005). Given the projected increase

in the number of Asian Americans, Asian American social workers will be increasingly valuable

in providing addiction treatment. To address the expanding need for services, NASW and other

social work organizations should focus efforts on increasing Asian representation in social work

and encouraging social workers to integrate addiction work in their practices.

The second implication of the current research is that more national studies on alcohol or

drug use among Asian American subgroups are needed to inform policy. The current study

confirms the value of conducting separate analyses for different Asian American subgroups in

order to understand the diverse experiences of these groups. Data on Asian subgroups is required

so that interventions can appropriately address the specific problems facing these groups.

A few national studies have begun to collect data that is more targeted to specific ethnic

groups (Ghosh, 2009), but there are several notable obstacles to overcome. Many national studies

have not included Asian Americans in their data analyses because their numbers are too small for

needed statistical power (Ghosh, 2009; Lee et al., 2003). Oversampling methods may need to be

used to achieve desirable sample sizes for data analysis (Ghosh, 2009). In addition, language

translation services are needed when national studies are conducted. National studies frequently

113

provide Spanish and English options, but only a few (including the NLAAS) have provided

Asian language translation services. Because of the absence of Asian language translation, many

federal surveys are likely to miss potential respondents and severely underestimate the

magnitude of alcohol use and related problems in this important and growing population.

Third, policies aimed at increasing the welfare of immigrants have historically focused on

assimilation—integrating various ethnic populations into the “American” way of life (Thurman,

Plested, Edwards, Chen, & Swaim, 2000). The findings of the current study do not support the

value of rapidly acculturating immigrants to American culture, but rather suggest that the

retention of cultural values and norms may protect the well-being of immigrants across

increasing length of stay in the U.S. and across immigrant generations. In other words, a

bicultural model may be optimal (Berry, 1998; Oh, Koeske, & Sales, 2002). The preservation of

aspects of original culture that are protective in dealing with acculturation and acculturative

stress may be especially important.

Finally, the current study supports the importance of policies to reduce discrimination

against immigrants. Since the early 1990’s, anti-immigrant sentiments have increased in the U.S.

(Gilbert & Terrell, 2005), suggesting that immigrants bring more harmful than positive

contributions to America. Although this study provided little direct evidence for the effect of

discrimination on alcohol use, we can assume that Asian Americans who are susceptible to such

sentiments internalize negative social views and experience psychological distress. This may

increase both the development of negative ethnic identity and risk for psychological dysfunction.

Policies to reduce racial discrimination, oppression, and prejudice need to be implemented to

help prevent such negative results of immigrants.

Recommendations for Future Research

114

There are a number of directions that future research can take with regards to studies on

alcohol use among Asian Americans. First, the present findings support the importance of

attending to the heterogeneity of substance use behaviors across Asian American subgroups

(Price et al., 2002; Wong et al., 2007). Although this study took into account the heterogeneity of

Asian cultures by conducting separate analyses for three different subgroups, only a single model

was applied within each group. Future studies examining different models are needed.

Future research on alcohol use and acculturation must use more comprehensive and

multidimensional measures of acculturation. In this study, language and generational status were

used as proxy measures of acculturation, but other aspects of ethnic identity and ethnic values

need to be included. Longitudinal research would also be helpful to better understand

acculturation processes in relation to alcohol use over time. In addition, in large-scale surveys of

nonclinical populations, it would be helpful to determine the degree to which drinking patterns

reflect problems and/or cultural norms. Future studies are needed to examine Asian subgroup

cultures in depth, and to identify drinking norms within cultures, and specific variables that

increase risk of alcohol use.

Another improvement in future research would be use of more nuanced and

comprehensive measures of drinking in order to more accurately estimate and compare subgroup

drinking patterns. No information was gathered in the current study about patterns of alcohol use,

changes in alcohol use over the lifespan, attitudes about personal alcohol intake, or the types of

alcohol consumed. In addition, the current NLAAS questionnaire assessed alcohol consumption

using self-reported quantity-frequency of 12-month use. More precision of measurement across a

longer time frame would be useful.

115

This study operationalized acculturative stressors as unfair treatment and perceived

racial/ethnic discrimination and family conflict, and the results for these measures only partially

supported the existence of the predicted relationship between acculturative stressors and alcohol

use. Future studies need to measure other acculturative stressors as well, stressors such as

occupational or residential discrimination, which may affect alcohol use. In the case of

discrimination, measuring intensity and types of experiences, such as episodic stress, daily

hassles, and chronic strain is a crucial step toward understanding the impact of discrimination on

well-being. Current results may be tentative until more work is completed using more culturally

appropriate and valid constructs, and future research is needed to replicate and extend these

findings before strong and valid conclusions can be made.

Future studies will be needed to simultaneously test the effects of socio-economic status,

gender, acculturation, acculturative stress, and social resources to better understand their

dynamic interrelationships in relation to drinking behavior. Additionally, future studies are

needed to investigate other possible protective factors such as ethnic enclaves and other social

resources.

Finally, other Asian subgroups need to be included in future studies potential high-risk

groups. According to SAMHA research (2004), 62% of Japanese Americans and 52% of Korean

Americans used alcohol over the past month, compared with only 25% of Filipino, Chinese, and

Vietnamese Americans. Inclusion of Japanese and Korean Americans, who appear to be at

greater risk for alcohol use, should be a focus for future research. Ideally, these future studies

should identify points for intervention for high-risk groups.

Conclusion

116

The goal of this dissertation was to test the effects of acculturation and acculturative

stress and to examine the moderating effects of social support and religiosity on alcohol use

among three Asian American subgroups, in an attempt to take into account heterogeneity of

Asian Americans. This study provided evidence for the acculturation model of alcohol use but

only partially supported the acculturative stress model to explain alcohol consumption as a

means to cope with stress. The acculturative stressors of unfair treatment, perceived racial/ethnic

discrimination, and family conflicts were not associated with alcohol use. If there is an

association between acculturative stress and drinking behavior, it is beyond what could be

demonstrated with the methodology used in the current study.

117

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Appendix A. Unfair treatment scale

In your day-to-day life how often have any of the following things happened to you?

1. You are treated with less courtesy than other people.