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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.
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,
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– 81 1948-1985/14/$12.00 DOI: 10.1037/a0036114
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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
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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.
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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.
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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.
References
Agency for Healthcare Research and Quality. (2013). 2012 national
healthcare quality and disparities reports. Rockville, MD: U.S. Gov-
ernment Printing Office.
Ashton, C. M., Haidet, P., Paterniti, D. A., Collins, T. C., Gordon, H. S.,
Malley, K. O., . . . Street, R. L. (2003). Racial and ethnic disparities in
the use of health services. Journal of General Internal Medicine, 18,
146 –152. doi:10.1046/j.1525-1497.2003.20532.x
Bodle, E. E., Islam, N., Kwon, S. C., Zojwalla, N., Ahsan, H., & Senie,
R. T. (2008). Cancer screening practices of Asian American physicians
in New York City. Journal of Immigrant and Minority Health, 10,
239 –246. doi:10.1007/s10903-007-9077-3
Bogart, L. M., Catz, S. L., Kelly, J. A., & Benotsch, E. G. (2001). Factors
influencing physicians’ judgments of adherence and treatment decisions
for patients with HIV disease. Medical Decision Making, 21, 28 –36.
doi:10.1177/0272989X0102100104
California Health Interview Survey (CHIS). (2005). Adult public use file.
Release 3.4. Los Angeles, CA: UCLA Center for Health Policy Re-
search.
Chae, D. H., Gavin, A. R., & Takeuchi, D. T. (2006). Smoking prevalence
among Asian Americans: Findings from the National Latino and Asian
American Study (NLAAS). Public Health Reports, 121, 755–763.
Chao, M. M., Chiu, C., Chan, W., Mendoza-Denton, R., & Kwok, C.
(2012). The model minority as a shared reality and its implication for
interracial perceptions. Asian American Journal of Psychology, 4, 84 –
92. doi:10.1037/a0028769
Chartier, K., & Caetano, R. (2010). Ethnicity and health disparities in
alcohol research. Alcohol Research and Health, 33, 152–160.
Cooper, L. A., Roter, D. L., Carson, K. A., Beach, M. C., Sabin, J. A.,
Greenwald, A. G., & Inui, T. S. (2012). The associations of clinicians’
implicit attitudes about race with medical visit communication and
patient ratings of interpersonal care. American Journal of Public Health,
102, 979 –987. doi:10.2105/AJPH.2011.300558
Cooper-Patrick, L., Gallo, J. J., Gonzales, J. J., Vu, H. T., Powe, N. R.,
Nelson, C., & Ford, D. E. (1999). Race, gender, and partnership in the
patient-physician relationship. Journal of the American Medical Asso-
ciation, 282, 583–589. doi:10.1001/jama.282.6.583
Cousin, G., Schmid Mast, M., Roter, D. L., & Hall, J. A. (2012). Concor-
dance between physician communication style and patient attitudes
predicts patient satisfaction. Patient Education and Counseling, 87,
193–197. doi:10.1016/j.pec.2011.08.004
Croskerry, P. (2009). Clinical cognition and diagnostic error: Applications
of a dual process model of reasoning. Advances in Health Sciences
Education, 14, 27–35. doi:10.1007/s10459-009-9182-2
Czopp, A. M. (2008). When is a compliment not a compliment? Evaluating
expressions of positive stereotypes. Journal of Experimental Social
Psychology, 44, 413– 420. doi:10.1016/j.jesp.2006.12.007
Dovidio, J. F., & Gaertner, S. L. (2000). Aversive racism and selection
decisions: 1989 and 1999. Psychological Science, 11, 315–319. doi:
10.1111/1467-9280.00262
Ely, J. W., Graber, M. L., & Croskerry, P. (2011). Checklists to reduce
diagnostic errors. Academic Medicine, 86, 307–313. doi:10.1097/ACM
.0b013e31820824cd
Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L.,
Iezzoni, L. I., & Banaji, M. R. (2007). Implicit bias among physicians
and its prediction of thrombolysis decisions for Black and White pa-
tients. Journal of General Internal Medicine, 22, 1231–1238. doi:
10.1007/s11606-007-0258-5
Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition:
Attitudes, self-esteem, and stereotypes. Psychological Review, 102,
4 –27. doi:10.1037/0033-295X.102.1.4
Gupta, A., Szymanski, D. M., & Leong, F. T. L. (2011). The “model
minority myth:” Internalized racialism of positive stereotypes as corre-
lates of psychological distress, and attitudes toward help-seeking. Asian
American Journal of Psychology, 2, 101–114. doi:10.1037/a0024183
Hall, G. C. N., & Yee, A. H. (2012). U.S. mental health policy: Addressing
the neglect of Asian Americans. Asian American Journal of Psychology,
3, 181–193. doi:10.1037/a0029950
Hammond, K. R. (1948). Measuring attitudes by error-choice: An indirect
method. The Journal of Abnormal and Social Psychology, 43, 38 – 48.
doi:10.1037/h0059576
Ho, M. Y., Lai, J. Y., & Cheung, W. Y. (2011). The influence of physicians
on colorectal cancer screening behavior. Cancer Causes and Control,
22, 1659 –1668. doi:10.1007/s10552-011-9842-4
Honda, K. (2004). Factors associated with colorectal cancer screening
among the U.S. urban Japanese population. American Journal of Public
Health, 94, 815– 822. doi:10.2105/AJPH.94.5.815
Jo, A. M., Maxwell, A. E., Wong, W. K., & Bastani, R. (2008). Colorectal
cancer screening among underserved Korean Americans in Los Angeles
County. Journal of Immigrant and Minority Health, 10, 119 –126. doi:
10.1007/s10903-007-9066-6
Johnson, R. L., Roter, D., Powe, N. R., & Cooper, L. A. (2004). Patient
race/ethnicity and quality of patient-physician communication during
medical visits. American Journal of Public Health, 94, 2084 –2090.
doi:10.2105/AJPH.94.12.2084
Jun, J., & Oh, K. M. (2013). Asian and Hispanic Americans’ cancer
fatalism and colon cancer screening. American Journal of Health Be-
havior, 37, 145–154. doi:10.5993/AJHB.37.2.1
Kahneman, D. (2003). A perspective on judgment and choice: Mapping
bounded rationality. American Psychologist, 58, 697–720. doi:10.1037/
0003-066X.58.9.697
Kahneman, D., & Klein, G. (2009). Conditions for intuitive expertise: A
failure to disagree. American Psychologist, 64, 515–526. doi:10.1037/
a0016755
Kahneman, D., Slovic, P., & Tversky, A. (1982). Judgment under uncer-
tainty: Heuristics and biases. New York, NY: Cambridge University
Press. doi:10.1017/CBO9780511809477
King, S. C. (2012). Cancer Screening—United States, 2010. MMWR.
Morbidity and Mortality Weekly Report, 61, 41– 45.
Lee, H. Y., Ju, E., Der Vang, P., & Lundquist, M. (2010). Breast and
cervical cancer screening among Asian American women and Latinas:
Does race/ethnicity matter? Journal of Women’s Health, 19, 1877–1884.
doi:10.1089/jwh.2009.1783
Lee, H. Y., Lundquist, M., Ju, E., Luo, X., & Townsend, A. (2011).
Colorectal cancer screening disparities in Asian Americans and Pacific
Islanders: Which groups are most vulnerable? Ethnicity & Health, 16,
501–518. doi:10.1080/13557858.2011.575219
Lee, J. W. R., Brancati, F. L., & Yeh, H.-C. (2011). Trends in the
prevalence of type 2 diabetes in Asians versus whites: Results from the
United States National Health Interview Survey, 1997–2008. Diabetes
Care, 34, 353–357. doi:10.2337/dc10-0746
Ma, G. X., Fang, C. Y., Feng, Z., Tan, Y., Gao, W., Ge, S., & Nguyen, C.
(2012). Correlates of cervical cancer screening among Vietnamese
American women. Infectious Diseases in Obstetrics and Gynecology,
2012, 1–11. doi:10.1155/2012/617234
Mast, M. S., Hall, J. A., & Roter, D. L. (2008). Caring and dominance
affect participants’ perceptions and behaviors during a virtual medical
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
80 IBARAKI, HALL, AND SABIN
http://dx.doi.org/10.1046/j.1525-1497.2003.20532.x
http://dx.doi.org/10.1007/s10903-007-9077-3
http://dx.doi.org/10.1177/0272989X0102100104
http://dx.doi.org/10.1037/a0028769
http://dx.doi.org/10.2105/AJPH.2011.300558
http://dx.doi.org/10.1001/jama.282.6.583
http://dx.doi.org/10.1016/j.pec.2011.08.004
http://dx.doi.org/10.1007/s10459-009-9182-2
http://dx.doi.org/10.1016/j.jesp.2006.12.007
http://dx.doi.org/10.1111/1467-9280.00262
http://dx.doi.org/10.1111/1467-9280.00262
http://dx.doi.org/10.1097/ACM.0b013e31820824cd
http://dx.doi.org/10.1097/ACM.0b013e31820824cd
http://dx.doi.org/10.1007/s11606-007-0258-5
http://dx.doi.org/10.1007/s11606-007-0258-5
http://dx.doi.org/10.1037/0033-295X.102.1.4
http://dx.doi.org/10.1037/a0024183
http://dx.doi.org/10.1037/a0029950
http://dx.doi.org/10.1037/h0059576
http://dx.doi.org/10.1007/s10552-011-9842-4
http://dx.doi.org/10.2105/AJPH.94.5.815
http://dx.doi.org/10.1007/s10903-007-9066-6
http://dx.doi.org/10.1007/s10903-007-9066-6
http://dx.doi.org/10.2105/AJPH.94.12.2084
http://dx.doi.org/10.5993/AJHB.37.2.1
http://dx.doi.org/10.1037/0003-066X.58.9.697
http://dx.doi.org/10.1037/0003-066X.58.9.697
http://dx.doi.org/10.1037/a0016755
http://dx.doi.org/10.1037/a0016755
http://dx.doi.org/10.1017/CBO9780511809477
http://dx.doi.org/10.1089/jwh.2009.1783
http://dx.doi.org/10.1080/13557858.2011.575219
http://dx.doi.org/10.2337/dc10-0746
http://dx.doi.org/10.1155/2012/617234
visit. Journal of General Internal Medicine, 23, 523–527. doi:10.1007/
s11606-008-0512-5
Miller, B. A., Chu, K. C., Hankey, B. F., & Reis, L. A. G. (2008). Cancer
incidence and mortality patterns among specific Asian and Pacific
Islander populations in the U.S. Cancer Causes and Control, 19, 227–
256. doi:10.1007/s10552-007-9088-3
Misra, R., Jiobu, K., Zhang, J., Liu, Q., Li, F., Kirkpatrick, R., & Ho, J.
(2013). Racial disparities in hepatitis B infection in Ohio: Screening and
immunization are critical for early clinical management. Journal
of Investigative Medicine, 61, 1121–1128.
Murphy, S. L., Xu, J., Kochanek, K. D., & Statistics, V. (2012). Deaths:
Preliminary data for 2010. National vital statistics reports. Hyattsville,
MD: National Center for Health Statistics. doi:10.4337/9781781004241
.00024
National Center for Health Statistics. (2011). Health, United States, 2010:
With special feature on death and dying. Washington, DC: U.S. Gov-
ernment Printing Office.
Nelson, H. D., Tyne, K., Naik, A., Bougatsos, C., Chan, B. K., & Hum-
phrey, L. (2009). Screening for breast cancer: An update for the U.S.
Preventive Services Task Force. Annals of Internal Medicine, 151,
727–737. doi:10.7326/0003-4819-151-10-200911170-00009
Pignone, M., Rich, M., Teutsch, S. M., Berg, A. O., & Lohr, K. N. (2002).
Screening for colorectal cancer in adults at average risk: A summary of
the evidence for the U.S. preventive services task force. Annals of
Internal Medicine, 137, 132–141. doi:10.7326/0003-4819-137-2-
200207160-00015
Sabin, J. A., & Greenwald, A. G. (2012). The influence of implicit bias on
treatment recommendations for 4 common pediatric conditions: Pain,
urinary tract infection, attention deficit hyperactivity disorder, and asth-
ma. American Journal of Public Health, 102, 988 –995. doi:10.2105/
AJPH.2011.300621
Sabin, J. A., Nosek, B. A., Greenwald, A. G., & Rivara, F. P. (2009).
Physicians’ implicit and explicit attitudes about race by MD race,
ethnicity, and gender. Journal of Health Care for the Poor and Under-
served, 20, 896 –913. doi:10.1353/hpu.0.0185
Shariff-Marco, S., Klassen, A. C., & Bowie, J. V. (2010). Racial/ethnic
differences in self-reported racism and its association with cancer-
related health behaviors. American Journal of Public Health, 100, 364 –
374. doi:10.2105/AJPH.2009.163899
Siy, J. O., & Cheryan, S. (2013). When compliments fail to flatter:
American individualism and responses to positive stereotypes. Journal
of Personality and Social Psychology, 104, 87–102. doi:10.1037/
a0030183
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2002). Unequal treatment:
Confronting racial and ethnic disparities in health care. Washington,
DC: The National Academies Press.
Smigal, C., Jemal, A., Ward, E., Cokkinides, V., Smith, R., Howe, H. L.,
& Thun, M. (2006). Trends in breast cancer by race and ethnicity:
Update 2006. CA: A Cancer Journal for Clinicians, 56, 168 –183.
doi:10.3322/canjclin.56.3.168
U.S. Cancer Statistics Working Group. (2013). United States cancer sta-
tistics: 1999 –2010 incidence and mortality web-based report. Atlanta,
GA: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention and National Cancer Institute. Retrieved
from www.cdc.gov/uscs
U.S. Census Bureau. (2008). The 2012 Statistical Abstract: Births, deaths,
marriages & divorces: Life expectancy. Washington, DC: U.S. Depart-
ment of Commerce. Retrieved from http://www.census.gov/compendia/
statab/cats/births_deaths_marriages_divorces/life_expectancy.html
U.S. Preventive Services Task Force. (2011). Guide to clinical preventive
services: Cancer. Retrieved from http://www.ahrq.gov/CLINIC/cps3dix
.htm#cancer
van Ryn, M., & Fu, S. S. (2003). Paved with good intentions: Do public
health and human service providers contribute to racial/ethnic disparities
in health? American Journal of Public Health, 93, 248 –255. doi:
10.2105/AJPH.93.2.248
Weisse, C. S., Sorum, P. C., Sanders, K. N., & Syat, B. L. (2001). Do
gender and race affect decisions about pain management? Journal of
General Internal Medicine, 16, 211–217. doi:10.1046/j.1525-1497.2001
.016004211.x
Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial
disparities in health: Evidence and needed research. Journal of Behav-
ioral Medicine, 32, 20 – 47. doi:10.1007/s10865-008-9185-0
Wong, S. T., Gildengorin, G., Nguyen, T., & Mock, J. (2005). Disparities
in colorectal cancer screening rates among Asian Americans and non-
Latino Whites. Cancer, 104, 2940 –2947. doi:10.1002/cncr.21521
Wu, T.-Y., Bancroft, J., & Guthrie, B. (2005). An integrative review on
breast cancer screening practice and correlates among Chinese, Korean,
Filipino, and Asian Indian American women. Health Care for Women
International, 26, 225–246. doi:10.1080/07399330590917780
Wu, T.-Y., West, B., Chen, Y.-W., & Hergert, C. (2006). Health beliefs
and practices related to breast cancer screening in Filipino, Chinese and
Asian-Indian women. Cancer Detection and Prevention, 30, 58 – 66.
doi:10.1016/j.cdp.2005.06.013
Yoo, G. J., Le, M. N., Vong, S., Lagman, R., & Lam, A. G. (2011).
Cervical cancer screening: Attitudes and behaviors of young Asian
American women. Journal of Cancer Education, 26, 740 –746. doi:
10.1007/s13187-011-0230-2
Yoo, H. C., Burrola, K. S., & Steger, M. F. (2010). A preliminary report on
a new measure: Internalization of the Model Minority Myth Measure
(IM-4) and its psychological correlates among Asian American college
students. Journal of Counseling Psychology, 57, 114 –127. doi:10.1037/
a0017871
Yoo, H. C., Gee, G. C., & Takeuchi, D. (2009). Discrimination and health
among Asian American immigrants: Disentangling racial from language
discrimination. Social Science and Medicine, 68, 726 –732. doi:10.1016/
j.socscimed.2008.11.013
Zolnierek, K. B. H., & Dimatteo, M. R. (2009). Physician communication
and patient adherence to treatment: A meta-analysis. Medical Care, 47,
826 – 834. doi:10.1097/MLR.0b013e31819a5acc
Received November 18, 2013
Revision received January 22, 2014
Accepted January 23, 2014 �
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81HEALTH STEREOTYPES AND CANCER DISPARITIES
http://dx.doi.org/10.1007/s11606-008-0512-5
http://dx.doi.org/10.1007/s11606-008-0512-5
http://dx.doi.org/10.1007/s10552-007-9088-3
http://dx.doi.org/10.4337/9781781004241.00024
http://dx.doi.org/10.4337/9781781004241.00024
http://dx.doi.org/10.7326/0003-4819-151-10-200911170-00009
http://dx.doi.org/10.7326/0003-4819-137-2-200207160-00015
http://dx.doi.org/10.7326/0003-4819-137-2-200207160-00015
http://dx.doi.org/10.2105/AJPH.2011.300621
http://dx.doi.org/10.2105/AJPH.2011.300621
http://dx.doi.org/10.1353/hpu.0.0185
http://dx.doi.org/10.2105/AJPH.2009.163899
http://dx.doi.org/10.1037/a0030183
http://dx.doi.org/10.1037/a0030183
http://dx.doi.org/10.3322/canjclin.56.3.168
http://www.cdc.gov/uscs
http://www.census.gov/compendia/statab/cats/births_deaths_marriages_divorces/life_expectancy.html
http://www.census.gov/compendia/statab/cats/births_deaths_marriages_divorces/life_expectancy.html
http://www.ahrq.gov/CLINIC/cps3dix.htm%23cancer
http://www.ahrq.gov/CLINIC/cps3dix.htm%23cancer
http://dx.doi.org/10.2105/AJPH.93.2.248
http://dx.doi.org/10.2105/AJPH.93.2.248
http://dx.doi.org/10.1046/j.1525-1497.2001.016004211.x
http://dx.doi.org/10.1046/j.1525-1497.2001.016004211.x
http://dx.doi.org/10.1007/s10865-008-9185-0
http://dx.doi.org/10.1002/cncr.21521
http://dx.doi.org/10.1080/07399330590917780
http://dx.doi.org/10.1016/j.cdp.2005.06.013
http://dx.doi.org/10.1007/s13187-011-0230-2
http://dx.doi.org/10.1007/s13187-011-0230-2
http://dx.doi.org/10.1037/a0017871
http://dx.doi.org/10.1037/a0017871
http://dx.doi.org/10.1016/j.socscimed.2008.11.013
http://dx.doi.org/10.1016/j.socscimed.2008.11.013
http://dx.doi.org/10.1097/MLR.0b013e31819a5acc
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.
REFERENCES
1. U.S. Bureau of Census. We the People: Asians in the United States Census
2000 Special Reports. Washington, DC: U.S. Government printing Office,
2004.
2. Caetano R, Clark CL, Tam T. Alcohol consumption among racial/ethnic
minorities: theory and research. Alcohol Health and Research World 1998;
22(4): 233–241.
3. Chae DH, Takeuchi DT, Barbeau EM, Bennett GG, Lindsey JC, Stoddard
AM, Krieger N. Alcohol disorders among Asian Americans: Associations
with unfair treatment, racial/ethnic discrimination, and ethnic identification
(the National Latino and Asian Americans Study, 2002–2003). Journal of
Epidemiology and Community Health 2008; 62:973–979.
4. Ja DY, Aoki B. Substance abuse treatment: Cultural barriers in the Asian-
American community. Journal of Psychoactive Drugs 1993; 25(1):61–71.
5. Grant BF, Dawson DA, Stinson FS, Chou SP, Dufour MC, Pickering RP.
The 12-month prevalence and trends in DSM-IV alcohol abuse and de-
pendence: United States, 1991–1992 and 2001–2002. Drug and Alcohol
Dependence 2004; 74(3):223–234.
6. Sakai JT, Ho PM, Shore JH, Risk NK, Price RK. Asians in the United
States: Substance dependence and use of substance-dependence treatment.
Journal of Substance Abuse Treatment 2005; 29(2):75–84.
7. Chi I, Lubben JE, Kitano HH. Differences in drinking behavior among three
Asian-American groups. Journal of Studies on Alcohol 1989; 50(1):15–23.
8. Zane N, Sasao T. Research on drug abuse among Asian Pacific Americans.
Drugs and Society 1992; 6(3):181–209.
9. Lum C, Corliss HL, Mays VM, Cochran SD, Lui CK. Differences in the
drinking behaviors of Chinese, Filipino, Korean, and Vietnamese college
students. Journal of studies on Alcohol and Drugs 2009; 70:568–574.
10. Wong FY, Halgin R. The ‘model minority:’ Bane or blessing for Asian
Americans? Journal of Multicultural Counseling and Development 2006,
34(1):38–49.
11. Dawson DA, Goldstein RB, Chou SP, Ruan WJ, Grant BF. Age at first
drink and the first incidence of adult-onset DSM-IV alcohol use disorders.
Alcoholism 2008; 32(12):2149–2160.
12. Grant BF, Dawson DA. Age at onset of alcohol use and its association
with DSM-IV alcohol abuse and dependence: Results from the National
Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse
1997; 9:103–110.
13. Gillman SE, Breslau J, Conron KJ, Koenen KC, Subraman SV, Zaslavsky
AM. Education and race-ethnicity differences in the lifetime risk of al-
cohol dependence. Journal of Epidemiology Community Health 2008;
62(3):224–230.
14. Harford TC, Muthen BO. The dimensionality of alcohol abuse and de-
pendence: A multivariate analysis of DSM-IV symptom items in the
National Longitudinal Survey of Youth. Journal of Studies on Alcohol
2001; 62(2):150–157.
15. Harford TC, Yi HY, Hilton ME. Alcohol abuse and dependence in college
and noncollege samples: A ten-year prospective follow-up in a national
survey. Journal of Studies on Alcohol 2006; 67(6):803–809.
16. Haber JR, Jacob T. Alcoholism risk moderation by a socio-religious di-
mension. Journal of Studies on Alcohol and Drugs 2007; 68(6):912–
922.
17. Kendler KS, Gardner CO, Prescott CA. Religion, psychopathology, and
substance use and abuse: A multimeasure, genetic-epidemiologic study.
American Journal of Psychiatry 1997; 154(3):322–329.
18. Brady KT, Sonne SC. The role of stress in alcohol use, alcoholism treatment,
and relapse. Alcohol Research and Health 1999; 23(4):263–271.
19. Courbasson CMA, Endler NS, Kocovski NL. Coping and psychological
distress for men with substance use disorders. Current Psychology 2002;
21(1):35–49.
20. D’Avanzo CE, Frye B, Froman R. Culture, stress and substance use in
Cambodian refugee women. Journal of Studies on Alcohol 1994; 55(4):
420–26.
21. Gong F, Takeuchi DT, Agbayani-Siewert P, Tacata L. Acculturation, psy-
chological distress, and alcohol use: Investigating the effects of ethnic
identity and religiosity. In Acculturation: Advances in Theory, Measure-
ment, and Applied Research. Chun KM, Organista PB, Marin G (Eds.).
Washington, DC: American Psychological Association, 2003.
22. Hendershot CS, Dliworth TM, Neighbors C, George WH. Differential
effects of acculturation on drinking behavior in Chinese- and Korean-
American college students. Journal of Studies on Alcohol and Drugs 2008;
69(1):121–128.
23. Hendershot CS, MacPherson L, Myers MG, Carr LG, Wall TL. Psychoso-
cial, cultural and genetic influences on alcohol use in Asian American
youth. Journal of Studies on Alcohol 2005; 66(2):185–195.
24. Hahm HC, Lahiff M, Guterman NB. Acculturation and parental attach-
ment in Asian-American adolescents’ alcohol use. J Adolesc Health 2003;
33(2):119–129.
25. Liu JM, Ong PM, Rosenstein C. Dual chain migration: Post-1965 Filipino
immigration to the United States. International Migration Review 1991;
25(3):487–513.
26. Gee GC, Chen J, Spencer MS, See S, Kuester OA, Tran D, Takeuchi D.
Social support as a buffer for perceived unfair treatment among Filipino
Americans: Differences between San Francisco and Honolulu. American
Journal of Public Health 2006; 96(4):677–684.
27. Gee GC, Delva J, Takeuchi DT. Relationships between self-reported unfair
treatment and prescription medication use, illicit drug use, and alcohol
dependence among Filipino Americans. American Journal of Public Health
2007; 96:933–940.
28. Mossakowski KN. Coping with perceived discrimination: Does ethnic iden-
tity protect mental health? Journal of Health and Social Behavior 2003;
44(3):318–331.
29. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th Ed. Washington, DC: American Psychiatric Associ-
ation, 1994.
30. Derogatis LR. SCL-90 Administration, Scoring and Procedures Manual-
I for R (revised) Version and Other Instruments of the Psychopathology
Rating Scale Series. Towson, MD: Clinical Psychometric Research, 1977.
31. Phinney JS. The Multigroup Ethnic Identity Measure: A new scale for use
with diverse groups. Journal of Adolescent Research 1992; 7(2):156–176.
32. StataCorp. Stata Statistical Software: Release 10. College Station, TX:
StataCorp LP, 2007.
33. U.S. Bureau of Census. State and County QuickFacts. 2008. Retrieved
March 02, 2010 from: http://quickfacts.census.gov/qfd/index.html
Copyright of American Journal of Drug & Alcohol Abuse is the property of Taylor & Francis Ltd and its
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express written permission. However, users may print, download, or email articles for individual use.
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-
21
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
REFERENCES
Almirol, E. B. (1982). Rights and obligations in Fili-
pino American families. Journal of Compar-
ative Family Studies, 13, 291-306.
Aoki, B., Ngin, C. P., Mo, B., & Ja, D. Y. (1989).
AIDS prevention models in Asian-American
communities. In V. M. Mays, G. W. Albee,
& S. F. Schnedier (Eds.), Primary prevention
of AIDS (pp. 290-308). Hanover, NH: Uni-
versity of New England Press.
Carrier, J. (2001). Some reflections on ethnographic
research on Latino and Southeast male ho-
mosexuality and HIV/AIDS. AIDS and Be-
havior, 5, 183-191.
Carrier, J., Nguyen, B., & Su, S. (1992). Vietnamese
American sexual behaviors & HIV infection.
The Journal of Sex Research, 29, 547-560.
Catania, J., Coates, T., & Stall, R. (1991). Changes
in condom use among homosexual men in
San Francisco. Health Psychology, 10(3),
190-199.
Centers for Disease Control and Prevention. (2001).
HIV/AIDS surveillance report. Atlanta, GA:
Author.
Chan, C. S. (1995). Issues of sexual identity in an
ethnic minority: The case of Chinese Ameri-
can lesbians, gay men, and bisexual people.
36 CHNG ET AL.
In A. R. D’Augelli & C. J. Patterson (Eds.),
Lesbian, gay, and bisexual identities over the
lifespan (pp. 86-101). New York: Oxford
University Press.
Choi, K-H., Coates, T. K., Catania, J. A., Lew, S., &
Chow, P. (1995a). High HIV risk among gay
Asian and Pacific Islander men in San Fran-
cisco. AIDS, 9, 306-308.
Choi, K.-H., Salazar, N., Lew, S., & Coates, T. J.
(1995b). AIDS risk, dual identity, and com-
munity response among gay Asian and Pa-
cific Islander men in San Francisco. In G. M.
Herek & B. Greene (Eds.), AIDS, identity,
and community: The HIV epidemic and les-
bians and gay men (pp. 115-134). Thousand
Oaks, CA: Sage.
Choi, K.-H., Kumekawa, E., Dang, Q., Kegeles, S.
M., Hays, R. B., & Stall, R. (1999). Risk and
protective factors affecting sexual behaviors
among young Asian and Pacific Islander Men
who have sex with men: Implications for
HIV prevention. Journal of Sex Education
and Therapy, 24, 47-55.
Choi, K.-H., Lew, S., Vittinghoff, J. A., Catania, J.
A., Barrett, D. C., & Coates, T. J. (1996).
The efficacy of brief group counseling in HIV
risk reduction among homosexual Asian and
Pacific Islander men. AIDS, 10, 81-87.
Choi, K.-H., Yep, G. A., & Kumekawa, E. (1998).
HIV prevention among Asian and Pacific Is-
lander American men who have sex with
men: A critical review of theoretical models
and directions for future research. AIDS Ed-
ucation and Prevention, 10(Suppl. A), 19-30.
Chng, C. L. & Geliga, J. (2000). Ethnic identity, gay
identity, sexual sensation seeking and HIV
risk taking among multiethnic men who have
sex with men. AIDS Education and Preven-
tion, 12(4), 326-339.
Chou, W.-S. (2001). Homosexuality and the cul-
tural politics of Tongzhi in Chinese society.
Journal of Homosexuality, 40, 27-46.
Dynes, W. R., & Donaldson, S. (1992). Asian homo-
sexuality. New York: Garland. Ekstrand, M.
L., & Coates, T. J. (1990). Maintenance of
safer behaviors and predictors of risky sex:
The San Francisco Men’s Health Study.
American Journal of Public Health, 80,
973-977.
Ford, C. S., & Beach, F. A. (1951). Patterns of sex-
ual behavior. New York: Harper & Row.
Fung, C. X. (1994). A lavender quest in latteland:
Searching for my queer Asian/Pacific Is-
lander brothers in Seattle. Unpublished
manuscript, Department of Asian American
Studies and Women’s Studies, University of
Washington, Seattle.
Gellert, G. A., Moore, D. F., Maxwell, R. M., Mai,
K. K., & Higgins, K. V. (1994). Targeted
HIV seroprevalence among Vietnamese in
Southern California. Genitourin Medicine,
70, 265-267.
Gilmore, N., & Somerville, M. (1994). Stigmatiza-
tion, scapegoating and discrimination in sex-
ually transmitted diseases: Overcoming them
and us. Social Science and Medicine, 39(9),
1339-1358.
Haour-Knipe, M., & Rector, R. (Eds). (1996).
Crossing borders: Migration, ethnicity and
AIDS. London: Taylor & Francis.
Hippler, M. (1989, September 14). Lavender
Godzillas. Bay Area Reporter, pp. 1-2..
Ho, P. S., & Tsang, A. K. (2000). Negotiating anal
intercourse in inter-racial gay relationships in
Hong Kong. Sexualities, 3, 299-322.
Houston-Hamilton, A., & Day, N. (1998). Preven-
tion and culture: Working downhill to
change HIV risk behavior. In J. W. Dilley &
R. Marks (Eds.), The UCSF AIDS Health
Project guide to counseling: Perspectives on
psychotherapy, prevention, and therapeutic
practice (pp. 101-119) San Francisco:
Jossey-Bass.
Lai, D. S. (1998a). Self-esteem and unsafe sex in Chi-
nese-American and Japanese-American gay
men. Unpublished doctoral dissertation, Cal-
ifornia School of Professional Psychology,
Alameda.
Lai, D. S. (1998b). Unpublished study. Richmond
Area of Multi-Services, San Francisco.
Landers, S., Kunches, L., Day, J., Fallas, G.,
Goldstein, R., Church, D., Wong, F. Y., &
Mayer K. (1998, June). Use of targeted out-
reach and OraSure test to measure HIV prev-
alence and associated risk among high-risk,
young men who have sex with men (MSM).
Paper presented at the 12th World AIDS
Conference, Geneva, Switzerland.
Lee, T. (2000, June 22- June 28). The gay Asian
American male—Striving to find an iden-
t i t y . R e t r i e v e d J u n e 8 , 2 0 0 1 , f r o m
www.asianweek.com.
Lemp, G. H., Hirozawa, A. M., Givertz, D., Nieri,
G. N., Anderson, L., Lindegren, M. L.,
Janssen, R., Katz, M. (1994). Seroprevalence
of HIV and risk behaviors among young ho-
mosexual and bisexual men: The San Fran-
cisco Berkeley Young Men’s Study. Journal
of the American Medical Association, 22,
449-454.
Liu, P., & Chan, C. S. (1996). Lesbian, gay, and bi-
sexual Asian-American and their families. In
J. Laird & R.-J. Green (Eds.), Lesbians and
gays in couples and families (pp. 137-152).
San Francisco: Jossey-Bass.
Manalansan, M. F., IV. (in press). Global divas: Fili-
pino gay men in New York City. Durham,
NC: Duke University Press.
SEXUAL HEALTH AMONG AAPI MSM 37
Marin, B. V., Gomez, C. A. & Tschann, J. M.
(1993). Condom use among men with sec-
ondary female sexual partners. Public Health
Reports, 108, 742-750.
Matteson, D. R. (1997). Bisexual and homosexual
behavior and HIV risk among Chinese-, Fili-
pino- and Korean-American men. The Jour-
nal of Sex Research, 34, 93-104.
Nagata, D. K. (1989). Japanese-American children
and adolescents. In J. Gibbs, L. Huang, &
Associates (Eds.), Children of color. San
Francisco: Jossey-Bass.
Nakajima, G. A., Chan, Y. H., & Lee, K. (1996).
Mental health issues for gay and lesbians
Asian Americans. In R. P. Cabaj & T. S. Stein
(Eds.), Textbook of homosexuality and men-
tal health (pp. 563-582). Washington, DC:
American Psychiatric Press.
Nemoto, T., Wong, F. Y., Ching, A., Chng, C. L.,
Bouey, P., Hendrickson, M., & Sember, R.
(1998). HIV seroprevalence, risk behaviors,
and cognitive factors among Asian and Pa-
cific Islander men who have sex with men: A
summary and critique of empirical studies
and methodological issues. AIDS Education
and Prevention, 10(Suppl. A), 31-47.
Ng, M. L., & Lau, M. P. (1990). Sexual attitudes in
the Chinese. Archives of Sexual Behavior, 9,
373-388.
Ona, F., Cadebes, C., & Choi, K. (1996). [Focus
groups with gay Asian and Pacific Islander
men in San Francisco]. Unpublished raw
data.
Osmond, D. H., Page, K., Wiley, J., Garret, K.,
Sheppard, H. W., Moss, A. R., Schrager, L.,
& Winkelstein, W. (1994). HIV infection in
homosexual and bisexual men 18 to 29 years
of age: The San Francisco Men’s Health
Study. American Journal of Public Health,
84, 1993-1997.
Price, R. K., Risk, N. K., Wong, M. M., & Klingle,
R. S. (2001, September). Drug use in Asian
American/Pacific Islander populations: Inci-
dence, prevalence, and data needs. Paper pre-
sented at the NIDA Bridging Science and
Culture to Improve Drug Abuse Research
Communities conference, Philadelphia.
Price, R. K., Risk, N. K., Wong, M. M., & Klingle,
R. S. (2002). Substance use and abuse in
Asian American and Pacific Islanders
(AAPIs): Preliminary results from three na-
tional surveys. Manuscript under review.
Rosenthal, E. (2002, April 12). Gays in China step
out, with one foot in the closet. The New
York Times.
Ross, M. W., Fernandez-Esquer, M. E., & Seibt, A.
(1995). Understanding across the sexual ori-
entation gap: Sexuality as culture. In D.
Landis & R. Bhagat (Eds.), Handbook of
Intercultural Training (2nd ed., pp.
414-430). Beverly Hills, CA: Sage.
Ruan, F. F. (1991). Sex in China: Studies in sexology
in Chinese culture. New York: Plenum.
Sabatier, R. (1996). Migrants and AIDS: Themes of
v u l n e r a b i l i t y a n d r e s i s t a n c e . I n
M.Haour-Knipe, & R. Rector (Eds). Cross-
ing borders: Migration, ethnicity and AIDS
(pp. 86-101). London: Taylor & Francis,
86-101.
San Francisco Department of Public Health. (1997).
AIDS surveillance report. San Francisco: Au-
thor.
Sanitioso, R. (1999). A social psychological perspec-
tive on HIV/AIDS and gay on homosexuality
active Asian men. Journal of Homosexuality,
36, 69-85.
Seage, G. R., Mayer, K. H., Lenderking, W. R.,
Wold, C., Gross, M., Goldstein, R., Cai, B.,
Hereen, T., Hingson, R., & Holmberg, S.
(1997). HIV and hepatitis B infection and
risk behavior and risk behavior in young and
bisexual men. Public Health Report, 112,
158-167.
Sin, E., Myers, T., Souza, T., & Gardner, L. (1994).
A needs assessment of the sexual behaviors
and attitudes of gay Asian men (and Asian
men who have sex with men). Unpublished
report, Gay Asian AIDS Project, Toronto,
Canada.
Sy, F., Chng, C. L., Choi, S., & Wong, F. (1998). Ep-
idemiology of HIV and AIDS among Asian
and Pacific Islander American, AIDS Educa-
tion and Prevention, 10(Suppl. A), 4-18.
Takaki, R. (1989). Strangers from a different shore:
A history of Asian Americans. Boston: Little,
Brown.
Takeuchi, D., & Young, K. N. J. (1994). Overview
of Asian and Pacific Islander Americans. In
N. Zane, D. T. Takeuchi, & K. N. J. Young
(Eds.), Confronting critical health issues of
Asian and Pacific Islander Americans (pp.
xxx). Thousand Oaks, CA: Sage.
Uba, L. (1994). Asian Americans. New York: Guild-
ford Press.
Wat, C. (2002). The making of a gay Asian commu-
nity: A oral history of pre-AIDS Los Angeles.
New York: Rowman & Littlefied.
Wong, F. Y., Chng, C. L., & Choi, K.-H. (Eds.).
(1998). HIV prevention among Asian and
Pacific Islander men who have sex with men:
Theories, research, applications, and poli-
cies. AIDS Education and Prevention,
10(Suppl. A).
Wong, F. Y., Chng, C. L., Ross, M. W., & Mayer, K.
H. (1998). Sexualities as social roles among
Asian and Pacific Islander gay, bisexual, les-
bian, and transgender individuals: Implica-
tions for community-based education and
38 CHNG ET AL.
prevention. Journal of Gay and Lesbian
Medical Association, 2, 157-166.
Wong, F. Y., Campsmith, M. L., Nakamura, G. V.,
Crepaz, N., & Begley, E. (2002). Reasons for
testing and care utilization among a group of
HIV-positive Asian Americans and Pacific Is-
landers in the U.S.: Findings from CDC’s
Supplement to HIV/AIDS Surveillance
(SHAS). Manuscript under review.
Wong, F. Y., & Edberg, M. C. (2000). Substance
use/HIV in 3 southeast DC communities
(NIDA-Funded Proposal, 2001-2005,
1R01DA14512-01). Washington, DC: Cen-
ter for Health Services Research and Policy,
George Washington University School of
Public Health and Health Services.
Wong, F. Y., & Edberg, M. C. (2001). Sexuality,
HIV/drug in 3 groups of Asian gay/bi
m e n / M S M ( N I D A – f u n d e d p r o p o s a l ,
2002-2007, 1R01DA/MH15623-01).
Washington DC: Center for Health Services
Research and Policy, George Washington
University School of Public Health and
Health Services.
World Health Organization. (1975). Education and
treatment in human sexuality: The training
of human professionals. (WHO Tech. Rep.
No. 572). Geneva, Switzerland: Author.
Yep, G. A. (1993). HIV/AIDS in Asian and Pacific Is-
lander communities in the U.S.: A review,
analysis, and integration. International
Quarterly of Community Health Education,
13(4), 293-315.
Yoshikawa, H., Chin, J., Kim, H., Hsueh, J., &
Rossman, E. (1999). Immigration, ethnicity
and acculturation in culturally anchored
HIV prevention for Asian/Pacific Islander
populations: A qualitative study 1999 (Ab-
stract 587). National HIV Prevention Con-
ference, Atlanta, GA.
Zane, N., & Kim, J. H. (1994). Substance use and
abuse. In N. Zane, D. T. Takeuchi, & K. N. J.
Young (Eds.), Confronting critical health is-
sues of Asian and Pacific Islander Americans
(pp. 316-343). Thousand Oaks, CA: Sage.
Zhang, K., Li, D., Li, H., & Beck, E. J. (1999).
Changing sexual attitudes and behavior in
China: implications for the spread of HIV
and other sexually transmitted diseases.
AIDS Care, 11, 581-589.
Zane, N., & Sasao, T. (1992). Research on drug
abuse among Asian Pacific Americans.
Drugs and Society, 6, 181-209.
Zane, N., Takeuchi, D. T., & Young, K. N. J. (Eds.).
(1994). Confronting critical health issues of
Asian and Pacific Islander Americans. Thou-
sand Oaks, CA: Sage.
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
http://search-proquest-com.jpllnet.sfsu.edu/dissertations/docview/1609204968/358ADE8925CD4861PQ/2?accountid=13802
http://search-proquest-com.jpllnet.sfsu.edu/dissertations/docview/1609204968/358ADE8925CD4861PQ/2?accountid=13802
O R I G I N A L P A P E R
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.
References
1. Ghosh C. Healthy people 2010 and Asian Americans or Pacific
Islanders: defining a baseline of information. Am J Public Health.
2003;93:2093–8.
2. Yu ESH, Liu WT. U.S. national health data on Asian Americans
and Pacific Islanders: a research agenda for the 1990s. Am J
Public Health. 1992;82:1645–52.
3. Chen MS, Hawks BL. A debunking of the myth of healthy Asian
Americans and Pacific Islanders. Am J Health Promot.
1995;9:261–8.
4. Douglas KC, Fujimoto D. Asian Pacific elders: implications for
health care providers. Clin Geriatr Med. 1995;11:69–82.
5. Kuo J, Porter K. Health status of Asian Americans: United States,
1992–94. Adv Data. 1998;298:1–16.
6. U.S. Census Bureau. We the people: Asians in the United States,
Census 2000 special reports. Available at http://www.census.gov/
prod/2004pubs/censr-17 . Updated 2004. Accessed 20 Oct
2010.
7. Mui AC, Shibusawa T. Asian American elders in the twenty-first
century: key indicators of well-being. 2008. p. 208.
8. Javier J, Huffman L, Mendoza F. Filipino child health in the
United States: do health and health care disparities exist? Prev
Chronic Dis. 2007;4:A36.
9. DeLaCruz F, McBride M, Compas L, Calixto PR, Van Derveer
C. White paper on the health status of Filipino Americans and
recommendations for research. Nurs Outlook. 2002;50:7–15.
10. Halfon N, Hochstein M. Life course health development: an
integrated framework for developing health, policy, and research.
Milbank Q. 2002; 80:433–79, iii.
11. Gomez S, Kelsey J, Glaser S, Lee M, Sidney S. Immigration and
acculturation in relation to health and health-related risk factors
among specific Asian subgroups in a health maintenance orga-
nization. Am J Public Health. 2004;94:1977–84.
12. Wise P. The transformation of child health in the United States.
Health affairs (Project Hope). 2004;23:9–25.
13. Fuller-Thomson E, Rotermann M, Ray JG. Elevated risk factors
for adverse pregnancy outcomes among Filipina-Canadian
women. J Obstet Gynaecol Can. 2010;32:113–9.
14. Cuasay LC, Sue Lee E, Orlander PP, Steffen-Batey L, Hans CL.
Prevalence and determinants of Type 2 Diabetes among Filipino-
Americans in the Houston, Texas metropolitan statistics area.
Diabetes Care. 2001;24:2054–8.
15. Chu KC, Chu KT. 1999–2001 cancer mortality rates for Asian
and Pacific Islander ethnic groups with comparisons to their
1988–1992 rates. Cancer. 2005;104(12 Suppl):2989–98.
470 J Immigrant Minority Health (2013) 15:462–471
123
http://www.census.gov/prod/2004pubs/censr-17
http://www.census.gov/prod/2004pubs/censr-17
16. Cho Y, Hummer R. Disability status differentials across fifteen
Asian and Pacific Islander groups and the effect of nativity and
duration of residence in the U.S. Soc Biol. 2001;48:171–95.
17. Kim G, Chiriboga DA, Jang Y, Lee S, Huang C, Parmelee P.
Heatlh status of older Asian Americans in California. J Am
Geriatr Soc. 2010;58:2003–8.
18. Fuller-Thomson E, Brennenstuhl S, Hurd M. Comparison of
disability rates among older adults in aggregated and separate
Asian American or Pacific Islander subpopulations. Am J Public
Health. 2010;101:94–100.
19. Helvik AS, Krokstad S, Tambs K. Socioeconomic inequalities in
hearing loss in a healthy population sample: The HUNT Study.
Am J Public Health. 2009;99(8):1376–8.
20. Rabinowitz PM, Kanta D, Sircar KD, Tarabar S, Galusha D,
Slade MD. Hearing loss among migrant agricultural workers.
J Agromedicine. 2005;10(4):9–17.
21. Roodhooft JM. Leading causes of blindness worldwide. Bull Soc
Belge Ophtalmol. 2002;283:19–25.
22. Anton SD, Manini TM, Milsom VA, et al. Effects of a weight loss
plus exercise program on physical function in overweight, older
women: a randomized controlled trial. Clin Interv Aging.
2011;6:141–9.
23. Paterson K, Hill K, Lythgo N. Stride dynamics, gait variability
and prospective falls risk in active community dwelling older
women. Gait Posture. 2011;33(2):251–5.
24. Nuru-Jeter AM, Thorpe RJ Jr, Fuller-Thomson E. Black-white
differences in self-reported disability outcomes in the U.S.: early
childhood to older adulthood. Public Health Rep. 2011;126(6):
834–43.
25. Gorman BK, Read JG. Gender disparities in adult health: an
examination of three measures of morbidity. J Health Social
Behav. 2006;47(2):95–110.
26. Macintyre S, Hunt K, Sweeting H. Gender differences in health:
are things really as simple as they seem? Soc Sci Med.
1996;42(4):617–24.
27. Murray JLC, Lopez AD. Alternative projections of mortality and
disability by cause 1990–2020: global burden of disease study.
Lancet. 1997;349(9064):1498–504.
28. Singh G, Miller B. Health, life expectancy, and mortality patterns
among immigrant populations in the United States. Can Journal
Public Health. 2004;95:I14–21.
29. Minkler M, Fuller-Thomson E, Guralnik J. Gradient of disability
across the socioeconomic spectrum in the United States. N Engl J
Med. 2006;355:695–703.
30. Mutchler JE, Pracash A, Burr JA. The demography of disability
and the effects of immigrant history: older Asians in the United
States. Demography. 2007;44:251–63.
31. Fuller-Thomson E, Yu B, Nuru-Jeter A, Guralnik J, Minkler M.
Basic ADL disability and functional limitation rates among older
Americans from 2000–2005: the end of the decline? J Gerontol
Ser A Biol Sci Medical Sci. 2009;64:1333–6.
32. Mui A, Kang SY. Acculturation stress and depression among
Asian immigrant elders. Soc Work. 2006;51:243–55.
33. Jane Field M, Jette MA, & of Medicine (U.S.). Committee on
disability in America: a new look, I. The future of disability in
America. 2007. p. 592.
34. U.S. Census Bureau. American Community Survey (ACS).
Available at: http://www.census.gov/acs/www/acs-php/quality_
measures_response_ 2006.php. Updated 2007. Accessed Jan
2011.
35. Use A—US Bureau of the Census. Design and methodology,
American Community Survey. Washington, US Government
Printing Office, 2009.
36. McBride M. Health and health care of Filipino American elders
[online]. Available at http:ororwww.standford.eduorgrouporethn
ogerorfilipino.html. Accessed Jan 2011.
37. Dey A, Lucas J. Physical and mental health characteristics of
U.S.- and foreign-born adults: United States, 1998–2003.
Advance data. 2006;369:1–19.
38. Frisbie W, Cho Y, Hummer R. Immigration and the health of
Asian and Pacific Islander adults in the United States. Am J
Epidemiol. 2001;153:372–80.
39. Merrill SS, Seeman TE, Kasl SV, Berkman LF. Gender differ-
ences in the comparison of self-reported disability and perfor-
mance measures. J Gerontol A Biol Sci Med Sci. 1997;52(1):
M19–26.
40. Rodrigues MA, Facchini LA, Thumé E, Maia F. Gender and inci-
dence of functional disability in the elderly: a systematic review.
Cad Saúde Pública Rio de Janeiro. 2009;25(Sup 3):S464–76.
41. Braveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS,
Metzler M, et al. Socioeconomic status in health research: one
size does not fit all. J Am Med Assoc. 2005;294:2879–88.
42. Schoeni RF, Martin LG, Andreski PM, Freedman VA. Persistent
and growing socioeconomic disparities in disability among the
elderly: 1982–2002. Am J Public Health. 2005;95:2065–70.
43. American Coalition for Filipino Veterans Inc. History. Available
at: http://usfilvets.tripod.com/id10.html. Accessed May 2012.
44. Williams DR. Socioeconomic differences in health: A review and
redirection. Soc Phsychol Q. 53: 81–99. 1990. In Williams DR,
Lavizzo-Mourey R, Warren RC. The concept of race and health
status in America. Public Health Rep 1994: 26–41.
45. Marmot MG, Adelstein AM, Bulusu L. Lessons from the study of
immigrant mortality. Lancet. 1984;112:1455–7.
46. Landale NS, Oropesa RS, Lanes DL, Gorman BK. Does Amer-
icanization have adverse effects on health?: stress, health habits,
and infant health outcomes among Puerto Ricans. Soc Forces.
1999;78:613–42.
47. Lee RD, Enmsminger ME, LaVeist TA. The responsibility con-
tinuum: never primary, coresident and caregiver heterogeneity in
the African American grandmother experience. Int J Aging
Human Dev. 2005;60:295–304.
48. Kington RS, Smith JP. Socioeconomic status and racial and
ethnic differences in functional status associated with chronic
diseases. Am J Public Health. 1997;87:805–10.
49. Ofstedal MB, Zimmer Z, Hermalin AI, Chan A, Chuang Y,
Natividad J, Tang Z. Short-term trends in functional limitation
and disability among older Asians: a comparison of five Asian
settings. J Cross Cult Gerontol. 2007;22:243–61.
50. Oza-Frank R, Stephenson R, Venkat Narayan KM. Diabetes
prevalence by length of residence among US immigrants.
J Immigrant Minority Health. 2011;13:1–8.
J Immigrant Minority Health (2013) 15:462–471 471
123
http://www.census.gov/acs/www/acs-php/quality_measures_response_
http://www.census.gov/acs/www/acs-php/quality_measures_response_
http://www.standford.eduorgrouporethnogerorfilipino.html
http://www.standford.eduorgrouporethnogerorfilipino.html
http://usfilvets.tripod.com/id10.html
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.
© 2016 Elsevier B.V. All rights reserved.
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.
References
[1] Pew Research Center, Social and Demographic Trends. The Rise of [2] Okazaki S. Influences of culture on Asian Americans’ sexuality. J Sex Res [3] Harman MJ, Johnson JA. Cross-cultural sex education: aspects of age, source, [4] Chung PJ, Borneo H, Kilpatrick SD, Lopez DM, Travis R, Lui C, et al. Parent- [5] Meneses LM, Orrell-Valente JK, Guendelman SR, Oman D, Irwin CE. Racial/ethnic [6] Kim JL, Ward LM. Silence speaks volumes: parental sexual communication [7] Kim JL. Asian American women’s retrospective reports of their sexual [8] National Asian Pacific American Women’s Forum. Reclaiming Choice, Broadening [9] Zhao JJ, Lau M, Flores G. 109. Communication between Asian-American [10] Hyeouk C, Hahm M, Barreto L. Asian American adolescents’ first sexual [11] Grunbaum JA, Lowry R, Kann L, Pateman B. Prevalence of health risk behaviors [12] Lee SJ, Rotheram-Borus MJ. Beyond the “model minority” stereotype: trends [13] Lowry R, Eaton DK, Brener ND, Kann L. Prevalence of health-risk behaviors [14] Schuster MA, Bell RM, Nakajima GA, Kanouse DE. The sexual practices of Asian [15] Centre for Public Health, Liverpool John Moores University. Prevention of sexually [16] Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual [17] Guilamo-Ramos V, Dittus P, Jaccard J, Goldberg V, Casillas E, Bouris A. The 13M. Frost et al. / Sexual & Reproductive Healthcare 10 (2016) 9–13 http://www.pewsocialtrends.org/2012/06/19/the-rise-of-asian-americans/2013 http://www.pewsocialtrends.org/2012/06/19/the-rise-of-asian-americans/2013 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0015 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0015 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0020 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0020 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0025 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0025 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0025 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0025 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0030 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0030 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0030 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0035 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0035 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0035 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0040 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0040 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0040 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0045 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0045 https://napawf.org/wp-content/uploads/2009/working/pdfs/NAPAWF_Reclaiming_Choice https://napawf.org/wp-content/uploads/2009/working/pdfs/NAPAWF_Reclaiming_Choice https://napawf.org/wp-content/uploads/2009/working/pdfs/NAPAWF_Reclaiming_Choice http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0050 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0050 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0050 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0050 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0055 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0055 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0055 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0060 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0060 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0060 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0065 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0065 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0065 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0070 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0070 http://www.jstor.org/stable/41639322 http://www.jstor.org/stable/41639322 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0075 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0075 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0075 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0080 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0080 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0080 https://www.nice.org.uk/guidance/ph3/evidence/evidence-briefing-update-prevention-of-sexually-transmitted-infections-stis-2006-65843250 https://www.nice.org.uk/guidance/ph3/evidence/evidence-briefing-update-prevention-of-sexually-transmitted-infections-stis-2006-65843250 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0085 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0085 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0085 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0090 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0090 http://refhub.elsevier.com/S1877-5756(16)30147-1/sr0090 Introduction 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 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 Asian immigrant communities have been crucial in expanding definitions of ISSN 1040-2659 print; ISSN 1469-9982 online/04/020149-08 © 2004 Taylor & Francis Ltd 150 Julie Sze
problems of Asian immigrant communities in the San Francisco Bay Area For example, the military pollution of Native Pacific Islander land in Hawaii Second, this essay considers the contributions made by the Asian immigrant The environmental justice movement emerged in the 1980s in the UnitedStates when community-based activities began to dovetail with the growing Asian American Activism for Environmental Justice 151
The environmental justice movement has several key start dates. It’s typically Another landmark date was the First National People of Color Environmental We, the people of color, gathered together at this multinational People of Color By beginning with “We, the people of color,” the Summit preamble enshrined The practical implication of constructing the movement in this way is that it Since the Summit, an increasing number of organizations have identified with 152 Julie Sze
is not surprising that Shin and Lee presented papers on occupational issues, since Over half of all textile and apparel workers in the United States are Asian Sociologists David Pellow and Lisa Park document the occupational health In both the San Francisco Bay Area and the East Coast of the United States, Boston’s Chinatown is squeezed between two medical institutions, which haveswallowed up one-third of the surrounding land in the last few decades. One Asian American Activism for Environmental Justice 153
a half of community mobilization and protest, the proposal was withdrawn. The new Major League baseball stadium in Chinatown. In immediate response, the place in Sunset Park, Brooklyn against a proposed sludge treatment plant. tions have focused on direct organizing on a wide range of issues that affect 154 Julie Sze
oil refinery and over 350 industrial facilities, including chemical plants and direct organizing on issues of community concern. One concrete result of the immigrant communities have organized around. The APEN is a key member of and environmental justice concern for Asian immigrant communities. Many an organization named Thimmakka, also based in the San Francisco Bay Area. Asian American Activism for Environmental Justice 155
languages, to communicate environmental and consumption issues such as Although the environmental justice movement has made great strides in thepast two decades, the leadership and the base of the movement still struggle mental justice movement is another example of the gap that still exists between RECOMMENDED READINGS
AsianWeek and Associated Press. 2000. “Philadelphia Chinatown Wins Stadium Fight.” November Brugge, D. Undated. “Environmental Justice and Asian Americans.” Asian American Revolutionary Bullard, R. (ed.). 1994. Unequal Protection: Environmental Justice and Communities of Color. San Francisco: Hofrichter, R. (ed.). 1993. Toxic Struggles: The Theory and Practice of Environmental Justice. Philadelphia: Geron, T. 2002. “The Greening of Asian Pacific America: APAs and the Environmental Justice Lavelle M. & M. Coyle. 1993. “Unequal Protection: The Racial Divide in Environmental Law.” Leong, A. 1995/1996. “The Struggle over Parcel C: How Boston’s Chinatown Won a Victory in 156 Julie Sze
Myers, S. 1993. “Proposal for Sludge Plant in Brooklyn Is Withdrawn.” and the High-Tech Global Economy. New York: New York University Press. Study in Environmental Justice.” Asian Law Journal 6: 189. � http://www.fs.fed.us/pnw/pubs/gtr534 � . States: A National Report on the Racial and Socio-Economic Characteristics of Communities with Hazardous Julie Sze is an Assistant Professor in American Studies at University of California at Davis. Health Promotion Practice 40S
There is growing interest in understanding individual Keywords: advocacy; Asian; minority health; com- 484762HPPXXX10.1177/1524839913484762H 1California State University, Fullerton, Fullerton, CA, USA Environmental Influences on Tobacco Use Among 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 Supplement Note: This article is published in the supplement Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 41S
>IntroductIon
Despites decades of aggressive educational and advo- Effective youth tobacco prevention must consider The purpose of this article is to describe the pro- efforts to develop and implement education programs >MetHod
This was a 3-year (2005-2008) descriptive study of the Data Collection Methods
Our community-informed assessment of environ- 42S HEaLTH PROMOTIOn PRacTIcE / September 2013
GIS mapping. GIS mapping involves the collection of Summaries from key informant interviews were Photovoice. Photovoice is a process that promotes com- Youth surveys. Due to a limitation in funding, a self- Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 43S
refusal including the lengthiness of the survey and dis- Data Collection, Management, and Analyses
Due to the multiple data activities and unique cbO all individual survey data were entered using SPSS between home address (obtained from individual sur- >results
as shown in Table 1, the overwhelming majority (n = Spatial analyses found associations between prox- Photographs and descriptions developed by the 44S HEaLTH PROMOTIOn PRacTIcE / September 2013
their community. One youth took a picture of a tobacco a smoke shop is on PcH (Pacific coast Highway), so as shown in figure 2, another youth selected and Driving by the ditch, people can see all the graffiti In contrast, when they went to Pasadena the youth table 1 Youth smoking in long beach
Anti- Pro- Both Pro ads center Library — 1 — table 2 tobacco Influences and Youth smoking in long beach
Variable Tobacco Influences p
Smoked in last 30 days in lifetime Yes 1.97 ns ship programs Yes 2.26 * *p < .05 Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 45S
This picture shows how clean Pasadena is and the Last, youth surveys indicated that perceptions of scores ranging from 0 to 18, the mean score was 5.8 Table 3 presents multiple logistic regression results >dIscussIon
We found that perceived environmental factors/ 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- Perhaps more important, youth were empowered to although many positive processes and outcomes that limit the generalizability and replicability of our Lessons Learned
ultimately, we hope this article describes how inno- table 3 Smoked 100 Cigarettes During Smoked in
Odds Adjusted Predictor variables **p < .01. ***p < .0001. Tanjasiri et al. / EnVIROnMEnTaL InfLuEncES On TObaccO uSE 47S
these assessments and recommendations are shared with furthermore, we credit the cbPR approach as essen- reFerences
banta, J. E., addison, a., Job, J. S., Yel, D., Kheam, T., & Singh, P. caspi, c. E., Kawachi, I., Subramanian, S. V., adamkiewicz, G., & cummings, K. M., & coogan, K. (1992). Organizing communities Difranza, J. R., norwood, b. D., Garner, D. W., & Tye, J. b. (1987). friis, R. H., Garrido-Ortega, c., Safer, a. M., Wankie, c., Griego, P. Israel, b. a., Schulz, a. J., Parker, E. a., & becker, a. b. (1998). Johnson, L. D., O’Malley, P. M., bachman, J. G., & Schulenberg, J. Kandula, n. R., Wen, M., Jacobs, E. a., & Lauderdale, D. S. (2009). Laws, M. b., Whitman, J., bowser, D. M., & Krech, L. (2002). Lew, R., & Tanjasiri, S. P. (2003). Slowing the epidemic of tobacco Lipton, R.I., banerjee, a., Levy, D., Manzanilla, n., & cochrane, Moore, L. V., Diez Roux, a. V., & brines, S. (2008). comparing Muggli, M. E., Pollay, R. W., Lew, R., & Joseph, a. M. (2002). Pierce, J. P., fiore, M. c., novotny, T. E., Hatziandreu, E. J., & Pierce, J. P., Gilpin, E. a., Emery, S. L., White, M. M., Rosbrook, Tanjasiri, S. P., Kagawa Singer, M. L., nguyen, T.-u., & foo, M. a. Tanjasiri, S. P., Lew, R., Kuratani, D. G., Wong, M., & fu, L. (2011). Wang, c., & burris, M. a. (1997). Photovoice: concept, methodol- Wildley, M. b., Young, R. L., Elder, J. P., De Moor, c., Wolf, K. R., Wong, M. M., Klingle, R. S., & Price, R. K. (2004). alcohol, Yel, D., bui, a., Job, J. S., Knutsen, S., & Singh, P. n. (2011).
SOCIO-CULTURAL FACTORS RELATED TO ALCOHOL USE
AMONG ASIAN AMERICANS
A dissertation submitted in partial fulfillment of the degree of Doctor of Philosophy 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 5 All rights reserved INFORMATION TO ALL USERS
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
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Copyright © 2010 by So-Youn Park This dissertation is dedicated to my mother, who has supported me financially,
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, Dr. Jeane W. Anastas my dissertation chair, allowed me the freedom to explore through Dr. Tazuko Shibusawa generously contributed time and her expertise in research on
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 A special thanks to Alexis Kuerbis, Camille Huggins, Soonhee Roh, Yeddi Park,
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,
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. I would like to extend my sincere thanks to Data Studio Service at Bobst Library at
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
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
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 Park, So-Youn. Socio-cultural factors related to alcohol use among Asian Americans. New York
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 CHAPTER II: Literature Review ………………………………………………………………………………….. 7
Alcohol Consumption ………………………………………………………………………………………………….. 7 Description of the Asian American Population ……………………………………………………………… 10 Filipinos ……………………………………………………………………………………………………………….. 12 Prevalence of Alcohol Use among Asian Americans ………………………………………………….. 14 Biological Factors ………………………………………………………………………………………………….. 19 Acculturation……………………………………………………………………………………………………… 20 34
Acculturative stress model for alcohol use …………………………………………………………. 35 Stress-buffering hypotheis: The role of social support and religisoity ……………………….. 40 Summary ………………………………………………………………………………………………………………….. 44 CHAPTER III: Method ……………………………………………………………………………………………….. 46
Statement of Research Questions and Explored Hypotheses …………………………………………… 46 Method of Sampling ……………………………………………………………………………………………. 52 Study Procedure ………………………………………………………………………………………………………… 52 Acculturation…………………………………………………………………………………………………….. 53 Discrimination………………………………………………………………………………………………. 54 Alcohol use ……………………………………………………………………………………………………… 56 Analytic Plan ……………………………………………………………………………………………………………. 57 CHAPTER IV: Results ………………………………………………………………………………………………… 63
Chateristics of the Sample ………………………………………………………………………………………….. 63 Addressing Multicollinearity ………………………………………………………………………………………. 68 CHAPTER V: Discussion …………………………………………………………………………………………….. 94
Alcohol Use ……………………………………………………………………………………………………………… 94 Chinese Americans …………………………………………………………………………………………….. 102 Study Limitations …………………………………………………………………………………………………….. 104 Social work practice ……………………………………………………………………………………………. 107 Conclusion ……………………………………………………………………………………………………………… 115
References …………………………………………………………………………………………………………………. 117
Appendices ………………………………………………………………………………………………………………… 1 48
Appendix A Unfair treatment scale ……………………………………………………………………………. 148 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 ……………………………… 45
Figure 2: Diagram of expected pathways among predictors of alcohol use for Asian Americans 50
Figure 3: Final model for Chinese Americans …………………………………………………………………… 76
Figure 4: Final model for Filipino Americans …………………………………………………………………… 85
Figure 5: Final model for Vietnamese Americans ……………………………………………………………… 92 1 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 2 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 3 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 4 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 5 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 6 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. 7 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 8 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 9 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 10 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 11 (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 12 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. 13 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 14 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, 15 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 16 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 17 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). 18 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. 19 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 20 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 21 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. 22 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. 23 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, 24 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, 25 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 26 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. 27 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. 28 Table 1: Summary of available studies on acculturation and alcohol use among Asian Americans (in reverse chronological order) Authors Acculturation
measure Liu & Asian Value Scale- Substance use Asian American male Chinese(n=40) Asian Americans Logistic regression
Despuses & Modified version language use, Alcohol per day College students European (n=110) Asian Americans MANCOVA
Wong et al. Place of birth (US proficiency
Use of alcohol in Cambodian, Laotian, 94 Those who were Logistic Regression
Su & Wong Language spoken Substance Use College students in a Those who preferred Correlation testing 29 eating American born vs. Foreign use of substance Sample size= 248 more likely to drink were more likely to between language at Hendershot, Suinn-Lew Asian Ever used alcohol past 30 days the past 2 weeks
College students in Chinese (n=223) Highly-acculturated ANOVA
Gong, Length of time in proficiency Alcohol Secondary data – the Filipino immigrants. Those who Multiple regression Chung Generation status Alcohol Adults Korean-Americans National Longitudinal U.S. born Asians Multiple regression 30 Alcohol abuse(lifetime) hazardous Epidemiological Study Yi & Daniel Modified version Use of alcohol- College student at the Students who were Logistic regression Akutsu, Sue, Contrasting Value Frequency & alcohol use University students Japanese (n=34) Acculturation was Hierarchical multiple Johnson, Place of birth (US residence in Frequency & Chinese, Japanese, Chinese, Japanese, T-test and ANOVA
Sue, Zane, English-language Frequency & College students Acculturation was MANOVA 31 Socialization with (Parents/ alcohol use Korean (n=24) drinking levels. 32
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 33
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, 34 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 35
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 36
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 37
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 38
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 39
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. 40
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 41
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 42
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). 43
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). 44
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. 45 Figure 1. Proposed conceptual model for Asian Americans’ alcohol use
46 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.
47
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. 48 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. 49
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. 50 Figure 2. Diagram of expected pathways among predictors of alcohol use for Asian 51 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 52 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 53 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. 54 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 55 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 56 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. 57 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 58 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. 59 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. 60 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. 61 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 62 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). 63 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 Chinese Filipino Vietnamese Unweighted N 600 508 520 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 64 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 65 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.
. 66 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
67 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 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 *p < .05, **p < .01, ***p < .001 n.s.: not significant 68 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 69 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. 70 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 71 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.
72 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 73 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 74 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 75 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 Perceived Racial/ethnic Family 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.
76 Figure 3: Final Model for Chinese Americans
B: logistic regression unstandardized coefficients. b: OLS Regression unstandardized coefficients. 77 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. 78 Table 6. Ordinal logistic regression results for alcohol use among Filipino Americans
Variable Odds ratio P-value 95% CI 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
79 Cut1 1.344 -2.22-4.91
Cut2 5.68 1.87-9.49 *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.
80
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 81 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. 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.
82 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 83 level of religiosity are better able to cope with unfair treatment and perceived racial/ethnic 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 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 84 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 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 *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.
85 Figure 4. Final Model for Filipino Americans
86 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.
87 Table 8. Ordinal logistic regression results for alcohol use among Vietnamese Americans
Variable Odds ratio P-value 95% CI 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
88 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 89 Hypothesis 4.2: Acculturation has an indirect effect on alcohol use through family conflict. It is 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 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. 90 level of religiosity are better able to cope with unfair treatment and perceived racial/ethnic 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 7.1: Acculturation has a direct effect on discrimination. It is hypothesized that Asian 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 91 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 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 *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.
92 Figure 5. Final Model for Vietnamese Americans
B: logistic regression unstandardized coefficients. b: OLS regression unstandardized coefficients. 93 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 No Partially No Hypothesis 4.1 No Hypothesis 5.1 No Partially No Hypothesis 6.1 No No Yes No Yes No 94 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 95 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 96 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. 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 97 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 98 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 99 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 REFERRENCES
Adler, N. E., Boyce, T., Chesney, M. A., Cohen, S., Folkman, S., Kahn, R. L., & Syme, S. L
(1994). Socioeconomic status and health: The challenge of the gradient. American
Psychologist, 49, 15-24.
Agarwal, D. P. (1996). Racial/ethnic and gender differences in alcohol use and misuse. In T.
Peters (Ed.), Alcohol misuse: A European perspective (pp. 23-40). London: Harwood
Academic Publishers.
Alegria, M. Vila, D., Woo, M., Canino, G., Takeuchi, D., Vera, M., …Shrout, P. (2004). Cultural
relevance and equivalence in the NLAAS instrument: Integrating etic and emic in the
development of cross-cultural measures for a psychiatric epidemiology and services study
of Latino. International Journal of Methods in Psychiatric Research, 13(4), 270-288.
Akutsu, P. D., Sue, S., Zane, N. W. S., & Nakamura, C. Y. (1989). Ethnic differences in alcohol
consumption among Asians and Caucasians in the United States: An investigation of
cultural and physiological factors. Journal of Studies on Alcohol, 50, 261-267.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental
Disorders (4th ed). Washington, D.C: American Psychiatric Association.
Anderson, J., Moeschberger, M., Chen, M. S., Jr., Kunn, P., Wewers, M. E., & Guthrie, R.
(1993). An acculturation scale for Southeast Asians. Social Psychiatry and Psychiatic
Epidemiology, 28, 134-141.
Archer, L., Dawson, D., Grant, B. (1995). What if Americans drank less? The potential effect on
the prevalence of alcohol abuse and dependence. American Journal of Public Health,
85(1), 61-66. 118 Arliss, R. M. (2007). Cigarette smoking, binge drinking, physical activity, and diet in 123 Asian
American and Pacific Islander community college students in Brooklyn, New York.
Journal of Health Community, 32(1), 71-84.
Asian American Federation of New York (2004). Recent immigration, limited English skills and
poverty common among Korean American New Yorkers, Census analysis shows.
Retrieved November 19, 2007 from http://www.aafny.org/proom/pr/pr20040421.asp.
Au, J. G., & Donaldson, S. I. (2000). Social influences as explanations for substance use
differences among Asian-American and European-American adolescents. Journal of
Psychoactive Drugs, 32(1), 15-23.
Austin, G., Prendergast, M., & Lee, H. (1989). Substance abuse among Asian American youth.
Prevention Research Update, 5, 1-25.
Barnes, J. S., & Bennett, C. E. (2002). The Asian population: 2000. Retrieved August 12, 2009,
from http://www.census.gov/prod/2002pubs/c2kbr01-16 .
Berkman, L. F., & Breslow, L. (1983). Health and ways of living: The Alameda County study.
New York: Oxford University Press.
Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology: An
International Review, 46, 5-68.
Berry, J. W. (1998). Acculturation and health: Theory and research. In S. S. Kazarian, & D. R.
Evans (Eds.), Cultural clinical psychology: Theory, research, and practice (pp. 39-57).
New York: Oxford University Press. Berry, J. W. (2003). Conceptual approaches to acculturation. In K. M.Chun, P. B. Organista, &
G. Marin (Eds.), Acculturation: Advance in theory, measurement, and applied research
(pp. 17-38). Washington, DC: American Psychological Association. 119 Berry, J. W. (2006). Stress perspectives on acculturation. In D. L. San & J. W. Berry (Eds.), The
Cambridge handbook of acculturation psychology (pp. 43-57). Cambridge, United
Kingdom: Cambridge University Press.
Bhattacharya, G. (1998). Drug use among Asian-Indian adolescents: Identifying protective/risk
factors. Adolescence, 33(129), 169-183.
Bhattacharya, G. (2002). Drug abuse risks for acculturating immigrant adolescents: Case study
of Asian Indians in the United States. Health and Social Work, 27(3), 175-183.
Bhattacharya, G. (2005). Social capital and HIV risks among acculturating Asian Indian men in
New York City. AIDS Education and Prevention, 17(6), 555-567.
Black, S., & Markides, K. S. (1993). Acculturation and alcohol consumption in Puerto Rican,
Cuban-American, and Mexican-American women in the United States. American Journal
of Public Health, 83, 890-893.
Braveman, P. A., Cubbin, C., Egerter, S., Chideya, S., Marchi, K. S., Metzler, M., & Posner, S.
(2005). Socio-economic status in health research: One size does not fit all. Journal of the
American Medical Association, 295, 2879-2888.
Breslow, R. A., Guenther, P. M., & Smothers, B. A. (2006). Alcohol drinking patterns and diet
quality: The 1990-2000 National Health Nutrition Examination Survey. American
Journal of Epidemiology, 163(4), 359-366.
Brook, J. S., Whiteman, M., Balka, E. B., Win, P. T., & Gursen, M. D. (1998). Drug use among
Puerto Ricans: Ethnic identity as a protective factor. Hispanic Journal of Behavioral
Science, 20, 241-254. 120 Brooks, P. J., Enoch, M. A., Goldman, D., Li, T. K., & Yokoyama, A. (2009). The alcohol
flushing responses: an unrecognized risk factor for esophageal cancer from alcohol
consumption. PLoS Medicine, 6(3), e50. doi:10.1371/journal.pmed.1000050
Brown, J. M., Council, C. L., Penne, M. A., & Gfroerer, J. C. (2005). Immigrants and Substance
Use: Findings from the 1999-2001 National Survey on Drug Use and Health. (DHHS
Publication No. SMA 04-3909, Analytic Series A-23). Rockville, MD: Substance Abuse
and Mental Health Services Administration, Office of Applied Studies. Retrieved August
19, 2008 from http://www.oas.samhsa.gov/immigrants/immigrants
Brown, S.D., Brady, T., Lent, R. W., Wolfert, J., & Hall, S. (1987). Perceived social support
among college students: Three studies of the psychometric characteristics and counseling
uses of the Social Support Inventory. Journal of Counseling Psychology, 34, 337-354.
Buki, L. P., Ma, T-C., Strom, R. D., & Strom, S. K. (2003). Chinese immigrant mothers of
adolescents: Self-perceptions of acculturation effects on parenting. Cultural Diversity and
Ethnic Minority Psychology, 9(2), 127-140.
Cabassa, L. J. (2003). Measuring acculturation: Where we are and where we need to go.
Hispanic Journal of Behavioral Sciences, 25(2), 127-146.
Caetano, R., & Clark, C. L. (2003). Acculturation alcohol consumption, smoking, and drug use
among Hispanics. In K. M.Chun, P. B. Organista, & G. Marin (Eds.), Acculturation:
Advance in theory, measurement, and applied research (pp. 223-240). Washington, DC:
American Psychological Association.
Caetabo, R., & Medina Mora, M. E. (1988). Acculturation and drinking pattern people of
Mexican descent in Mexico and the United States. Journal of Studies on Alcohol, 49,
462-471. 121 Caetano, R., & Mora, M. E. M. (1988). Acculturation and drinking among people of Mexican
descent in Mexico and the United States. Journal of Studies on Alcohol, 49(5), 462-471.
Caetano, R., Clark, C. L., & Tam, C. (1998). Alcohol consumption among racial/ethnic
minorities: Theory and research. Alcohol Health & Research World, 22(4), 233-239.
Caetano, R., Ramisetty-Mikler, S., Vaeth, P. A. C., & Harris. T. R. (2007). Acculturative stress,
drinking, and intimate partner violence among Hispanic couples in the U.S. Journal of
Interpersonal Violence, 22, 1431-1447.
Caetano, R., Tam, T., Greenfield, T., Cherpitel, C., & Midanik, L. (1997). DSM-IV alcohol
dependence and drinking in the U.S. population: A risk analysis. AEP, 7(8), 524-548.
Canino, G. J., Burman, A., & Caetano, R. (1992). The prevalence of alcohol abuse and/or
dependence in two Hispanic communities. In J. E. Helzer & G. Canino (Eds.),
Alcoholism in North America, Europe, and Asia (pp. 131-155). New York, NY: Oxford
University Press. Cappell, H., & Greely, J. (1987). Alcohol and tension reduction: An update on research and
theory. In H. T. Blane, & K. E. Leonard (Eds.), Psychological theories of drinking and
alcoholism (pp. 227-271). New York: Guildford Press.
Castillo, L. G., Cano, M. A., Chen, S. W., Blucker, R., & Olds, V. (2008). Family conflict and
intragroup marginalization as predictors of acculturative stress in Latino college students.
International Journal of Stress Management, 15, 43-52.
Castillo, L. G., Conoley, C. W., Brossart, D. F., & Quiros, A. (2007). Construction and
validation of the intragroup marginalization inventory. Cultural Diversity and Ethnic
Minority Psychology, 12, 232-240. 122 Center for Disease Control and Prevention. (2006). Alcohol and public health. Retrieved April 2,
2009 from http://www.cdc.gov/alcohol.
Center for Health Workforce Studies and National Association of Social Workers (2006).
Licensed social workers in the United States, 2004: Supplement. Retrieved April 30,
2009 from http://workforce.socialworkers.org/studies/supplemental/supplement_ch2
Center for Multicultural Mental Health Research (2009). National Latino and Asian American
Study. Retrieved May 29, 2009 from http://www.multiculturalmentalhealth.org/nlaas.asp
Cervantes, R.C., Padilla, A. M., & de Snyder, N. S. (1991). The Hispanic Stress Inventory: A
culturally relevant approach to psychological assessment. Psychological Assessment, 3,
438-447.
Chae, D. H., Takeuchi, D. T., Barbeau, E. M., Bennett, G. G., Lindsey, J. C., Stoddard, A. M., &
Krieger, N. (2008). Alcohol disorders among Asian Americans: association with unfair
treatment, racial/ethnic discrimination, and ethnic identification (the National Latino and
Asian American Study, 2002-2003). Journal of Epidemiological Community Health, 62,
973-979.
Chang, D. F. (2002). Understanding the rates and distribution of mental disorders. In K. S.
Kurasaki, S. Okazaki, & S. Sue (Eds.), Asian American mental health: Assessments
theories and methods (pp. 9-27). New York: Kluwer Academic/ Plenum.
Chavez, D. V., Moran, V. R., Reid, S. L., & Lopez, M. (1997). Acculturative stress in children:
A modification of the SAFE scale. Hispanic Journal of Behavioral Sciences, 19, 34-44.
Chawla, N., Neighbors, C., Lewis, M. A., Lee, C. M., & Larimer, M. E. (2007). Attitudes and
perceived approval of drinking as mediators of the relationship between the importance
of religion and alcohol use. Journal of Studies on Alcohol and Drugs, 68(3), 410-418. 123 Chen, H., Mallinckrodt, B., & Mobley, M. (2002). Attachment pattern of East Asian
international students and source of perceived social support as moderators of the impact
of U.S. racism and cultural distress. Asian Journal of Counseling, 9(1-2), 27-48.
Chen, W. W. (2003). Drug abuse prevention research for Asian and Pacific Islander Americans.
In Z. Sloboda & W. J. Bukoski (Eds.), Handbook of drug abuse prevention: Theory,
science, and practice (pp. 411-426). New York: Kluwer Academic/Plenum.
Cheng, C. (1997). Are Asian American Employees a model minority or just a minority? Journal
of Applied Behavioral Science, 33(3), 277-290.
Chi, I., Kitano, H. H. L., & Lubben, J. E. (1988). Male Chinese drinking behavior in Los
Angeles. Journal of Studies on Alcohol, 49(1), 21-25.
Chi, I., Lubben, J. E., & Kitano, H. H. L. (1989). Differences in drinking behavior among three
Asian-American groups. Journal of Studies on Alcohol, 50(1), 15-23.
Chin, K., Lai, T., & Rouse, M. (1991). Social adjustment and alcoholism among Chinese
immigrants in New York City. Substance Use & Misuse, 25, 709-730.
Chung, Y. W. (1990-1991). Ethnicity and alcohol/drug use revisited: A framework for future
research. The International Journal of the Addictions, 25(5A & 6A), 581-605.
Chung, S. (2002). The role of generational status in alcohol consumption and alcohol-related
disorders: A study of a national sample of United Statues-born vs. foreign-born Chinese-,
Japanese-, and Korean-Americans (Doctoral dissertation). AAT 3068448
Cohen, S., & Lemay, E. P. (2007). Why would social networks be linked to affect and health
practices? Health Psychology, 26 (4), 410-417.
Cohen, S., & Pressman, S. (2004), The stress-buffering hypothesis. In N. Anderson (Ed.),
Encyclopedia of health and behavior. Thousand Oaks, CA: Sage Publications. 124 Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis.
Psychological Bulletin, 98(2), 310-357.
Constantine, M. G., & Sue, D. (2006). Factors contributing to optimal human functioning in
people of color in the United States. The Counseling Psychologist, 34, 228-244.
Cross National Collaborative Group (1992). The changing rate of major depression. Journal of
the American Medical Association, 268, 3098-3105.
Culler, I., Arnod, B., & Maldonado, R. (1995). Acculturation rating scale for Mexican
Americans-II: A revision of the original ARSMA scale. Hispanic Journal of Behavioral
Health Science, 17(3), 275-304.
D’Avanzo, C. E., Frye, B., & Froman, R. (1994). Culture, stress and substance use in Cambodian
refugee women. Journal of Studies on Alcohol, 55, 420-426.
Dawson, D., Archer, L., & Grant, B. (1996). Reducing alcohol-use disorders via decreased
consumption: a comparison of population and high-risk strategies. Drug and Alcohol
Dependence, 42, 39-47.
Dawson, D., Grant, B., & Hartford, T. (1995). Variation in the association of alcohol
consumption with five DSM-IV alcohol problem domains. Alcohol Clinical Experimental
Research, 19, 6-74.
Despues, D., & Friedman, H. (2007). Ethnic differences in health behavior among college
students. Journal of Applied Social Psychology, 37(1), 131-142.
Dufour, M. C. (1999). What is moderate drinking: Defining “drinks” and drinking levels. Alcohol
Research & Health, 23(1), 5-14.
Ellison, C. G., & Levin, J. S. (1998). The religion-health connection: evidence, theory, and future
directions. Health Education and Behavior, 25(6), 700-720. 125 Ellison, C. G., Boardman, J. D., Williams, D. R., & Jackson, J. S. (2001). Religious involvement,
stress, and mental health: findings from the 1995 Detroit area study. Social Forces, 80(1),
215-249.
Epstein, J. A., Botvin, G. J., Dusenbury, L., & Diaz, T. (1997). Validation of an acculutration
measure for Hispanic adolescents. Pscyhological Reports, 79, 1075-1079.
Ericsson, N. R., Campos, J., & Tran, H. (1991). PC-Give and David Hendry’s econometric
methodology. Retreived May 1, 2010 from
http://www.federalreserve.gov/pubs/ifdp/1991/406/ifdp406
Evans-Campbell, Liconclo, K. D., & Tateuchi, D. T.(2007). Race and mental health: Past
debates, new opportunities. In W. R. Avision, J.D. McLeod, & B.A. Pescosolido (Eds.)
Mental health, social mirror (pp. 169-190). New York, NY: Springer.
Farver, J. M., Xu, Y., Bhadha, B. R., & Narang, S. (2007). Ethnic identity, acculturation,
parenting beliefs, and adolescent adjustment: A comparison of Asian Indian and
European American families. Merrill-Palmer Quarterly, 53(2), 184-215.
Finch, B. K. & Vega, W. A. (2003). Acculturation stress, social support, and self-rated health
among Latinos in California. Journal of Immigrant Health, 5(3), 109-117.
Fong, T. W. & Tsuang, J. (2007). Asian-Americans, addictions, and barriers to treatment.
Psychiatry, 4(11), 51-58.
Gallagher-Thompson, D., Tazeau, Y. N., Basilio, L., Hansen, H., Polich, T. Menendez, A., &
Villa, M. L. (1997). The relationship of dimensions of acculturation to self-reported
depression in older, Mexican-American women. Journal of Clinical Neuropsychology, 3,
123-127. 126 Garcia (2005). Buscando trabajo: Social networking among immigrants from Mexico to the
United States. Hispanic Journal of Behavioral Health Sciences, 27, 3-22.
Gee, G. C., Chen, J., Spencer, M. S., See, S., Kuester, O. A., Tran, D., & Takeuchi, D. (2006).
Social support as a buffer for perceived unfair treatment among Filipino Americans;
Differences between San Francisco and Honolulu, American Journal of Public Health,
96(4), 677-684.
Gee, G. C., Delva, J., &Takeuchi, D. (2007). Relationships between self-reported unfair-
treatment and prescription medication use, illicit drug use, and alcohol dependence
among Filipino Americans. American Journal of Public Health, 97(5), 933-940.
Gee, G. C., & Ro, A. (2009). Racism and discrimination. In C. Trinh-Shevrin, N. S. Islam, & M.
J. Rey, Asian Americans communities and health: context, research, policy, and action
(pp. 364-402). San Francisco, CA: Jossey-Bass.
Ghosh, C. (2009). Asian Americans health research: Baseline data and funding. In C. Trinh-
Shevrin, N. S. Islam, & M. J. Rey, Asian Americans communities and health: context,
research, policy, and action (pp. 73-103). San Francisco, CA: Jossey-Bass.
Gilbert, M. J. (1985). Alcohol related practices, problems and norm among Mexican Americans:
An overview. In D. Spiegler, D. Tate, S. Aitken, & C. Christian (Eds.), Alcohol use
among U.S. ethnic minorities: Proceedings of a conference on the epidemiology of
alcohol use and abuse among ethnic minority group. (pp. 115-134). (National Institute on
Alcohol Abuse and Alcoholism Research Monograph No.18). Bethesda, MD: DHHS
Gilbert, M. J., & Cervantes, R. C. (1986). Patterns and practices of alcohol use among Mexican
Americans: A comprehensive review. Hispanic Journal of Behavioral Science, 8, 1-60. 127 Gilbert, N., & Terrell, P. (6th Ed.) (2005). Dimensions of social welfare policy. New York:
Pearson.
Gong, F., Takeuchi, D. T., Agbayani-Siewert, P., & Tacata, L. (2003). Acculturation,
psychological distress and alcohol use: Investigation the effects of ethnic identity ad
religiosity. In K. M.Chun, P. B. Organista, & G. Marin (Eds.), Acculturation: Advance in
theory, measurement, and applied research (pp. 189-206). Washington, DC: American
Psychological Association.
Gordon, M. M. (1964). Assimilation in American Life: The role of race, religion, and national
origin. New York, Oxford University Press.
Goto, S. G., Gee, G. C., & Takeuchi, D. T. (2002). Strangers still? The experience of
discrimination among Chinese American Journal of Community Psychology, 30(2), 21-
224.
Gottheil, E., Druley, K. A., Pashko, S., & Weinstein, S. P. (1987). Stress and addiction. New
York: Brunner/Mazel.
Gottlieb, B. H. (1987). Using social support to protect and promote health. Journal of Primary
Prevention, 8(1-2), 49-70.
Grant, B. F., Dawson, D. A., Stinson, F. S. , Chou, S. P., Dufour M. C., & Pickering, R. P.
(2004). The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence:
United States, 1991-1992 and 2001-2002. Drug and Alcohol Dependence, 74, 223-235.
Greeley, J. & Oei, T. (1999). Alcohol and tension reduction. In K. E. Leonard, & H. T. Blane
(Eds), Psychological theories of drinking and alcoholism (2nd ed., pp. 14-53). New York:
The Guilford Press 128 Green, C. A., Freeborn, D. K., & Polen, M. R. (2001). Gender and alcohol use: the role of social
support, chronic illness, and psychological well-being. Journal of Behavioral Medicine,
24(4), 383-399.
Griffin, R., Mosher, C., Rotolo, T, & Drapela, L. (2004). An examination of drug and alcohol
use among Asian-Americans. Paper presented at the annual meeting of the American
Sociological Association, Hilton San Francisco, CA. Conference paper/unpublished
manuscript) retried from http://www.allacademic.com/meta/p109734_index.html
Hahm, H. C., Lahiff, M., & Guterman, N. B. (2003). Acculturation and parental attachment in
Asian-American adolescents’ alcohol use. Journal of Adolescent Health, 33, 119-129.
Harachi, T. W., Catalano, R. F., Kim, S., & Choi, Y. (2001). Etiology and prevention of
substance use among Asian American youth. Prevention Science, 2(1), 57-65.
Harrell, S. P. (2000). A multidimensional conception of race-related stress: Implications for the
well-being of people of color. American Journal of Orthopsychiatry, 70, 42-57.
Health Services Administration, Center for Mental Health Services. U.S. Department of Health
and Human Services (2005). Dietary Guidelines for Americans. Retrieved July 30, 2009,
from http://www.health.gov/dietaryguidelines/dga2005/document/pdf/DGA2005
Heath, D. W. (1991). Alcohol studies and anthropology. In D. J. Pitman & H. R. White (Eds.),
Society, culture, and drinking pattern reexamined (pp. 87-108). New Brunswick, NJ:
Rutgers Center of Alcohol Studies.
Helms, J. E. & Cook, D. A. (1999). Using race and culture in counseling and
psychotherapy:Theory and process. Needham Heights, MA: Allyn & Bacon. 129 Hendershot, C. S., Macpherson, L., Myers, M. G., Carr, L. G., & Wall, T. L. (2005).
Psychosocial, cultural and genetic influences on alcohol use in Asian American youth.
Journal of Studies on Alcohol, 66, 185-195.
Hirschman, C. & Shipp, C. M. (2001). The state of the American dream: race and ethnic
socioeconomic inequality in the United States, 1970-1990. In D. B. Grusky (Ed.), Social
Stratification: Class, race, and gender in sociological perspective (pp. 623-642). Boulder,
CO: Westview.
Horwistz, A. V., & Davis, L. (1994). Are emotional distress and alcohol problems differential
outcomes to stress?: An exploratory test. Social Science Quarterly, 75, 607-621.
Izuno, T., Miyakawa, M., Tsunoda, T., Parrish, K. M., Kono, H., Ogata, M., Harford, T.C., &
Towle, M. S. (1992). Alcohol-related problems encountered by Japanese, Caucasians,
and Japanese-Americans. The International Journal of the Addictions, 27(12), 1389-
1440.
Ja, D. & Aoki, B. (1993). Substance abuse treatment: Cultural barriers in the Asian-American
community. Journal of Psychoactive Drugs, 25, 61-71.
Ja, D., & Yuen, F. K. (1997). Substance abuse treatment among Asian Americans. In E. Lee
(Ed.), Working with Asian Americans: A guide for clinicians (pp. 296-308). New York:
The Guilford Press.
Jackson, J. S., Brown, T. N., Williams, D. R., Torres, M., Sellers, S., & Brown, K. (1996).
Racism and the physical and mental health status of African Americans: A thirteen year
National Panel Study. Ethnicity and Disease, 6, 132-147. 130 Jackson, P. B., & Lassiter, S. (2001). Self-esteem and race. In T. J. Owens, S. Sheldon, & N.
Goodman (Eds.), Extending self-esteem theory and research: Sociological and
psychological cultures (pp. 223-254). Cambridge, England: Cambridge University Press.
Johnson, R. C., & Nagoshi, C. R. (1990). Asian-Americans and alcohol. Journal of Psychoactive
Drugs, 22, 45-52.
Johnson, R. C., Nagoshi, C. T., Ahern, F. M., Wilson, J. R., & Yuen, S. H. L. (1987). Cultural
factors as explanations for ethnic group differences in alcohol use in Hawaii. Journal of
Psychoactive, 19(1), 67-75.
Kalodner, C. R., Delucia, J. L., &, Ursprung, A. W. (1989). An examination of the tension
reduction hypothesis: The relationship between anxiety and alcohol in college students.
Addictive Behaviors, 14, 649-654.
Kaplan, L. (2005). Addiction treatment workforce. Retrieved December 10, 2008 from
http://www.ncsl.org/programs/health/addictionib.htm
Kerr-Correa, F., Igami, T. Z., Hiroce, V., & Tucci, A. M. (2007). Pattern of alcohol use between
gender: A cross-cultural evaluation. Journal of Affective Disorders, 102(1-3), 265-275.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., …Kendler,
K.S. (1994). Lifetime and 12-mongth prevalence of DSM-III-R psychiatry disorders in
the United States: Results from the National Comorbidity Survey. Archives of General
Psychiatric, 51, 8-19.
Keys, K. M., & Hasin, D. S. (2008). Socio-economic status and problem alcohol use: the positive
between income and the DSM-IV alcohol abuse diagnosis. Addiction, 103(7), 1120-1130. 131 Kim, B. S. K., Atkinson, D. R., & Yang, P. H. (1999). The Asian value scales (AVS):
Development, factor analysis, validation, and reliability. Journal of Counseling
Psychology, 46, 342-352.
Kim, S., McLeod, J. H., & Shantzis, C. (1995). Cultural competence for evaluators working with
Asian-Americans communities: Some practical Considerations. In Substance Abuse and
Mental Health Services Administration (Ed.),Cultural Competence for Evaluators: A
guide for alcohol and other drug abuse prevention practitioners working with
ethnic/racial communities.(OSAP Cultural Competence Series I, DHHS. Publication No.
[SAM]95-3066, pp.203-260).Rockville, MD: SAMHSA.
Kitano, H. H. L., Iris, C., Rhee, S., Law, C. K., & Lubben, J. E. (1990). Norms and alcohol
consumption: Japanese in Japan, Hawaii and California. Journal of Studies of Alcohol,
53(1), 33-39.
Kitano, H. L., Lubben, J. E., & Chi, I. (1988). Predicting Japanese American drinking behavior.
The International Journal of the Addiction, 23(4), 417-428.
Klatsky, A. L., Siegelaub, A. B., Landay, C., & Friedman, G. D. (1983). Racial patterns of
alcoholic beverage use. Alcoholism: Clinical and Experimental Research, 7, 372- 377.
Kuo, W. H. (1995). Coping with racial discrimination: The case of Asian Americans. Ethnic and
Racial Studies, 18(1), 109-127.
Kuramoto, F. H. (1997). Asian Americans. In J. Philleo & F. L. Brisbane (Eds.), Cultural
competence in substance abuse prevention. Washington, D.C.: NASW Press.
Lai, E., & Arguelles, D. (2003). The new face of Asian Pacific America: Numbers, diversity and
changes in the 21st century. Berkeley, CA: Consolidated Printers, Inc. 132 Lee, E. (1997). Overview: The assessment and treatment of Asian American families. In E. Lee
(Ed.), Working with Asian Americans: A guide for clinicians (pp. 3-36). New York: The
The Guilford Press.
Lee, E. & Mock, M. R. (2005). Chinese Families. In M. McGoldrick, J. Giordano, & N. Garcia-
Preto (Eds.). (3rd ed.), Ethnicity and family therapy (pp. 302-318). New York: The
Guilford Press. Lee, M. Y., Law, P. F. M., & Eo, E. (2003). Perception of substance use problems in Asian
American communities by Chinese, Indian, Korean and Vietnamese populations. Journal
of Ethnicity in Substance Abuse, 2(3), 1-29.
Lee, R. M. (2003). Do ethnic identity and other-group orientation protect against discrimination
for Asian Americans? Journal of Counseling Psychology, 50, 133-141.
Lee, R. M. (2005). Resilience against discrimination: Ethnic identity and other-group orientation
as protective factors for Korean Americans. Journal of Counseling Psychology, 52, 36-44.
Lee, R., & Liu, H. (2001). Coping with intergenerational family conflict: Comparison of Asian
American, Hispanic, and European American college students. Journal of Counseling
Psychology, 48, 410-419.
Lee, S., Koeske, G. F., & Esther, S. (2004). Social support buffering of acculturative stress: a
study of mental health symptoms among Korean international students. International
Journal of Intercultural Relations, 28(5), 399-414.
LeMarchand, L. L., Kolonel, L. N., & Yoshizawa, C. N. (1989). Alcohol consumption pattern
among the five major ethnic groups in Hawaii: Correlations with incidence of esophageal
and oropharyngeal cancer. In National Institute on Alcohol Abuse and Alcoholism (Ed.), 133 Alcohol use among U.S. ethnic minorities (NIAAA Research Monograph 18, DHHS
Publication No. [ADM] 89-1435, pp. 355-371). Rockville, MD: NIAAA.
Lenug, P. K., & Boehnlien (2005). Vietnamese Families. In M. McGoldrick, J. Giordano, & N.
Garcia-Preto (Eds.). (3rd ed.), Ethnicity and family therapy (pp. 363-376). New York:
The Guilford Press. Leu, J., Yen, I. H., Gansky, S. A., Walton, E., Adler, N. E., & Takeuchi, D. T. (2008). The
association between subjective social status and mental health among Asian immigrants:
Investigation the influence of age at immigration. Social Science & Medicine, 66(5),
1152-1164.
Lewonski, S. (1998). Elderly legal immigrants and welfare reform: An analysis of the effects of
the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. The
Kansans Journal of Law Public Policy, 53, 53-67.
Liang, C., Li, L. C., & Kim, B. S. K. (2004). The Asian American Racism-Related Stress
Inventory: Development, factor analysis, reliability, and validity. Journal of Counseling
Psychology, 51(1), 103-114.
Lin, K. M., & Cheung. F. (1999) Mental health issues for Asian Americans. Psychiatric Services,
50, 774-780.
Long, J. S., & Freese, J. (2nd Ed.) (2006). Regression models for categorical dependent variables
using Stata. College Station, Texas: A Stata Press Publication.
Loue, S. (2003). Diversity issues in substance abuse treatment and research. New York, NY:
Kluwer Academic.
Louise, K. B. (2001). White paper on the health status on Asian Americans and Pacific Islanders
and recommendations for research. Nursing Outlook, 40, 173-178. 134 Lubben, J. E., Chi, I., & Kitano, H. H. (1988). Exploring Filipino American drinking behavior.
Journal of Studies on Alcohol, 49(1), 26-29.
Luczak, S. E., Elvine-Kreis, B., Shea, S. H., Carr, L. G., & Wall, T. L. (2002). Genetic risk for
Alcoholism related to level of response to alcohol in Asian American men and women.
Journal of Studies on Alcohol, 63, 74-82.
Makimoto, K. (1998). Drinking patterns and drinking problems among Asian-Americans and
Pacific Islanders. Alcohol Health & Research World, 22(4), 270-276.
Margiglia, F. F., Kulis, S., & Hecht, M. (2001). Ethnic labels and ethnic identity as predictors of
drug use among middle school students in the Southwest. Journal of Research on
Adolescence, 11, 21-48.
Marin, G. & Gamba, R. J. (2003). Acculturation and changes in cultural values. In K. M.Chun,
P. B. Organista, & G. Marin (Eds.), Acculturation: Advance in theory, measurement, and
applied research (pp. 83-94). Washington, DC: American Psychological Association.
Matsuyoshi, J (2001). Substance abuse interventions to Japanese and Japanese American clients.
In S. L. A. Straussner (Ed.), Ethnocultural factors in substance abuse treatment (pp. 345-
392). New York: The Guilford Press.
McLaughlin, D. G., Raymonda, J. S., Murakami, S. R., & Goebert, D. (1987). Drug use among
Asian Americans in Hawaii. Journal of Psychoactive Drug, 19(1), 85-94.
Mena, F. J., Padilla, A. M., & Maldonado, M. (1987). Acculturative stress and specific coping
strategies among immigrants and later generation college students. Hispanic Journal of
Behavioral Sciences, 9(2), 207-225.
Mental Health Services Administration (Ed.),Cultural Competence for Evaluators: A guide for
alcohol and other drug abuse prevention practitioners working with ethnic/racial 135 communities(OSAP Cultural Competence Series I, DHHS. Publication No. [SAM]95-
3066, pp. 203-260).Rockville, MD: SAMHSA.
Mercado, M. M. (2000). The invisible family: Counseling Asian American substance abusers
and their families. The Family Journal, 8(3), 267-272.
Moon, S. S., & DeWeaver, K. L. (2005). An empirical test of the Multicultural/Multimodal/
Multisystem (MULTI-CMS): Approach for Korean immigrant families. Journal of Social
Work Research and Evaluation, 6(1), 57-74.
Mulia, N., Schmidt, L, Bond, J. Jacobs, L., & Korcha, R. (2008). Stress, social support and
problem drinking among women in poverty. Addiction, 103(8), 1283-1293.
Mullen, K., Blaxter, M., & Dyer, S. (1986). Religion and attitude towards alcohol use in the
Western Isles. Drug and Alcohol Dependence, 18(1), 51-72.
Mulvaney-Day, N. E., Alegria, M., & Sribney, W. (2007). Social cohesion, social support, and
health among Latinos in the United States. Social Science & Medicine, 64, 477-495.
Nadal, K. L. (2000). F/Pilipino American substance abuse: Sociocultural factors and methods of
treatment. Journal of Alcohol and Drug Education, 46, 26-36.
National Asian Pacific American Families Against Substance Abuse (NAPAFASA). (2005).
Alcohol, tobacco, and other drug fact sheet: Asian American and Pacific Islanders.
Retrieved February 15, 2007 from
http://www.napafasa.org/resources/doc/ATOD%20Fact%20Sheet .
National Association of Social Workers (NASW) (2003). Practice research network. Retrieved
April 25, 2010,from http://www.socialworkers.org/naswprn/surveyOne/demogr
National Institute on Drug Abuse (2005). Info facts: treatment trends. Retrieved February 15,
2007 from http://www.drugabuse.gov/PDF/InfoFacts/TreatmentTrends05 . 136 Nemoto, T., Huang, K., & Aoki, B. (1998). Strategies for accessing and retaining Asian drug
users in research studies. In M. R. De La Rosa, B. Segal, & R.Lopez (Eds.), Conducting
drug abuse research with minority populations Advances and issues (pp. 151-165).New
York: Haworth Press.
Noh, S., & Kaspar, V. (2003). Perceived discrimination and depression: Moderating effects of
coping, acculturation, and ethnic support. American Journal of Public Health, 93 (2),
232-238.
Noh, S., Kaspar, V., Hou, F., & Rummens, J. (1999). Perceived racial discrimination, depression,
and coping: A study of Southeast Asian Refugees in Canada. Journal of Health and
Social Behavior, 1999, 40, 193-207.
Oh, Y., Koeske, G., & Sales, E. (2002). Acculturation, stress, and depressive symptoms among
Korean immigrants in the United States. Journal of Social Psychology, 142, 511-526.
Parrish, M. (1995). Alcohol abuse prevention research in Asian American and Pacific Islander
communities. In P. A. Langton, L.G. Epstein, & M.A. Orlandi (Eds.), The challenge of
participatory research: Preventing alcohol-related problems in ethnic communities.
Special collaborative NIAAA/CSAP monograph based on a NIAAA conference May 18-
19, 1992 (pp. 389-409). Rockville, MD: US Department of Health and Human Services.
Peele, S. (1986). The implications and limitations of genetic models of alcoholism and other
addictions. Journal of Studies on Alcohol, 47 (1), 63-73.
Pennell, B., Bowers, A., Carr, D., Chardoul, S., Cheung, G. Dinkelmann, K.,. . .Torres, M.
(2004). The development and implementation of the National Comorbidity Survey
Replication, the National Survey of American Life, and the National Latino and Asian 137 American Survey. International Journal of Methods in Psychiatric Research, 13, 241-
269.
Phelps, R. E., Taylor, J. D., & Gerard, P.A. (2001). Cultural mistrust, ethnic identity, racial
identity, and self-esteem among ethnically diverse black students. Journal of Counseling
& Development, 79(2), 209-216.
Phinney, J. S. (1996). Stages of ethnic identity development in minority group adolescents. The
Journal of Early Adolescence, 9(1-2), 34-49.
Phinney, J. S., Horenczyk, G., Liebkind, K., & Vedder, P. (2001). Ethnic identity, immigration,
and well-being: An interactional perspective. Journal of Social Issues, 57(3), 493-510.
Phinney. J. S. (2003). Ethnic identity and acculturation. In K. M.Chun, P. B. Organista, & G.
Marin (Eds.), Acculturation: Advance in theory, measurement, and applied research (pp.
63-82). Washington, DC: American Psychological Association.
Platt, A., Sloan, F. A., & Costanzo, P. (2010). Alcohol-consumption trajectories and associated
characteristics among adults older than age 50. Journal of Studies on Alcohol and Drug,
71 (2), 169-179
Preze, D. J., Fortuna, L., & Alegria, M. (2008). Prevalence and correlated of everyday
discrimination among U.S. Latinos. Journal of Community Psychology, 36(4), 421-433.
Price, R. K., Risk, N. K., Wong, M.M., & Klingle, R. S. (2002). Substance use and abuse by
Asian Americans and Pacific Islander: Preliminary results from four national
epidemiological studies. Public Health Reports, 117, S39-S50.
Puddey, I. B., Rakic, V., Dimmitt, S. B., & Beilin, L. J. (1999). Influence of pattern of drinking
on cardiovascular disease and cardiovascular risk factors: a review. Addiction, 94(5),
649-663. 138 Pugh, L. A. & Bry, B. (2007). The protective effects of ethnic identity for alcohol and marijuana
use among Black young adults. Cultural Diversity and Ethnic Minority Psychology,
13(2), 187-193.
Recio Adrados, J. (1993).Acculturation: The broader view. In M. R. D. LaRosa, J. Recio Adraos
(Ed.), Drug abuse among minority youth: Methodological issues and recent research
advances (NIAAA Research Monograph 130 NIH Publication No. 93-3479 pp. 57-78).
Rockville, MD: NIAAA. Reeves, T. J., & Bennett, C. E. (2004). We the people: Asians in the United States. Census 2000
Special Report. Retrived from August 15, 2009,
http://www.census.gov/prod/2004pubs/censr-17 .
Rehm J., Gmel, G., Sempos, C. T., & Trevisan, M (2003a). Alcohol-related morbidity and
mortality. Alcohol Research & Health, 27(1), 39-51.
Rehm, J., Room, R., Graham, K., Monteiro, M., Gmel, G., & Sempos, C. T. (2003b). The
relationship of average volume of alcohol consumption and patterns of drinking to burden
of disease: an overview. Addiction, 98, 1209-1228.
Ringwalt, C., Graham, P., Sanders-Phillips, K., Browne, D., & Paschall, M. (1999). Ethnic
identity as a protective factor in the health behaviors of African-American male
adolescent. In S. B. Kar (Ed.), Substance abuse prevention: A multicultural perspective
(pp. 131-151). Amityville, NY: Baywood.
Ro, M. (2009). The workforce. In C. Trinh-Shevrin, N. S. Islam, & M. J. Rey, Asian Americans
communities and health: context, research, policy, and action (pp. 549-566). San
Francisco, CA: Jossey-Bass. Room, R., Babor, T., & Rehm, J. (2005). Alcohol and public health. Lancet, 365(9458), 519-530. 139 Root, M. P. P. (2005). Filipino families. Chinese Families. In M. McGoldrick, J. Giordano, & N.
Garcia-Preto (Eds.). (3rd ed.), Ethnicity and family therapy (pp. 319-331). New York:
The Guilford Press. Russell, M., Light, J. M., & Gruenewald, P. J. (2004). Alcohol consumption and problems: the
relevance of drinking patterns. Alcoholism: Clinical and Experimental Research, 28(6),
921-930.
Sakai, J. T., Ho, P.M., Shore, J. H., Risk, N. K., & Price, R. K. (2005). Asians in the United
States: Substance dependence and use of substance-dependence treatment. Journal of
Substance Abuse Treatment, 29, 75-84.
Salagado de Snyder, V. N. (1987). Factors associated with acculturative stress and depressive
symptomatology among married Mexican immigrant women. Psychology of Women
Quarterly, 11, 475-488.
Salant, T., & Lauderdale, D. S. (2003). Measuring culture: A critical review of acculturation and
health in Asian immigrant populations. Social Science & Medicament, 57, 71-90.
Sayette, M. A. (1999). Does drinking reduce stress? Alcohol Research & Health, 23(4), 250-255.
Schoenborn, C. A., & Adams, P. F. (2002). Alcohol use among adults: United States, 1997-98.
Advance Data 324.Retrived March 6, from http://www.cdc.gov/nchs/data/ad/ad324
Sellers, R. M., & Shelton, J. N. (2003). The role of racial identity in perceived racial
discrimination. Journal of Personality and Social Psychology, 84(5), 1079-1092.
Sellers, R. M., Caldwell, C. H., Schmeelk-Cone, M. A., & Zimmerman, M. A. (2003). Racial
identity, racial discrimination, perceived stress, and psychological distress among African
American Young Adults. Journal of Health and Social Behavior, 44(3), 302-.317 140 Shannon, M.T. (1989). Health promotion and illness prevention: a biopsychosocial perspective.
Health and Social Work, 14, 32-40.
Shen, B., & Takeuchi, D. T. (2001). A structural model of acculturation and mental health status
among Chinese Americans. American Journal of Community Psychology, 29(3), 387-
418.
Shin, S., & Hutton, E. M. (2002). Working with Korean immigrants alcohol abusing clients: a
sociocultural approach. Journal of Immigrants and Refugee Services, 1(2), 1-19.
Siegel, K., Anderman, S. J., & Schrimshaw, E. W. (2001). Religion and coping with health-
related stress. Psychology and Health, 16, 631-653.
Smith, M. J. W. (2005, Winter). Developing a social work labor force to meet the increasing
demand for substance abuse services in the United States. SPS Practice Update, 1-2.
Retrieved from May 12, 2010, www.nasw.org.
Smokowski, P. R., David-Ferdon, C., & Stroupe, N. (2009). Acculturation and violence in
minority adolescents: A review of the empirical literature. Journal of Primary Prevention,
30, 215-263
So, D. W, & Wong, F. Y. (2006). Alcohol, drugs, and substance use among Asian-American
college students. Journal of Psychoactive Drugs, 38(1), 35-42.
Sodowsky, G. R., Lai, E. W., & Plake, B. S. (1991). Moderating effects of sociocultural
variables on acculturation attitudes of Hispanic and Asian Americans. Journal of
Counseling and Development, 70, 194-204.
St. Lawrence, J. S., Brasfiedl, T. L., Jefferson, K. W., Allyene, E., & Shirely, A. (1994). Social
support as a factor in African-American adolescents’ sexual behavior. Journal of
Adolescent Research, 9(3), 292-310. 141 StataCorp. (2007). Stat statistical software: Release 10. College Station, TX: Statacorp LP.
Stockdale, S. E., Wells, K. B., Tang, L., Belin, T. R., Zhang, L., & Sherbourne, C. D. (2007).
The importance of social context: neighborhood stressors, stress-buffering mechanisms,
and alcohol, drug, and mental health disorders. Social Science and Medicine, 65(9),
1867-1881.
Subramanian, S. K., & Takeuchi, D. (1999). The complexities of diversity: Substance abuse
among Asian Americans. In S. B. Kar (Ed.), Substance abuse prevention: A multicultural
perspective (pp. 185-198). Amityville, NY: Baywood.
Substance Abuse and Mental Health Service Administration (1998). Prevalence of substance use
among racial and ethnic subgroups in the United States 1991-1993. Rockville, MD:
Office of Applied Studies, SAMHSA.
Substance Abuse and Mental Health Service Administration (2003). SAMHSA Newsletter XI(3).
Retrieved December 9, 2009 from
http://www.samhsa.gov/samhsa_news/volumeXI_3/article9.htm
Substance Abuse and Mental Health Service Administration (2004). Results from the 2003
National Survey on Drug Use and Health: National Findings. NSDUH Series, H-
25.Rockville, MD: Office of Applied Studies, SAMHSA.
Substance Abuse and Mental Health Service Administration (2007). Results from the 2006
National Survey on Drug Use and Health: National Findings. Retrieved December 10,
2009 from http://www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.
Sue, S., & Nakamura, C. Y. (1984). An integrative model of physiological and
socio/psychological factors in alcohol consumption among Chinese and Japanese
Americans. Journal of Drug Issues, 14(2), 349-364. 142 Sue, S., Zane, N., & Ito, J. (1979). Alcohol drinking patterns among Asian and Caucasian
Americans. Journal of Cross-Cultural Psychology, 10(1), 41-56.
Suinn, R. M., Rickard-Figueroa, K., Lew, S., &Vigil, P. (1987). The Suinn-Law Asian Self-
Identity Acculturation Scale: An initial report. Educational and Psychological
Measurement, 47, 401-407.
Sustento-Senirches, J. (1997). Filipino American families. In E. Lee (Ed.), Working with Asian
Americans: A guide for clinicians (pp. 101-113). New York: The Guildford Press.
Syme, S. L., & Yen, I. H. (2000). Social epidemiology and medical sociology: Different
approaches to the same problem. In E.C. Brid, P. Conrad, & A. M. Fremont (Eds.),
Handbook of medical sociology (pp. 365-376). Upper Saddle River, NJ: Prentice-Hall.
Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.) (2007). Boston,
MA: Pearson Education, Inc.
Takeuchi, D. T., Hong, S, Gile, K., & Alegria, M. (2007). Developmental contexts and mental
disorders among Asian Americans. Research in Human Development, 4(1&2), 49-69.
Takeuchi, D. T., Zane, N., Hong, S, Chae D., Gong, F., Gee, G., Walton, E., Sue, S., & Alegria,
M. (2007). Immigration-related factors and mental disorders among Asian Americans.
American Journal of Public Health, 97(1), 84-90.
Thompson, R. A., & Flood, M. F., & Goodvin, R. (2006). Social support and developmental
psychopathology. In D. Cicchetti & D. J. Cohen, Developmental psychopathology (2nd
ed.). (pp. 1-37). Hoboken, NJ: John Wiley & Sons Inc.
Thurman, P. J., Plested, B., Edwards, R. W., Chen, J., & Swaim, R. (2000) Intervention and
treatment with ethnic minority substance abusers. In J. Aponte & J. Wohl (Eds.), 143 Psychological intervention and cultural diversity (2nd ed., pp. 214-249), Needham
Heights, Massachusetts: Allyn & Bacon .
Trimble, J. E. (2003). Social change and acculturation. In K. M. Chun, P. B. Organista, & G.
Marin (Eds.), Acculturation: Advance in theory, measurement, and applied research (pp. 3-14). Washington, DC: American Psychological Association.
Tsunoda, T., Parrish, K., Higuchi, S., Stinson, F. S., Kono, H., Ogata, M., & Harford, T. C.
(1992). The effects of acculturation on drinking attitudes among Japanese in Japan and
Japanese Americans in Hawaii and California. Journal of Studies on Alcohol, 53(4), 369-
377. U.S. Department of Health and Human Services (2001). Mental health: Culture, race, and
Ethnicity– a supplement to mental health. A report of the Surgeon General. Rockville,
MD: U.S. Department of Health and Human Services, Substance Abuse and Mental.
U.S. Department of Health and Human Services (2009, June 10). Cancer and Asians/Pacific
Islanders. Retrieved from
http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=53&ID=3055
U.S. Department of Health and Human Services (2010a , March 14). Healthy People 2000.
Alcohol and other drugs. Retrieved from
http://lancaster.ne.gov/City/HEALTH/hp2010/Alcoth
U.S. Department of Health and Human Services (2010b, March 14). Health People 2010
Retrieved from http://www.healthypeople.gov/About/hpfact.htm
Uba, L. (1994). Asian Americans: Personality patterns, identity, and mental health. New York,
NY: The Guilford Press. 144 Varma, S. C., & Siris, S. G. (1996). Alcohol abuse in Asian Americans: Epidemiological and
treatment issues. The American Journal on Addictions, 5, 136-143.
Vega, W. A., & Gill, A. G. (1999). A model for explaining drug use behavior among Hispanic
adolescents. In M. R. De La Rosa, B. Segal, & R. Lopez (Eds.), Drug abuse research
with minority populations: Advances and issues (pp. 57-74). New York: New York Press,
Inc. Vega, W., Zimmerman, R., Warheit, G., & Gil, A. (2003). Acculturation, stress and Latino
adolescent drug use. Retrieved March 13, 2009, from
http://www.mhsip.org/pdfs/Vega
Wall, T. L., & Ehlers, C. L. (1995). Genetic influences affecting alcohol use among
Asian.Alcohol Health and Research World, 19, 184-189.
Wei, M., Heppner, P. P., Mallen, M., Ku, T. Y., Liao, K. Y. H., & Wu, T. F. (2007).
Acculturative stress, perfectionism, years in the United States, and depression among
Chinese international students. Journal of Counseling Psychology, 54, 385-394.
White, H. (1980). A heteroskedasticity-consistent covariance matrix estimator and a direct test
for heteroskedasticity. Econometrica, 48 (4), 817-838.
Wills, T. A. (1990). Stress and coping factors in the epidemiology of substance use. In L. T.
Kozlowski, H. M. Annis, H. D. Cappell, F. B. Glaser, M. S. Goodstadt, Y. Israel et al
(Eds.), Research advances in alcohol and drug problems (pp.215-250). New York:
Plenum. Wills, T. A., & Shiffman, S. (1985). Coping and substance use: A conceptual framework. In S.
Shiffman & T. A. Wills (eds.), Coping and substance use (pp. 3-24). Orlando, FL:
Academic Press. 145 Wills, T. S., Yaeger, A. M., & Sandy, J. M. (2003). Buffering effect of religiosity for adolescent
substance use. Psychology of Addictive Behavior, 17(1), 24-31
Wong, F. Y., Huang, Z. H., Thompson, E. E., De Leon, J. M., Shah, M. S., Park, R. J., & Do, T.
D. (2007). Substance use among a sample of foreign-and U.S.-born Southeast Asians in
an urban setting. Journal of Ethnicity in Substance Abuse, 6(1), 45-66.
Xu, Y. M., Ross, C., Ryan, R., & Wang, B. (2005). Cancer risk factors of Vietnamese Americans
in rural South Alabama. Journal of Nursing Scholarship, 3, 237-244.
Yancey, A. K., Aneshensel, C. S., & Driscoll, A. K. (2001). The assessment of ethnicity identity
in a diverse urban youth population. Journal of Black Psychology, 27, 190-208.
Yi, J. K. & Danile, A. M. (2001). Substance use among Vietnamese American college students.
College Student Journal, 35(1), 13-23.
Yip, T., Gee, G. C., & Takeuchi, D. T. (2008). Racial discrimination and psychological distress:
The impact of ethnic identity and age among immigrant and United States-born Asian
Adults. Developmental Psychology, 44(3), 787-800.
Yoo, H. C., Gee, G. C., Lowthrop, C. K., & Robertson, J. (2009). Self-reported racial
discrimination and substance use among Asian Americans in Arizona. Journal of
Immigrant and Minority Health, doi: 10.1007/s10903-009-9306-z
Yoshikawa, H., Wilson, P. A., Chae, D. H., & Cheng, J. (2004). Do family and friendship
networks protect against the influence of discrimination on mental health and HIV risk
among Asian and Pacific Islander gay men? AIDS Education and Prevention, 16(1), 84-
100.
Young, K., & Takeuchi, D. T. (1998). Racism. In L. C. Lee & W. S. Nolan (Eds.), Handbook of
Asian American psychology (pp. 401-432). Thousand Oaks, CA: Sage 146 Yu, J., Clark, L. P., Chandra, L., Dias, A., & Lai, T. F. M. (2009). Reducing cultural barriers to
substance abuse treatment among Asian Americans: a case study in New York City.
Journal of Substance Abuse Treatment, 37(4), 398-406.
Yu, S. M., & Vyas, A. N. (2009). The health of children and adolescents. In C. Trinh-Shevrin, N.
S. Islam, & M. J. Rey, Asian Americans communities and health: context, research,
policy, and action (pp. 107-131). San Francisco, CA: Jossey-Bass.
Zamboanga, B. L., Raffaelli, M., & Horton, N. J. (2006). Acculturation status and heavy alcohol
use among Mexican American college students: Investing the moderating role of gender.
Addictive Behaviors, 31, 2188-2198.
Zane, N. W. W., & Huh-Kim, J. (1998). Addictive behaviors. In L. C. Lee & N. W. S. Zane
(Eds.), Handbook of Asian American psychology (pp. 527-554). Thousand Oaks, CA:
Sage.
Zane, N., & Huh- Kim, J. H. (1994). Substance use and abuse. In N.W. S. Zane, D. T. Takeuchi,
& K. N. J. Young (Eds.), Confronting Critical Health Issues of Asian and Pacific
Islander Americans (pp. 316-346). Thousand Oaks, CA: Sage Publication.
Zane, N., & Mak, W. (2003). Major approaches to the measurement of acculturation among
ethnic minority populations: A content analysis and an alternative empirical strategy. In
K. M.Chun, P. B. Organista, & G. Marin (Eds.), Acculturation: Advance in theory,
measurement, and applied research (pp. 39-60). Washington, DC: American
Psychological Association. Zane, N., & Sasso, T. (1992). Research on drug abuse among Asian Pacific Americans. In J.E.
Trimble, C.S. Bolek, & S. J. Niemcryk (Eds.), Ethnic and multicultural drug abuse:
perspective on current research (pp.181-205). New York: Haworth Press. 147 Zimmerman, R. S., Vega, W. A., Gil, A. G., Warheit, G. J., Apospori, E., & Biafora, F. (1994).
Who is Hispanic? Definitions and their consequences. American Journal of Public
Health, 84(12), 1985-1987. 148 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. (1) Never 2. You are treated with less respect than other people.
(1) Never 3. You receive poorer service than other people at restaurant or stores
(1) Never 4. People act as if they think they are not smart.
(1) Never 5. People act as if they are afraid of you.
(1) Never 149
6. People act as if you are dishonest.
(1) Never 7. People act as if you are not as good as they are.
(1) Never 8. You are called names or insulted.
(1) Never 9. You are threatened or harassed.
(1) Never 150 Appendix B. Perceived racial/ethnic discrimination scale 1. How often do people dislike you due to your race/ethnicity? (1) Never 2. How often do people treat you unfairly due to your race/ethnicity?
(1) Never 3. How often have you seen friends treated unfairly due to their race/ethnicity?
(1) Never 151 Appendix C. Family conflict scale Please tell me how frequently the following situations have occurred to you. 1. You have felt that being too close to your family interfered with your goals.
(1) Hardly ever or never 2. Because you have different customs, you have had arguments with other members of your (1) Hardly ever or never 3. Because of the lack of family unity, you have felt lonely and isolated.
(1) Hardly ever or never 4. You have felt that family relations are becoming less important for people that you are close to.
(1) Hardly ever or never 5. Your personal goals have been in conflict with your family.
(1) Hardly ever or never 152 Appendix D. Statistical regression models in path analysis: Ordinal logistic and ordinary least 153 Appendix E. IRB approval notice New York University UCAIHS APPROVAL NOTICE Date: 26-Jan-2010
PI Name: So-Youn Park Dear Investigator,
Your Initial Review submission was reviewed and approved following an Exempt review under Approval Date: 26-Jan-2010 Please remember to use HS#(10-0041) on any documents or correspondence with the IRB Please note that the IRB has the prerogative and authority to ask further questions, seek We wish you the best as you conduct your research. If you have any questions or need further Sincerely,
UCAIHS STAFF 154 Appendix F. Characteristics of Chinese, Filipino, and Vietnamese Americans in weighted Chinese Filipino Vietnamese
n (%)/mean n (%)/mean n (%)/mean
Gender
Female 1,174,382 (52.5) 883,572 (52.5) 529,215 (52.5)
Male 1,060,443 (47.5) 797,848(47.5) 477,871 (47.5)
Marital status
Married 1,472,872 (65.9) 1,146,898 (68.2) 721,953 (71.7)
Divorced 226,587(10.1) 163,574 (9.7) 69,695 (6.9)
Never married 2,234,825 (24.0) 370, 948 (22.1) 215,439 (21.4)
Education
Less than high school 389,532 (17.4) 182,950 (10.9) 319,476 (31.7)
High school graduate 362,210 (16.2) 341,852 (20.3) 212,054 (21.1)
College 464,035 (20.8) 537,490 (32.0) 236,524 (23.5)
Graduate school 1,019,048 (45.6) 619,127 (36.8) 239,033 (23.7)
Religion
Protestantism 455,409 (20.5) 257,906 (15.5) 55,351 (5.5)
Catholic 174,758 (7.9) 1,194,573 (71.9) 330,369 (32.9)
Other religion 492,654 (22.2) 113,090 (6.8) 548,601 (54.7)
No religion 198,046 (49.4) 96,055 (5.8) 68,456 (6.8)
Generation
First generation 1,961,686 (88.1) 1,397,569 (83.1) 982,053 (97.8)
Second generation 92,727 (4.16) 147,561 (8.8) 21,755 (2.17)
Third generation 173,322 (7.74) 136,289 (8.1) 0
Family support
Yes 318,248 (85.7) 1,443,570 (86.1) 753,295 (75.2)
No 1,908,945 (14.3) 232,556 (13.9) 248,434 (24.8)
Friend support
Yes 1,989,955 (89.1) 1,484,198 (88.6) 745,360 (74.4)
No 243,234 (10.1) 190,549 (11.4) 245,369 (25.6)
Religiosity
Never 1,342,765 (60.5) 278,871 (16.8) 237,122 (23.6)
One to three times a month 575,380 (18.9) 574,439 (34.6) 448,512 (44.7)
Once a week or more 302,721 (13.6) 808,315 (48.6) 317,144 (31.6)
155 Alcohol use
Abstaining 1,369,627 (61.3) 746,825 (44.6) 720,859 (71.9)
Light-to-moderate drinking 798,051 (17.8) 833,758 (49.8) 258,180 (26.7)
Risky drinking 67,147 (3.0) 93,901 (5.6) 13,668 (1.4) 156 Appendix G. Correlation matrix among all variables among Chinese Americans
1 2 3 4 5 6 7 8 9 10
1. Alcohol use 1
2. Age -.21*** 1
3. Gender .31*** -.002 1
4. Income .15*** -.09* .11** 1
5. Education .14*** -.30*** .10* .32*** 1
6. Marital status .89* -.26*** -.08 -.23*** .04 1
7. Protestantism -.04 .07 -.03 -.02 .14*** .13** 1
8. Catholicism .11** .11** .05 -.01 -.01 -.01 -.15*** 1
9. Other religion -.01 .02 -.02 -.02 -.21*** -.03 .28*** -.15*** 1
10. No religion -.02 -.13** .02 .03 .06 -.08* .52*** -.27*** -.51*** 1
11. English proficiency .28*** -.37*** .09 .28*** .52*** .23*** .18*** .10* -.13** -.09*
12. Generation .24*** .03 .08 .02 .06 .09* .23*** .19*** -.11** .21***
13. Unfair treatment .21*** -.27*** .10* .16*** .18*** .18*** -.001 -.01 -.003 .01
14. Racial/ethnic discrimination .05 -.05 .01 .06 .04 -.004 -.08 -.07 .03 .08*
15. Family conflict .13** -.06 -.04 .03 .10* .18*** .01 .05 .02 -.05
16. Family support -.004 -.09* -.10* .12** .11** -.03 .04 .01 .002 -.04
17. Friend support -.08* -.28*** -.08*** .16* .19*** .14*** .04 -.05 .007 -.02
18. Religiosity -.10 .07 .08 -.05 -.07 .21*** .02 .07 -.25*** -.31***
*p < .05, **p < .01, <***p < .001 157 Appendix G. Correlation matrix among all variables among Chinese Americans continued
11 12 13 14 15 16 17 18
1. Alcohol use
2. Age
3. Gender
4. Income
5. Education
6. Marital Status
7. Protestantism
8. Catholicism
9. Other religion
10. No religion
11. English proficiency 1
12. Generation .34*** 1
13. Unfair treatment .28*** .09* 1
14. Racial/ethnic discrimination -.05 -.12** .37*** 1
15. Family conflict .13** .01 .31*** .21*** 1
16. Family support .04 .02 .04 .009 -.12** 1
17. Friend support .16*** .01 .17*** .12** .05 .37*** 1
18. Religiosity .08 -.04 -.07 -.01 -.14* .18*** .11* 1
*p < .05, **p < .01, ***p < .001
158 Appendix H. Correlation matrix among all variables among Filipino Americans
1 2 3 4 5 6 7 8 9 10 2. Age -.30*** 1
3. Gender .38*** .005 1
4. Income .07 -.004 .07 1
5. Education .06 -.16*** -.01 .30*** 1
6. Marital Status .11* -.31*** -.08 -.23*** -.05 1
7. Protestantism -.03 -.04 -.02 .05 -.02 -.04 1
8. Catholicism -.05 .08 -.01 -.0002 .04 .02 -.71*** 1
9. Other religion .05 .04 .03 -.05 -.07 -.06 -.12** -.43*** 1
10. No religion .10* -.14** .03 -.03 .01 .10* -.10* -.36*** -.06 1
11. English proficiency .22*** .32*** -.02 .17*** .44*** .15*** -.009 -.03 -.02 .11*
12. Generation .16*** .21*** .03 -.09* -.07 .10* .05 -.19*** .13** .15***
13. Unfair treatment .16*** .17*** .17*** .05 .09* .009 .09 -.10* .04 .01
14. Racial/ethnic discrimination -.03 .05 .08 .04 .14** -.06 .05 -.003 -.04 -.04
15. Family conflict .01 -.09* -.09 -.02 .05 .03 .08 -.08 .042 -.01
16. Family support .04 -.09* -.04 .06 .11* .007 .003 .07 -.10* -.04
17. Friend support .05 -.32*** -.07 .08 .23*** .11* .004 -.001 -.02 -.01
18. Religiosity -.25*** .29*** -.08 .04 .12** -.20*** .15*** -.03 -.02 -.24***
*p < .05, **p < .01, ***p < .001
159 Appendix H. Correlation matrix among all variables among Filipino Americans continued.
11 12 13 14 15 16 17 18 12. Generation .14** 1
13. Unfair treatment .03 .13** 1
14. Racial/ethnic discrimination -.03 -.04 .51*** 1
15. Family conflict .005 -.03 .34*** .23*** 1
16. Family support .01* -.09 .02 .02 -.10* 1
17. Friend support .24*** .05 .11** .07 .04 .46*** 1
18. Religiosity -.12* -.18*** -.07 .10* .01 .09* -.04 1 160 Appendix I. Correlation matrix among all variables among Vietnamese Americans
1 2 3 4 5 6 7 8 9 10 2. Age -0.10* 1
3. Gender .37*** .02 1
4. Income .16*** -.12** .07 1
5. Education .14** -.29*** .20*** .33*** 1
6. Marital status .06 -.31*** .02*** -.20*** .01 1
7. Protestantism -.06 -.07 -.03 .04 .01 .09* 1
8. Catholicism -.02 .01 .01 -.06 -.02 -.04 -.16*** 1
9. Other religion -.02 .06 -.03 .004 .001 -.03 -.24*** -.78*** 1
10. No religion .12** -.09* .08 .06 .03 .06 -.06 -.20*** -.30*** 1
11. English proficiency .22*** -.50*** .12** .36*** .56*** .21*** .12** -.04 -.06 .10*
12. Generation .03 -.011* .01 -.03 -.13* -.02 .23*** .05 -.15*** .02
13. Unfair treatment .28*** -.28*** .16*** .16*** .19*** .21*** .11* -.04 -.06 .08
14. Racial/ethnic discrimination .23*** -.15*** .06 .018*** .23*** .09* .04 .05 -.11* .07
15. Family conflict .16*** -.20*** .01 .09* .12** .25*** .07 .0 -.06 .03
16. Family support .07* -.04 -.006 .20*** .13*** -.07 -.06 .03 .02 -.04
17. Friend support .13** -.17*** .04 .21*** .22*** .06 -.01 .04 -.02 -.03
18. Religiosity -.12** .04 -.06 -.09* .01 .01 .21*** .59 -.62*** -.16***
*p < .05, **p < .01, ***p < .001
161 Appendix I. Correlation matrix among all variables among Vietnamese Americans continued.
11 12 13 14 15 16 17 18 6. Marital status
7. Protestantism 12. Generation .08 1
13. Unfair treatment .30*** .02 1
14. Racial/ethnic discrimination .17*** -.04 .47*** 1
15. Family conflict .20*** .01 .42*** .24*** 1
16. Family support .13** -.02 .08 .12** .03 1
17. Friend support .21*** -.04 .13** .15*** .10** .35*** 1
18. Religiosity -.04 .07 .01 .07 -.001 .01 .03 1
*p < .05, **p < .01, ***p < .001
162 Appendix J. Direct as well as indirect paths from generation to alcohol use
The indirect effect of third generation on alcohol use is estimated by the product of two
path coefficients, ΔR2 ge * ΔR ed, because the indirect effect is effects. The indirect effect of the third generation status on alcohol use is estimated by
multiplying the direct effect of the third generation status on unfair treatment (ΔR2 ge) by the
direct effect of unfair treatment on alcohol use (ΔR2ed):
Indirect effect: ΔR2 ge (0.02) * ΔR ed (0.003) = 0.00006, in terms of ΔR Third Unfair Alcohol Direct effect: R2 gd
R2 ge =0.02 R ed =0.003
THE HEALTH CONSEQUENCES OF ASIAN IMMIGRANT INTEGRATION
by
Annie Eun Young Ro
A dissertation submitted in partial fulfillment Doctor of Philosophy in The University of Michigan 1 Doctoral Committee
Professor Arline T. Geronimus, Chair UMI Number: 349312 2 All rights reserved
INFORMATION TO ALL USERS In the unlikely event that the author did not send a complete manuscript a note will indicate the deletion.
UMT UMI 34931 22 Copyright 20 12 by ProQuest LLC.
All rights reserved. This edition of the work is protected against uest 78 9 East Eisenhower Parkway 6 Ann Arbor, Ml 48106-13 46 ACKNOWLEDGEMENTS
I am indebted to a number of people who have provided intellectual, social and
emotional support during my dissertation writing and throughout my time here at
Michigan. Truly, this dissertation is the product of a group effort.
My dissertation committee chair, Dr. Arline Geronimus, has guided this project
from its infancy. Her commitment to use rigorous scholarship to highlight structural
inequities has been the bedrock of my training and will continue to inspire me as I leave
Michigan. I am also grateful to her for the opportunity to work at the Population Studies
Center, which has been one of the highlights of my graduate training.
Dr. Gilbert Gee has been a gracious mentor throughout my graduate career. His
scholarly insight and advice have always provided encouragement and clarity. I look
forward to working with him during my postdoctoral fellowship.
Dr. John Bound has provided invaluable advice on the methodology of this
project. His analytical input has greatly strengthened my dissertation and I feel
incredibly fortunate to have had him on my committee.
Dr. Derek Griffith has consistently provided helpful feedback to develop my
theoretical arguments and I have appreciated his thorough and discerning comments.
My colleagues at the University of Michigan School of Public Health and
Population Studies Center have unselfishly shared their expertise and time through the
years. Kurt Christensen, Nancy Fleischer, Maggie Hicken, Danya Keene, Erin
ii Linnenbringer and Akilah Wise read the earliest and roughest drafts, pored over Stata
output with me and sat many hours over coffee, offering moral support as only they
could. They are wonderful friends and have made my time at Michigan especially
memorable.
I have received generous financial support from various sources. I would like to
acknowledge the Population Studies Center pre-doctoral traineeship from the National
Institutes of Aging and the Rackham Merit Fellowship from the Horace H. Rackham
School of Graduate Studies for their multiple years of funding. I would also like to thank
Drs. Arline Geronimus and John Bound for providing summer funding.
My family, Sung Hyon and Okey Ro, Michael Connolly and Christina Ro-
Connolly, have been enthusiastic cheerleaders and my strongest supporters. This
dissertation is for them.
Finally, my husband Fernando Rodriguez – my best friend and partner in every
sense of the word. I could not have done it without him.
i n TABLE OF CONTENTS
Acknowledgements ii v List of Figures vii Chapter 1 1 11 Chapter 2 Critical Literature Review 1 3 Introduction 13 Asian Immigrant Health Trajectories 1 4 Acculturation and Health Trajectories 20 New Framework for Understanding Asian Immigrant Integration 2 7 Different Integration Experiences 52 Conclusion 72 References 74 Chapter 3 – Empirical Paper 1 8 5 Introduction 85 Aims and Hypotheses 92 Methods 94 Results 104 Discussion 10 8 References 120
Chapter 4 -Empirical Paper 2 1 24 Introduction 124 28 Methods 1 29 Results 1 34 Discussion 1 41 References 1 60 Chapter 5 – Discussion 1 62 Appendix A 1 65 Appendix B 1 77 Appendix C 1 84 Appendix D 1 87 Appendix E 194
IV LIST OF TABLES
Table 2-1. Contexts of Reception and Influences on Integration Processes 53 Table 3-1. Historical Cohorts and Corresponding Year of Entry Cohorts 98 Table 3-2. Weighting Example for NHIS Survey Year 2002, 5-9 years of U.S. Residence
101 Table 3-3. Asian Sample Sizes, by Year of Entry Cohort and Survey Years 1 14 Table 3-4. Sample Characteristics by Cohort 1 15 Table 3-5. Prevalence of Health Outcomes for Cohort/Duration Groups, Matched by Age 16 Table 3-6. Cohort Differences in Sociodemographic Characteristics 1 17 Table 3-7. Cohort Differences and Duration Differences in Physical Health Outcomes
1 18 Table 3-8. Duration Effects within Cohorts 1 19 Table 4-1. Sample Characteristics 1 47 Table 4-2. Mean Prevalence of Disability by Wage/Salary and Duration, Age
Standardized 1 49 Table 4-3. Regression Results for Aggregated Asian Sample 1 51 Table A-l. Cohort Weighting for NHIS Survey Year 19 95 1 66 Table A-2. Cohort Weighting for NHIS Survey Year 19 96 1 67 Table A-3. Cohort Weighting for NHIS Survey Year 19 97 1 68 Table A-4. Cohort Weighting for NHIS Survey Year 1998 1 69 Table A-5. Cohort Weighting for NHIS Survey Year 19 99 1 70 Table A-6. Cohort Weighting for NHIS Survey Year 2000 1 71 Table A-7. Cohort Weighting for NHIS Survey Year 2001 172
Table A-8. Cohort Weighting for NHIS Survey Year 2002 1 73 Table A-9. Cohort Weighting for NHIS Survey Year 2003 174
Table A-10. Cohort Weighting for NHIS Survey Year 2004 1 75 Table A-l 1. Cohort Weighting for NHIS Survey Year 2005 1 76 v Table B-1. Cohort Differences in Sociodemographic Characteristics, Fully Adjusted 78 Table B-2. Cohort and Duration Differences in Physical Health Outcomes, Fully
Adjusted Model 1 80 Table B-3. Duration Effects within Cohorts, Fully Adjusted Model 1 81 Table C-1. Mean Prevalence of Disability by Per Capita HH Inc and Duration, Age
Standardized 185
Table E-1. Regression Results for Aggregated Asian Sample, Fully Adjusted Models 195
Table E-2. Chinese Regression Results, Fully Adjusted Models 197
Table E-3. Japanese Regression Results, Fully Adjusted Models 199
Table E-4. Filipino Regression Results, Fully Adjusted Models 201
Table E-5. Asian Indian Regression Results, Fully Adjusted Models 203
Table E-6. Korean Regression Results, Fully Adjusted Models 205
Table E-7. Vietnamese Regression Results Fully Adjusted Models 207
VI LIST OF FIGURES
Figure 4-1. Aggregated Asians Wage/Salary and Duration Interaction 152
Figure 4-2. Aggregated Asians Per Capita Household Income and Duration Interaction Figure 4-3. Filipino Wage/Salary and Duration Interaction 1 54 Figure 4-4. Asian Indian Wage/Salary and Duration Interaction 1 55 Figure 4-5. Chinese Per Capita Household Income and Duration Interaction 1 56 Figure 4-6. Filipino Per Capita Household Income and Duration Interaction 1 57 Figure 4-7. Asian Indian Per Capita Household Income and Duration Interaction 1 58 Figure 4-8. Vietnamese Per Capita Household Income and Duration Interaction 1 59 Figure D-l Chinese Economic Measures and Disability by Duration 1 88 Figure D-2. Japanese Economic Measures and Disability by Duration 1 89 Figure D-3. Filipino Economic Measures and Disability by Duration 1 90 Figure D-4. Asian Indian Economic Measures and Disability by Duration 1 91 Figure D-5. Korean Economic Measures and Disability by Duration 192
Figure D-6. Vietnamese Economic Measures and Disability by Duration 1 93 vn LIST OF APPENDICES
Appendix A 165 NHIS Cohort Weighting Scheme for Chapter 3
Appendix B 177 Full Regression Models for Chapter 3
Appendix C 184 Age Standardized Disability Tables by Per Capital Household Income for Chapter 4
Appendix D 187 Graphs of Predicted Disability Prevalence and Economic Measures by Asian Appendix E 194 Full Regression Models for Chapter 4
vm CHAPTER 1
Introduction
The Asian immigrant population in the United States has grown considerably
within the past fifty years. Between 1970 and 2000, the number of immigrants from Asia
increased on average 4% per year. This steady immigrant flow has fueled the growth of
the overall Asian American population; between 2000 and 2010, Asians were the fastest
growing racial/ethnic group in the United States with a 43.3% percentage increase that
outpaced even Hispanics (Humes, Jones, & Ramirez, 2011).
As the Asian American population composes a more substantial segment of
American society, the importance of identifying forces driving their overall health
patterns becomes more significant as well. At first glance, the health status of Asians
appear very positive, as their health outcomes are very similar, or even superior to,
native-born Whites. Compared to other racial groups, Asians have lower prevalence of
chronic diseases, the longest life expectancy and favorable maternal and child outcomes
(NCHS, 2008; OMH, 2009). Their positive health patterns are statistically accounted for
by behavioral factors, such as a lower likelihood of smoking and drinking, or higher
economic resources (Rogers, Hummer, & Nam, 2000). Behaviors and resources may
empirically explain the Asian health advantage, but their prominence in the public health
1 literature obscures a full account of health influences arising from contextual and
environment factors.
A favorable health profile does not preclude Asian Americans from the negative
health consequences of a socially stratified society. As with other racial groups, Asians
have undergone social classifications that are predicated on the racial hierarchy that
creates and enforces social order. Racial categorization is a marker of the inequalities in
power and status, as American society has historically organized access to goods and
resources along racial lines (Smedley & Smedley, 2005). The eventual health impacts of
racialization can operate through racial residential segregation, experiences of racial
discrimination or inequitable medical access and care. These stressors and barriers can
erode health advantages as Asian immigrants interact with American society.
Asian Americans occupy a unique space within the racial hierarchy. One on
hand, they have long experienced negative social consequences of racialization. The
earliest Asian immigrants in the late 19th century were subject to segregation, racial
violence and eventual legal exclusion from the United States. The historical nadir of
their marginalization was the internment of Japanese Americans during World War II.
Current views of Asian Americans are less overtly negative, but are still informed by
stereotypes that depict Asians as un-American, foreign and untrustworthy. These views
are further fueled by national anxiety over the economic rise of Asian countries, first
Japan, then China and India.
On the other hand, Asians have access to educational and material resources that
are similar to those of the White American majority. The college graduation rates for
2 many Asian ethnic groups are well above the national average, as are the median
household incomes and percent in professional occupations (Census, 2011; Crissey,
2009). This duality forces us to acknowledge that the health impacts of racial
classification cannot be approximated by socioeconomic (SES) measures. Instead, we
must explicitly consider how the social, economic and political forces that have
determined a group’s content, importance and meaning (Omi & Winant, 1994), uniquely
impact health.
Migration and integration are the central pieces by which we understand Asian
Americans’ place in the American social hierarchy. Migration has established their
favorable population-level SES characteristics, but has also formed their status as
outsiders. Salient forces of migration and integration include immigration policy, labor
market conditions and coethnic communities. These forces create the context in which
Asian immigrants must operate in the United States, as well as underlie the population’s
characteristics. For example, immigration policy plays an important role in
understanding the current demographic and socioeconomic features of Asian Americans,
as it establishes definitive criteria for who can enter the United States (Park & Park,
2005). Accordingly, different eras of immigration policy have affected the characteristics
of the Asian population by setting various occupational or educational requirements.
Likewise, the occupational opportunities immigrants encounter in the labor market can
impact their subsequent socioeconomic status and available resources. Such a structural
analysis can expand our understanding of health production to include larger contextual
factors. In this dissertation, I examine the roles of migration and integration in
influencing the health trajectories of Asian immigrants. Health trajectories refer to the
changing health status of Asian immigrants as they spend more time in the United States.
They are of particular interest to public health researchers, as they provide insight into the
larger experiences of Asian immigrants in the United States and how they may affect
health. Currently, health trajectories are interpreted though a lifestyle and behavioral
framework that has shaped the majority of Asian American health literature. When we
apply a structural perspective, it widens our interpretive lens to create a more complex
picture of integration that considers several dimensions across which Asian immigrants
are being incorporated into American society. Specifically, I identify and test social
determinants of Asian immigrant health that originate from the historical and structural
forces that have surrounded their economic, social and cultural integration into the United
States. My dissertation is arranged by the following chapters. Chapter 2 is a critical
review of the literature on health trajectories among Asian immigrants. Chapters 3 and 4
are my two empirical papers in which I test two aspects of health trajectories.
In Chapter 2,1 review the current knowledge of health trajectories among Asian
immigrants. I then discuss acculturation theory, which is the most prevalent interpretation
of health trajectories. Acculturation theory assumes that as immigrants spend more time
in the United States, they adopt Western behaviors while simultaneously shedding their
ethnic lifestyles; worsening health is a consequence of poor diets and other harmful
lifestyle changes. I argue that the lifestyle and behavioral assumptions inherent in the
4 acculturation theory exclude explicit consideration of contextual factors that shape the
larger experiences of Asian immigrants in the United States.
I then present a model of understanding health trajectories that incorporates social
determinants of health that arise from structural forces. This model, called Contexts of
Disease, begins with a discussion of several ways in which Asian immigrants are being
incorporated into American society: economic, social and cultural. Economic integration
involves their employment and occupational trajectories. Social integration is
immigrants’ incorporation into American social structure that is racially stratified.
Cultural integration involves immigrants’ changing cultural identity, which is expressed
in one’s cultural practices, values and identification. These aspects of integration
produce health-related stressors and coping mechanisms that impact health outcomes.
For example, economic integration can offer material resources that offer better access to
medical care, social integration can produce stressful experiences of racial discrimination
and cultural integration can develop co-ethnic social networks.
These processes can interact in a number of ways, but I detail two examples of
contexts of disease: one is the intersection of economic and social integration and the
other is the intersection of social and cultural integration. I end my paper with a
discussion of how economic, social and cultural integration processes and their related
health outcomes can vary across different groups of Asian immigrants. I discuss
potential differences among different entry cohorts, Asian ethnicities, and gender.
The following two chapters empirically test aspects of my framework. Chapter 3
examines how groups of Asian immigrants entering the United States in different cohorts
5 may have unique health trajectories. I use Portes and Zhou’s segmented assimilation
theory as the theoretical framework for this paper. They suggest that an immigrant’s
integration depends largely on the circumstances that surround migration: pre-migration
characteristics and features of the receiving country, such as domestic policies, societal
reception and co-ethnic communities. Likewise, the health resources and detriments that
immigrants accrue from the various dimensions of integration will vary according to such
contexts of reception.
Between 1965 and 2000, Asian immigration was marked by distinct periods that
were impacted by certain immigration policies and had specific societal reception and
varying levels of co-ethnic support. I hypothesize that cohorts entering under different
periods would have demographic and health profiles that reflect the circumstances of
entry. For example, more recent cohorts would have better educational status and
baseline health because of restrictive immigration policies that favored the highly-skilled.
This selectivity could extend to health, as high educational attainment and migration
involves fitter and healthier individuals. I further hypothesize that immigrants entering
under separate periods would have unique health trajectories, in other words, that the
effect of duration would vary across cohorts.
I use the 1995-2005 waves of the National Health Interview Survey as the
primary analytic dataset for this paper. The NHIS is a repeated cross-sectional survey
with a nationally representative sample; this design enables me to create cohorts and
follow them through the survey waves. This quasi-cohort analysis provides a unique way
to examine both cohort and duration effects simultaneously in the same sample. My
6 analysis includes three physical health outcomes: disability, fair/poor self rated health and
obesity based on BMI.
Chapter 4 examines one of the contexts of disease examples I detail in my critical
literature review, the intersection of economic and social integration. Economics
research has found that immigrants earn more with increasing duration in the United
States. Economic assumptions about SES as a Fundamental Cause of Disease would
suggest that these rising material resources would translate into improving health
trajectories for longer-term immigrants, as high socioeconomic status (SES) can provide
better health care access, reduce one’s exposure to health risks or facilitate one’s
residence into a better neighborhood. This viewpoint does not consider potential
stressors that emerge from Asian immigrants’ social integration, such as racial
discrimination or barriers to upward mobility, such the glass ceiling. When we consider
social integration alongside economic integration, health trajectories are better
understood within a socio-ecological stress and coping framework, in which the stressors
and related resources arise from these dimensions of integration. While Asian
immigrants may be earning higher incomes with longer residence, they are also exposed
to stressors that originate from their marginalized status as non-White, foreign born. I
hypothesize that because of regular and continued engagement in the stress and coping
process, longer term immigrants will display the weakest relationship between income
and physical health measures. I also hypothesize that this pattern will differ across Asian
ethnicities, as the unique immigration histories and co-ethnic resources will differentially
impact the stress and coping process.
7 I use the 2005-2007 waves of the American Community Survey (ACS) to
conduct my analyses. This survey only includes one measure of physical health,
disability status. This measure assesses one’s sensory, physical, cognitive, self-care,
mobility and work limitations.
Instead of focusing on a single disease outcome in my empirical papers, I used
measures of general physical health. These measures align with the World Health
Organization (WHO) definition of health as a “state of complete physical, emotional and
social well-being, and not merely the absence of disease or infirmity,” (WHO, 1946).
Because I suggest that structural factors impact the entire health profile of Asian
immigrants, my measures are accordingly broad enough to include a range of possible
illnesses that can reflect the overall state of population health. I propose three measures to
assess general physical health: self-rated health, disability, and body mass index (BMI).
Self-rated health – This is commonly a single-item measure that asks respondents
to rate their overall health as excellent, very good, good, fair or poor. The measure
assesses health across a broad range of illnesses and is understood as “a summary
statement about the way in which numerous aspects of health, both subjective and
objective, are combined within the perceptual framework of the individual respondent,”
(Tissue, 1972). Self-rated health has been found to be a predictor of mortality, health
utilization behaviors, and disability (Benyamini & Idler, 1999; Ferraro, Farmer, &
Wybraniec, 1997; Idler & Benyamini, 1997; Idler & Kasl, 1995).
Disability – This outcome refers to limitations in tasks and roles that are caused by
one or more health conditions (Pope & Tarlov, 1991). It is a useful measure of overall
8 health because it encompasses specific health problems (disease or condition, a missing
extremity or organ, or any type of impairment), as well as disorders not always thought of
as health-related problems (i.e., alcoholism, drug dependency or reaction, senility,
depression, retardation) (IHIS, 2010). Disability is detrimental to one’s quality of life
and is predictive of mortality (Scott, Macera, Cornman, & Sharpe, 1997).
Obesity – This is a measure of body composition that is a strong risk factor for
chronic diseases, including Type II diabetes, gallbladder disease, high blood pressure and
osteoarthritis (Must et al., 1999). While the accuracy of self-reported height and weight
varies by sociodemographic characteristics (namely, age, ethnicity and gender)
(Engstrom, Paterson, Doherty, Trabulsi, & Speer, 2003), the limited work on Asian
Americans suggests that this will not impact their BMI classification (Brunner Huber,
2007). Including BMI will also provide a useful counter point to current interpretations
of health trajectories. Overweight/obesity or increasing BMI are the most-often studied
health outcomes in relation to a duration effect, most likely because of the close
connection to diet and exercise, two central factors in the lifestyle and behavior
framework. If my findings lend support to the role of contextual factors, I can offer
alternative interpretations of changing BMI.
Together, my three dissertation papers narrate a story about the structural
influences on Asian immigrant health trajectories. In doing so, I hope to demonstrate
how health can be produced from historical and contextual factors that are not typically
associated with physical health outcomes. This will expand our understanding of health
9 as a state of well-being, as well as the interconnected roles of policy, community and
individuals in shaping it.
10 References
Benyamini, Y., & Idler, E. L. (1999). Community studies reporting association between Brunner Huber, L. R. (2007). Validity of self-reported height and weight in women of Census. (2011). Money Income of Households—Median Income by Race and Hispanic Crissey, S. R. (2009). Educational Attainment in the United States: 2007. Washington, Engstrom, J. L., Paterson, S. A., Doherty, A., Trabulsi, M., & Speer, K. L. ( 2003).
Accuracy of self-reported height and weight in women: an integrative review of Ferraro, K. F., Farmer, M. M., & Wybraniec, J. A. (1997). Health trajectories: Long-term Humes, K. R., Jones, N. A., & Ramirez, R. R. (2011). Overview of Race and Hispanic Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of Idler, E. L., & Kasl, S. V. (1995). Self-Ratings of Health – Do They Also Predict Change IHIS. (2010). FLGOOUT: How difficult to go out to events without special equipment. Must, A., Spadano, J., Coakley, E. H., Field, A. E., Colditz, G., & Dietz, W. H. ( 1999).
The Disease Burden Associated With Overweight and Obesity. JAMA, 282(16), NCHS. (2008). Health, United States, 2008. Hyattsville, MD: National Center for Health OMH. (2009). Asian American/Pacific Islander Profile. Retrieved October 16, 2009, Omi, M., & Winant, H. (1994). Racial Formation in the United States from the 1960s to Pope, A. M. D., & Tarlov, A. (1991). Disability in America: Towards a National Agenda Rogers, R. G., Hummer, R. A., & Nam, C. (2000). Living and Dying in the USA: 11 http://www.ihis.us/ihis-action/variables/FLGOOUT http://www.omhrc.gov/tcmplates/browse.aspx?lvl=2&lvlid=53 Scott, W. K., Macera, C. A., Cornman, C. B., & Sharpe, P. A. (1997). Functional health Smedley, A., & Smedley, B. D. (2005). Race as biology is. fiction, racism as a social Tissue, T. (1972). Another Look At Self-rated Health Among the Elderly. Journal of WHO. (1946). Preamble to the Constitution of the World Health Organization as adopted 61 States (Official Records of the World 12 CHAPTER 2 CRITICAL LITERATURE REVIEW
Introduction Immigration has historically been one of the main political and social issues in the
United States. Within the past 40 years, however, the country has seen a dramatic
increase in immigration that is unlike any previous era. Accordingly, there is a growing
body of literature on the health status and health needs of these contemporary immigrants
(Kandula, Kersey, & Lurie, 2004). Of particular interest to public health researchers are
immigrants’ health trajectories once they have settled in the United States, as these
patterns represent the health consequences of integration processes. Acculturation has
dominated the public health literature as the primary influence on health trajectories. The
health impacts of acculturative processes have been largely conceptualized through
individual-level behavioral changes that represent the extent to which immigrants adopt
unhealthy “Western” lifestyles and shed ethnic resources that are thought to be health-
protective, such as social networks and ethnic diets (Abraido-Lanza, Armbrister, Florez,
& Aguirre, 2006; Salant & Lauderdale, 2003).
The emphasis on individual-level change can diminish the significance of other
dimensions of integration. Immigrants are not only changing their behavior, but are
becoming incorporated into American society across many levels. Social, economic and
cultural aspects of integration have been examined in other disciplines, but their health
13 impacts have not been widely explored. These forms of integration may also contribute
to a more complete understanding of immigrant health patterns, as they better incorporate
structural factors that influence all aspects of incorporation into the United States.
For Asian Americans, factors that influence immigrant health are critical to
understanding overall population-level health patterns, as the population is primarily
foreign-born. In this critical literature review, I will review our current knowledge on
Asian immigrant health trajectories and discuss their popular interpretations. I will then
present new framework for understanding population-level Asian immigrant health
trajectories called Contexts of Disease that is guided by principles of social determinants
of health. A social determinants perspective considers key determinants of health status
to be cultural, social and economic factors, over such individual-level factors such as
medical care inputs or utilization (Dunn & Dyck, 2000). This framework augments our
understanding by casting a wider net for identifying health influences to include
economic, social and cultural dimensions of integration processes that have not
previously been considered in health trajectories. My discussion of the framework ends
with a consideration of how contexts of disease can vary across groups with different
contexts of reception into the United States.
Asian Immigrant Health Trajectories
Much of our current knowledge on immigrant health trajectories comes from the
body of literature that examines the relationship between duration of residence in the
United States and health. This literature provides a descriptive overview of Asian
immigrants’ health patterns as they spend more time in the United States. Duration
14 represents processes of integration that progress with longer residence in the United
States. There are several kinds of health trajectories we can expect: immigrant health
profiles can improve with increased residence in the United States, such that those with
longer duration have lower disease prevalence than more recent immigrants; they can
worsen such that those with longer duration have higher disease prevalence than recent
immigrants; or they can remain relatively stable, controlling for other factors.
This section examines 43 quantitative studies of Asian immigrants that assess the
effect of years in the United States on health outcomes. The studies were located through
a key word search using “Asian”, “immigrant”, “duration” and “health” on Pubmed and
Google Scholar journal databases. Additional studies were identified through a citation
search of frequently cited papers duration and health among Asians (Cho & Hummer,
2001; Frisbie, Cho, & Hummer, 2001).
Findings from the Current Literature
Notably, there is some evidence for changing health status with increased
residence in some health outcomes, but not others. There is little evidence that mental
health, as measured by symptoms of psychological distress, depressive symptoms, or
mood or anxiety disorders, worsens with longer U.S. residence (Dey & Wilson Lucas,
2006; Diwan, Jonnalagadda, & Gupta, 2004; W. H. Kuo, 1976; Marshall, Schell, Elliott,
Berthold, & Chun, 2005; Mossakowski, 2007; Zhang & Ta, 2009).
On the other hand, physical health outcomes, such as BMI, number of chronic
conditions, self-rated health and disability, appear to show some evidence of a duration
effect in aggregated Asian populations, such that there is a higher likelihood of worsening
15 health across these measures with longer US residence (de Castro, Gee, & Takeuchi,
2008b; Dey & Wilson Lucas, 2006; Frisbie et al., 2001; Goel, McCarthy, Phillips, &
Wee, 2004; Lauderdale & Rathouz, 2000; Y. Park, Neckerman, Quinn, Weiss, & Rundle,
2008; Roshania, Venkat Narayan, & Oza-Frank, 2008; Sanchez-Vaznaugh, Kawachi,
Subramanian, Sanchez, & Acevedo-Garcia, 2008; Singh & Miller, 2004; Singh &
Siahpush, 2002; Zhang & Ta, 2009). Even within a single physical health outcome,
however, support for the trend varies across different measures. For example, in studies
of disability in nationally-representative samples of aggregated Asians, the negative
duration effect is seen in bed days and work disability (Dey & Wilson Lucas, 2006;
Frisbie et al., 2001; Ro & Gee, 2009; Singh & Siahpush, 2002), but not consistently in
mobility, activity and self-care limitations (Frisbie et al., 2001; Mutchler, Prakash, &
Burr, 2007; Ro & Gee, 2009; Singh & Miller, 2004). The majority of these studies were
conducted with large-scale, nationally representative samples, suggesting that the
heterogeneity is not due to sampling biases or methodological differences, but because of
underlying variation in the duration effect. While this variation does not itself cast doubt
on acculturation, the inconsistencies suggest complexity within duration’s health effect.
Even within the relatively robust physical health patterns, health trajectories
appear to vary by sample and sociodemographic characteristics. While the majority of
physical health studies were conducted on nationally-representative samples of the
aggregated Asian population, some studies used non-random community-based samples
of specific Asian ethnicities and did not find evidence of worsening health with increased
time in the United States. For example, poorer self-rated health was associated with
16 longer duration in a nationally-representative sample of aggregated Asians (Frisbie et al.,
2001), yet this relationship was not present among a sample of Korean older adults
affiliated with Florida-area churches and senior centers (Jang, Kim, & Chiriboga, 2005).
The differences across populations can arise from the weaker methodology of the smaller
non-random samples, but can also be suggestive of heterogeneity in integration
experiences across Asian ethnicity, ages, age at migration and gender.
Age and gender are two such characteristics that have been shown to moderate
health trajectories in nationally-representative datasets. Lauderdale & Rathouz (2000)
found that the effect of duration on the odds of obesity and overweight differed across
men and women; women had higher odds for more substantial weight gain. Increasing
years in the United States was associated with a higher odds for overweight among men
and obesity among women. Two studies found a moderating effect of current age on the
relationship between duration and disability status; a relationship between longer duration
and poorer disability outcomes was more pronounced among younger immigrants (Ro &
Gee, 2009), but did not exist among elderly Asian immigrants (Mutchler et al., 2007).
Current age may mitigate the differences in health between elderly short-term and longer-
term immigrants, as the natural aging process may overtake any health benefit of a
shorter duration.
Years in the United States provide a broad view of health trajectories, yet they do
not offer insight into actual health risks or health-related processes that are occurring with
increased residence. Health behaviors are one potential mechanism that can lead to
changing health with duration, but they have not been widely researched. Fewer studies
17 still consider these changing health patterns with a health outcome. The few available
studies suggest longer term-immigrants consume fewer vegetables, yet exercise more and
smoke more or less, depending on gender. The methodological limitations of these
studies weaken their conclusions; the majority of these studies used non-random samples
with small, unique populations (Misra, Patel, Davies, & Russo, 2000; Parikh, Fahs,
Shelley, & Yemeni, 2009; Taylor et al., 2007). For example, one study sampled
respondents from a member directory of a national organization of Punjabi Indians.
However, the few studies that have used nationally-representative datasets confirm some
of the findings from smaller studies (Kandula & Lauderdale, 2005). The health behaviors
that appear to be related to increased duration (i.e., more exercise, yet unhealthier diet)
oppose one another, leaving little clarity about the nature of the actual health outcomes
that can be predicated on these behaviors.
Implications of Findings
Patterns in the published literature expose the many gaps in our understanding of
health trajectories and health-related integration processes among Asian immigrants. Our
comprehension of the nature of health trajectories may be sparse, but this review also
points to future directions.
First, health trajectory patterns vary across health outcomes. While there does not
appear to be a significant relationship between mental health and duration, duration is
most robustly associated with physical health outcomes in the empirical literature,
particularly BMI, chronic conditions and self-rated health. Although there were
differences across these general physical health outcomes in the preliminary data
18 analyses, they may still be a more useful starting point for investigating a new framework
over specific disease outcomes, as health behavior mechanisms or other more proximal
health risk factors have not yet been convincingly identified. There some is evidence of
changing health behaviors with increased years of U.S. residence, yet these studies have
some methodological limitations and interpretation weaknesses.
Further, there is no one clear health trajectory pattern, as the relationship between
duration and health varies widely in different analytic scenarios across health outcomes,
groups and diverse demographic characteristics. If we understand years in the United
States to represent processes of integration that impact health trajectories, it seems that
Asian immigrants have a complex picture of integration. If acculturation was indeed the
chief process, we would expect to see negative relationship, whereby increasing duration
is associated with worsening health. Instead, the literature implies that duration can
represent other processes that may have different health impacts. Ascribing duration-
associated health variation to acculturation alone overlooks these potentially important
processes. Future research should consider the role of these alternative pathways and
better elucidate their role in immigrant integration and subsequent health patterns.
Finally, there is heterogeneity in the duration effect within the population of
Asian immigrants. In the empirical literature, age and gender appear to moderate the
effect. Younger immigrants and men display a more positive relationship between
duration and health outcomes compared to older immigrants and women. Another
important source of heterogeneity is across Asian ethnic groups. While the absence of an
obvious duration pattern among the different Asian ethnic groups could be due to smaller
19 sample sizes that reduce statistical power, it is also possible that ethnic differences
encompass influential differences in immigration history, diet, regional concentration,
labor market patterns and sociodeomographic characteristics. Future research should
consider whether such can factors impact health trajectories.
Acculturation and Health Trajectories
Acculturation is the most prevalent explanation for changing health trajectories
associated with integration, yet it falls short in elucidating the complexity we see in the
literature. First, it assumes that all groups experience the same advancement towards
Anglo-conformity and does not consider variations from this integration process.
Secondly, pathways between acculturation and health outcomes have been limited to
individual-level behaviors. Finally, its definition and measurement throughout the
literature have been vague, leaving few clear health-related mechanisms. In this section,
I review the literature on acculturation and health and offer critiques of acculturation
theory that underscore the need for a more comprehensive understanding of Asian
immigrant integration and subsequent health outcomes.
Acculturation is formally defined as a process of change that two societies and
their respective individuals undergo when they come into contact (Moyerman & Forman,
1992). Early definitions considered dynamic changes in both immigrants and the
receiving society. Robert Park (1928) was among the first social scientists to suggest that
migration was inevitably accompanied by social change. The migrant would be
“emancipated” from the social norms of his home society and eventually would “learn to
look upon the world in which he was born and bred with something of the detachment of
20 a stranger”. With this new enlightenment, migrants would break down historical and
traditional bonds of their new countries and expedite a new social order. Out of this
conceptualization came one of the classic definitions of acculturation from Redfield,
Linton, and Herskovits (1936) who said it was a “phenomena which result when
individuals having different cultures come into first-hand continuous contact, with
subsequent changes in the original culture patterns of either or both groups”.
Park’s protegee, Milton Gordon (1964), identified three potential assimilation
outcomes: Anglo-Conformity, The Melting Pot and Cultural Pluralism. While Gordon
initially conceived a variety of possible outcomes, he came to assume that acculturation
primarily involved Anglo-Conformity, or change on the part of an immigrant group in the
direction of middle-class Anglo culture (Alba & Nee, 1997). His viewpoint heavily
influenced subsequent scholarship and Anglo-Conformity has become the prevalent
framework for acculturation as it is studied in social sciences today (Salant & Lauderdale,
2003). Marmot and Syme (1976) were among the first to consider the health effects of
this process. They examined the role of acculturative factors in predicting rates of
coronary and heart disease (CHD) among Japanese Americans living in California. Their
work was preceded by a series of articles from the Ni-Hon-San Studies, a collaborative
study in Japan, Hawaii and California that documented a gradient of coronary heart
disease among Japanese men; men in Japan had the lowest rates, Japanese in Hawaii had
intermediate rates and Japanese in California had the highest. This gradient was not fully
explained by differences in behavioral risk factors, such as diet or smoking (Marmot et
21 al., 1975; Worth, Kato, Rhoads, Kagan, & Syme, 1975). Marmot and Syme hypothesized
that this gradient could be explained by the loss of protective Japanese cultural features
due to increasing acculturation.
In their sample of Japanese-American men, they measured acculturation in three
ways: culture of upbringing, cultural assimilation and social assimilation. They found
that each of the acculturation measures was associated with increasing prevalence of
CHD, net of dietary preferences, smoking and other CHD risk factors. Out of the
acculturative measures, culture of upbringing had the strongest effect on CHD; those
respondents reporting a more Japanese upbringing had lower odds for CHD. They
concluded that social and cultural factors play an important role on the etiology of CHD
and that the retention of non-Western cultural values may be protective.
Marmot and Syme’s analysis was novel in its emphasis on the influence of social
and cultural factors, over and above typical physiological risk factors associated with
CHD (serum cholesterol levels, blood pressure, body weight). However, subsequent
scholarship has not expanded upon these early findings to improve our understanding of
the relationship between acculturation and health. As a result, many of the limitations of
this landmark study have become emblematic of the shortcomings of the larger field.
One limitation was their placement of Japanese and Western culture at two ends
of a continuum with immigrants invariably becoming more Westernized at the expense of
their Japanese cultural orientation. The complexity in the health trajectory empirical
literature casts doubt on this linear progression. Even within Marmot and Syme’s study,
we see evidence of a complex picture of integration and health outcomes. They created
22 an acculturation typology by crossing culture of upbringing by social assimilation,
resulting in three categories: 1) traditional (traditional upbringing/no social assimilation),
2) intermediate (traditional upbringing/social assimilation, Western upbringing/no social
assimilation) and 3) non-traditional (Western upbringing/social assimilation) groups.
They found a gradient of CHD prevalence that progressively increased from traditional,
intermediate and non-traditional. However, their definition of acculturation may be
better exemplified by the intermediate group, as they experienced the highest degree of
cultural change as they moved from a traditional upbringing to social assimilation. The
prevalence of CHD for the intermediate group was lower than the non-traditional group,
however.
A related limitation was their assumption that much of the health impacts
emerged from behaviors that reflected immigrants’ changing lifestyles. This lifestyle and
behavioral interpretation has become the standard way by which to understand
acculturation’s health effects. A commonly cited definition in public health research
describes acculturation as “process whereby immigrant change their behavior and
attitudes towards those of the host society,” (Rogler, Cortes, & Malgady, 1991). While
behaviors are certainly immediate health influences, this narrow view of acculturation is
problematic because it disregards contextual factors that shape the social and political
landscape that determine the kind of lifestyle and subsequent behaviors immigrants will
adopt.
Gordon’s conceptualization of immigration was essentially an optimistic one; he
believed that immigrants would naturally progress through stages that would eventually
23 lead to assimilation. This suggests that acculturation is progressive; an individual begins
with cultural acculturation and ends with complete assimilation, the latter characterized
by the “absence of value and power conflict” with the host society (Hazuda, Stern, &
Haffner, 1988). There are some historical precedents to his theory, such as German,
Italian, and Irish immigrants who migrated to the United States in the late 19th century
and have become interwoven in American society (Alba & Nee, 1997). There is no
mention, however, of structural or social barriers that might impede this progression,
leading one to assume that as individuals adopt “American” ways of life and
understanding, they will seamlessly integrated into mainstream society.
Waters (1999) denies such a benign view of the social landscape and suggests that
immigrants are thrust into a racial hierarchy that has been forged through historical
struggle and maintained by enduring discrimination. In other words, we cannot separate
the immigrant experience from issues of race and power that dominate social hierarchies.
Likewise, Bhatia and Ram (2001) argue that unless we consider the existing class and
racial structures of the host society when considering acculturation, “we undervalue the
asymmetrical relations of power and the inequities and injustices faced by certain
immigrant groups as a result of their nationality, race or gender.” Their arguments were
preceded by Shibutani and Kwan (1965), who argue that how a person is treated in a
society depends “not on what he is” but on the “manner in which he defined”. In their
view, immigrant cultural change, as conceptualized by increasing acculturation, is
impeded by limitations that originate from the fundamental color line between Whites
and non-Whites.
24 As public health researchers move towards ecological understandings of health
that highlight the dynamic interplay between individuals and their social and physical
environments, the lifestyle and behavior framework that assumes progression towards
Anglo norms appears incomplete. Conflating health trajectories with acculturation
bolsters two assumptions about Asian immigration integration that promote Gordon’s
simplistic acculturation process. First is the inevitability and linearity of acculturation.
This process is thought to operate at a linear pace that can be approximated in year
intervals and advances in a similar fashion across different Asian sub groups, ages and
genders. The second assumption is that Asian immigrant health (and any associated
changes) is largely a product of individual behaviors and cultural beliefs, keeping much
of the discussion of immigrant health at this level of understanding.
The field has grown considerably since Marmot and Syme’s study was first
published. Hunt et al. (2004) document over a six-fold increase in the acculturation
literature on Medline in the thirty-year period between 1970 and 2000. The upsurge in
the literature has not demonstrated a convincing pattern between acculturation and health
or a common explanation of why it would affect health (Salant & Lauderdale, 2003).
The messiness of the acculturation and health literature can stem from the
ambiguity of the acculturation concept itself. While the concept has been part of the
national lexicon for nearly as long as the history of American immigration itself (Glazer,
1993), it remains notoriously vague and dynamic. The concept is rarely articulated
clearly in empirical work and is presumed to be implicitly and commonly understood. As
Hunt et al. (2004, p. 974) state in their critical review of acculturation in Hispanic health
25 research, “Fuller delineation of the concept is left to a presumed understanding of what
constitutes a culture, which traits should be ascribed to the ‘mainstream’ versus the ethnic
culture, and what adapting to a new cultural system might entail”. Similar critiques have
been leveled at the construct in Asian immigrant health research (Salant & Lauderdale,
2003). The wide range of proxy measures for acculturation reflects the field’s lack of
definitional convergence; the concept has been measured as language proficiency, social
contacts or relationships, nativity, duration of residence in new country, cultural
participation and “western lifestyle” (Salant & Lauderdale, 2003). Each of these
measures is assumed to be a mechanism by which acculturation affects health, but the
array of measures suggests that there are a host of mechanisms that acculturation initiates,
some of which have contradictory hypotheses on health outcomes. On one hand,
increased acculturation is thought to lead to better health outcomes, as immigrants
consume healthier foods, exercise more and experience fewer barriers to care with
increased familiarity of the United States. Conversely, acculturation is also hypothesized
to lead to worse health outcomes, as immigrants experience more social or health
disadvantages with greater integration into the United States. Further, with increasing
acculturation, they also adopt unhealthy habits and lifestyles that are associated with poor
health in American society (Abraido-Lanza et al., 2006; Takeuchi, Hong, Gile, &
Alegria, 2007). The range of measures and potential theoretical pathways produce
different results, leaving few robust theories about the relationship of acculturation on
health. 26 Assuming that acculturation drives Asian immigrant health trajectories without
considering the drawbacks in the acculturation literature obscures our identification of the
specific integration processes that impact immigrant health. Given the variety of
acculturation measures, we do not gain any specific knowledge of specific health-related
processes when we simply attribute any changes in immigrant health to “acculturation” or
“changing lifestyles”. It is unclear whether more years in the United States assumes that
respondents have changed their diets, acquired better language skills, achieved social
mobility, shed ethnic identity or adopted other “westernized” lifestyle changes. In this
way, we perpetuate the pervasiveness of acculturation without adding any specific
knowledge of heath-risks or resources immigrants accrue.
New Framework for Understanding Asian Immigrant Integration
In light of the shortcomings of the extant literature, I develop a new social
determinants of health framework of understanding Asian immigrant health trajectories
that stands in contrast to popular lifestyle and behavioral frameworks that are closely tied
to acculturation theory. This new framework, called Contexts of Disease, assumes that
Asian immigrants’ health trajectories are produced within the structural constraints of
their place in the new American society, their interactions with non-immigrants, their
labor experiences and their developing ethnic identity. These forces manufacture health
risks, buffers and resources that are jointly experienced by Asian immigrants to impact
their overall health patterns.
The framework begins with the identification of several dimensions across which
Asian immigrants experience integration. The idea that integration can occur across
27 several dimensions is not new; Gordon (1964) identified seven dimensions of
assimilation: cultural/behavioral, structural, marital, identificational, attitude receptional,
behavior receptional, and civic. While his original typology has fallen out of favor (Alba
& Nee, 1997), identifying multiple components of integration considers specific health-
related resources and risks across multiple aspects of the immigrant experience. I
identify three dimensions of integration that may be related to health outcomes among
Asian immigrants: economic, social and cultural. Economic integration involves their
employment and occupational trajectories. Social integration is immigrants’
incorporation into American social structure that is racially stratified. Cultural
integration involves immigrants’ changing cultural identity, which is expressed in one’s
cultural practices, values and identification.
I explore the health consequences of these processes through a concept called
Contexts of Disease, which are formed from the intersecting resources and stressors from
each form of integration. These contexts of disease arise from social-ecological theories
of health, which suggest that proximal health influences arise from individual’s
adaptation to their surroundings. I also use stress and coping theories to explain how
resources and barriers from integration processes can produce health outcomes. I provide
two examples for Asian immigrants and discuss their potential health outcomes.
I end my framework with a discussion of how integration experiences can differ
across groups of immigrants with alternative characteristics. I use Portes and Zhou’s
segmented assimilation as a guiding theory to explain why different groups experience
alternate integration. This theory suggests that contexts of reception, such as policies of
28 the host government, the values and prejudices of the receiving society, and the
characteristics of the coethnic community, determine the kinds of integration experiences
immigrants will have. For Asian immigrants, this might be best illustrated in different
year of entry cohorts, as these cohorts entered under unique U.S. immigration policy eras,
geopolitical circumstances and societal receptions. Other potentially salient group
differences are Asian ethnicity and gender.
Dimensions of Integration
Economic Integration
The economic integration of immigrants considers their economic and work
trajectories as they spend more time in the United States. The economic integration of
immigrants has been considerably researched in the economics literature. Among the
first researchers to consider immigrants’ wage earnings over time was Barry Chiswick
(1978). Using the 1970 Census, he found that the foreign-born appeared to have a
particular pattern of wage earnings with increasing duration in the United States. While
they experienced an initial decline in wage earnings in the first five years after
immigrating, over time, their wages increased, eventually surpassing the native born in
11 or 12 years.
Chiswick’s work combined all immigrants to the U.S., but his patterns have been
replicated in studies of individual Asian ethnic groups as well. Zhou and Kamo used the
1980 Census to examine wage assimilation, analyzing the Chinese and Japanese groups
only. They found that Chinese immigrants had similar wage assimilation patterns as
Chiswick’s model, but the Japanese immigrants did not. The explained the difference by
29 employment circumstances; many Japanese immigrants were for Japanese companies
abroad, making their wages high upon entry to the United States. The Chinese, in the
other hand, represented a common model of wage assimilation found among immigrants
(Zhou & Kamo, 1994). More recently, Akresh found support for Chiswick’s model of
wage assimilation among all immigrants in the baseline survey of the New Immigrant
Survey (NIS), but did not stratify Asian immigrants (2007).
Some have called Chiswick’s analysis and others that have used similar methods
into question, primarily due to their use of cross-sectional data to infer a time-related
pattern. Borjas, in particular, questioned Chiswick’s findings after using a quasi-cohort
analysis to examine earnings patterns over time. Using the 1970 and 1980 censuses,
Borjas argued that the higher wages that longer-term immigrants enjoyed was due to
changes in the human capital and occupational skills between newer and older
immigrants (Borjas, 1985). In particular, newer immigrants (those entering the U.S. after
1970) did not experience the same levels of wage assimilation compared to their older
counterparts. Borjas suggested this was due to the declining “quality” of newer
immigrants.
Despite the heated debate, Borjas’ quasi-cohort model still suggests wage increase
among immigrants, although not at the same speed as Chiswick’s models. This was
especially the case for Asian immigrants, who still displayed substantial within-cohort
increases of up to 20% between the 1970 and 1980 censuses (Borjas, 1985). While
Borjas’ analysis does not suggest complete wage assimilation with native-Whites, the
30 within-cohort increases that were commensurate with more years in the United States still
suggest an underlying process whereby immigrants increase their earnings with duration.
Others have adopted Borjas’ quasi-cohort analysis and have found similar within-
cohort increases for Asian immigrants. Lalonde and Topel (1991) replicated his findings
in the 1980 Census and found that Asian immigrants experienced higher wages with
increasing duration in the United States, but did not reach convergence with native-born
Whites because of their substantial disadvantage immediately post-migration. Scheoni
(1997) found that a combined sample of Chinese, Korean and Japanese immigrants from
the 1970, 1980 and 1990 Censuses experienced substantial wage increases with duration,
eventually surpassing the wages of native-born Whites. Filipino also experienced wage
increases, but did not converge with native-born Whites. Central to this debate is
whether the foreign-born reach the same wage levels as Whites; what does not appear to
be in dispute is the increase in earnings over time.
One of the most commonly accepted explanations for wage assimilation is the
human capital argument (Akresh, 2007; Borjas, 1985; Chiswick, 1986). Human capital is
the set of intangible resources embedded within individuals that influence their future
income (Becker, 1962). Examples of human capital include education or on-the-job
training. According to this theory, the initial depression in earnings is due to a period of
resource-intensive investment in human capital that commences upon arrival to the
United States (Chiswick, 1986). During this period, immigrants are learning job skills
that are specific to the U.S. labor rnarket, such as English language skills, US-specific
professional skills, and professional contacts. Because of selective migration (such that
31 talented economic migrants are motivated to migrate for better occupational rewards in
the United State vis-a-vis their home countries) these immigrants possess an advantage in
the acquisition and application of human capital. As a result, immigrants can readily
transfer their newly acquired human capital characteristics towards securing better
occupational opportunities, which can be seen in their improved employment status,
occupation and w age.
Social Integration
The social integration of Asian immigrants involves their integration into a
racialized social hierarchy and the experiences and encounters associated therein. This
dimension of integration can range from immigrants’ growing understanding of the
American social hierarchy (Waters, 1999), to their personal encounters and relationships
with members of the host society (Massey, 1981). Consistent across this range is the
role of national understandings of citizenship and migrants’ rights in determining the
nature of these interactions (Ager & Strang, 2008). In this way, the social integration of
Asian immigrants must consider how the racial formation of Asians, that is, the “Asian
race”, has developed into a salient social construct (Omi & Winant, 1994). Such
racialization constructs a distinct group that is attributed with certain value-laden
characteristics and stereotypes (Griffith, Johnson, Ellis, & Schulz, 2010).
As immigrants enter a new society, their identity as foreigners quickly intersects
with the social and racial hierarchy (Waters, 1999). Throughout history, immigrants have
been targets of hostility and suspicion, particularly during periods of economic hardship
or war. Immigrants from southern and Eastern Europe in the early 1900’s were heavily
32 ostracized upon entering the United States (Alba & Nee, 2003). While obvious hostility
may not be as evident today, recent policies, such as Arizona’s racial profiling law,
English-only statutes, limitations to immigrants’ education and social services, and other
anti-immigrant policies, are underwritten by individuals and organizations with strong
nativist sentiments (Hing, 1997).
This racial hierarchy is complicated by the centrality of the immigrant story in
America’s narrative of national history. The United States is routinely referred to as a
country of immigrants; this representation has given rise to enduring notions about the
nature of the United States. Geronimus and Thompson identify one such ideology, the
“American Creed”, which proposes that success is available to individuals who are
committed to hard work and have the determination to succeed (2004). This ‘American
Creed’ ideology props up notions of personal responsibility and hard work, which are
underscored by the assumption of equality for those who try hard. Immigrants fully
embrace America as a land of opportunity (Espiritu, 1994), which motivates them
towards sacrifice and hard work.
For Asian immigrants, the juxtaposition of the American Creed ideal and the
racialized social hierarchy have been defining features in their racialization process; that
is, the creation of the Asian race as a salient construct with value-laden characteristics
that are used to classify and arrange social relationships. On the one hand, their
educational and occupational achievement is held as proof of the validity of the American
Creed. This ‘model minority’ stereotype is a widely-held view of Asian Americans that
emphasizes the role of cultural values in their perceived economic and academic success
33 (Suzuki, 1977). Although this stereotype can lead to favorable judgment by the White in-
group, it is simultaneously linked to ostracism by both Whites and non-Whites.
This phenomenon, called “racial triangulation”, situates Asians between Whites
and non-Whites in the racial landscape. On one hand, Asians are viewed as competent
and hard-working, but their citizenship is continually in question. The continual use of
the “model minority” label maintains a degree of differentiation of Asians from Whites,
despite their similar educational and occupational achievements (Chang, Tugade, &
Asakawa, 2006). Further, Whites’ valorization of Asians as a successful minority
relative to other racial groups fosters fractious inter-racial relationships, perpetuating a
zero-sum mentality whereby only a single racial group can operate successfully within
the American racial landscape (C. J. Kim, 1999). Asians are lauded for their dutiful
commitment, yet they are concurrently viewed as having few or no barriers to their
success, controlling too much economic power and working too hard to succeed. This
has resulted in inaccurate interpretations of Asian American “culture” (i.e., deferential,
authoritarian) and increased frictions among other racial groups who are simultaneously
vilified for their poor work ethic (C. J. Kim, 1999; Lee, 2000).
Research on attitudes towards Asian Americans provides a glimpse into the
complex racial landscape in which Asian immigrants must operate. While the model
minority trope implies that Asians have few experiences of discrimination and barriers to
integration, empirical work on Americans’ views of Asians suggest otherwise. Lin and
colleagues found that Asians were viewed as having high competence but low sociability.
Among their sample, low sociability was the driving factor behind rejection of Asian
34 Americans, as measured by high scores on an anti-Asian stereotypes scale and social and
cultural avoidance of Asians (Lin, Kwan, Cheung, & Fiske, 2005). In the 2000 General
Social Surveys, Asians consistently had the most social distance with other racial groups.
Among White respondents, only 6% expressed compatibility with Asian groups,
compared to 15% for Blacks and 13% for Hispanics. Thirty-two percent of Whites
considered Asians the group they had the least in common with, the highest out of all
racial groups (Smith, 2001). Similarly, a Los Angeles Times poll found that over half of
Black and Latino respondents and over forty percent of Whites considered Asians
“inscrutable”. Asians are not viewed as facing any racial discrimination; less than 20%
of all respondents in the Los Angeles Times poll thought that Asians faced any barriers to
equal opportunities. White respondents believed Asians had fewer barriers than did their
own fellow whites. In fact, White, Black and Latino respondents reported that Asians
held too much economic power and worked the hardest to succeed- even more than
Whites (Lee, 2000).
One outcome of Asian immigrants’ social integration is experiences of racial
discrimination. Contrary to beliefs that Asians do not experience discrimination, reports
of discrimination suggest that it is a common experience in their interpersonal exchanges.
In a Commonwealth Foundation survey, 18% of Asians believed that they would have
received medical better care had they been of a different race or ethnic group. The
National Latino and Asian American Survey (NLAAS), the first national psychiatric
epidemiological study that solely surveyed Latinos and Asians, found that over ten
percent of the Asian sample reported frequently feeling that they are treated with less
35 courtesy than others. Nearly 18% of the Asian sample reported that they are sometimes
or often disliked because of their race. The rates vary among the different ethnicities,
with certain groups like the Filipinos, having higher discrimination prevalence than
others. Over 20% of the total Asian sample in the California Health Interview Survey
(CHIS) reported experiencing poor treatment because of their race in a medical setting
sometimes or often (Gee & Ro, 2009).
Cultural Integration
This form of integration concerns cultural identity development, which focuses on
the individual-level experiences of immigrants and considers their adaptation of personal
values and beliefs as they interact with American society. Expressions of cultural
identity can include cultural practices, values and identification (Schwartz, Unger,
Zamboanga, & Szapocznik, 2010). Cultural practices are the lifestyle choices and
behaviors such as language use, media preferences, social affiliations, and cultural
customs and traditions. Cultural identification is the attachment to a cultural group and
the positive esteem derived from it. This aspect has been explored in other concepts as
ethnic identity, which is generally seen as having self-identification, feelings of
belongingness and connection to a group, a sense of shared values and attitudes towards
one’s ethnic group (Phinney, Horenczyk, Liebkind, & Vedder, 2001).
As immigrants first enter the United States, they encounter a new environment
with distinctive characteristics that order routines of daily living, such as language use or
communication patterns. Qualitative works and literature have aptly chronicled the
loneliness, fear and alienation that often accompany immigration (Constantine,
36 Kindaichi, Okazaki, Gainor, & Baden, 2005; Yoon, Lee, Koo, & Yoo, 2010). Kim
describes the feelings this way:
Some of the surprises may awaken or shaken strangers Early researchers coined the phrase “culture shock” (Oberg, 1960), which has
become a popular term to describe social difficulties and psychological reactions to
unfamiliar cultural environments. In her model of cross-cultural adaptation, Kim (2001)
uses tenants of ecological systems theory to suggest that these factors create
environmental fluctuation to which immigrants must respond in order to achieve an
overall “fit” between the individual and the environment. She goes on to propose that as
immigrants confront environmental challenges and adapt to their immediate
surroundings, they in turn develop their cultural identities. This process encompasses a
dynamic negotiation between one’s original cultural orientations and the demands of the
new environment.
Several psychological models of cultural identity development that have been
applied to Asian Americans detail this process further (Uba, 1994, Phinney 1989). For
example, Uba applies the Minority Identity model to Asian Americans and identifies five
stages of ethnic identity development: Conformity; Dissonance; Resistance and
Immersion; Introspection; and Synergetic Articulation and Awareness (Uba, 1994). This
37 and similar models were developed primarily for heuristic use in clinical settings and are
not meant to classify individuals by personality sub-types. Instead, they view ethnic
identity as a positive resource that is achieved after serious consideration of one’s
affiliation with a marginalized group.
Contexts of Disease
While I have articulated economic, cultural and social integration separately,
these processes do not occur in isolation from one another. Some researchers have
suggested that different dimensions of integration occur chronologically, most often with
economic integration preceding social and cultural integration (Bean & Stevens, 2003).
It is possible that economic integration may facilitate certain social and cultural
experiences, but a temporal ordering is difficult to establish. Instead, immigrants are
simultaneously undergoing occupational-related development while interacting with
American society and developing their cultural identities.
Likewise, the respective health resources and risks from each dimension of
integration are simultaneously experienced. In this way, the physical health effects of
integration may best be understood in the interactive or cumulative effects of economic,
social and cultural integration. The processes of integration create contexts of disease
which are the collective health-related resources and barriers that result from the
economic, social and cultural integration. For example, economic integration can
produce material resources, such as residence in wealthier neighborhoods or access to
better medical care. Social integration can produce social mobility resources, such as
38 social capital, or stressors, such as experiences of racial discrimination. Cultural
integration can provide such resources as co-ethnic identity.
Contexts of disease can be understood through the combination of two
interpretive frameworks: social-ecological theories of health and stress and coping
theories. Social-ecological theories of health have their roots in ecology, which asserts
that living organisms continually adapt to meet the changing demands of their
environments. Social-ecological theories integrate social and biological reasoning to
explain how individuals “embody” historically and politically-produced environments in
their health behaviors and well-being (Krieger, 2001a, 2001b). The social and physical
environment can serve as a symbolic stimulus, leading individuals to alter their
behaviors, norms and problem-solving actions to avoid any potential harm.
Stress and coping theories also rely on this dynamic relationship and assert that
the environment can be a source of harmful contaminants or stressors (Moos, 1979).
These stressors produce health outcomes by impacting health directly or initiate coping
behaviors that have eventual health impacts.
Stressors can directly impact health by activating a physiological ‘flight or fight’
response that releases hormones, which in turn raise heart rate and blood pressure,
suppress the immune system and alter brain activity (McEwen & Seeman, 1999). When
such responses are perpetually maintained or accumulate over the lifecourse, they create
‘wear and tear’ on the body and have a greater negative health impact (McEwen &
Seeman, 1999). Measures such as allostatic load, an array of biomarkers that are
associated with a prolonged stress response, have been associated with increased risk for
39 decreased mental and physical functioning and cardiovascular disease (Seeman, Singer,
Rowe, Horwitz, & McEwen, 1997).
Coping responses are behavioral, emotional and social responses to stressors that
manage or alter the source of the stress and regulate stressful emotions (Folkman &
Lazarus, 1980). Coping strategies can directly harm health, such as through drug or
alcohol use (Chae, Takeuchi, Barbeau, Bennett, Lindsey, & Krieger, 2008; Chae,
Takeuchi, Barbeau, Bennett, Lindsey, Stoddard et al., 2008; Jackson & Knight, 2006).
Coping strategies can also indirectly lessen the effect of the stressor and its eventual
health impact. Syme first articulated this concept in relation to the contextual factors that
surround Black Americans and play a role in their higher prevalence of hypertensions
vis-a-vis Whites: “Those with hypertension seem to be faced with demanding social
situations in which aspirations are blocked, in which meaningful human intercourse is
restricted, and in which the outcome of important events in uncertain,” (1979, p. 96).
He suggested some that individuals in demanding situations must employ prolonged and
high-effort coping responses to attempt to control their environment.
This framework is inspired by Geronimus, James, Walters and Peasron, who have
adapted socioecological stress and coping models to take into account how communities
of color contend with stressors that arise from larger structural barriers. Geronimus’
weathering hypotheses considers how social inequity and racialized ideologies result in
African Americans’ disproportionate exposure to stress (Geronimus & Thompson, 2004).
James identifies John Henryism (JH) as a high-effort coping strategy that some African
Americans utilize when confronted with stressors. It is an outgrowth of larger ideology
40 that took hold of African Americans after Emancipation, where freed slaves adopted high
effort coping in order to create a new American identity, express core American values of
“hard work”, “self-reliance” and “freedom”, and resist new forms of oppression (James,
1994). The JH hypothesis states that continuous, high-effort coping with demanding
psychosocial stressors could compromise health among those with lower SES, as
environmental demands will exceed personal coping resources. Walters and Simoni’s
indigenist model of Native women’s health situates the stress-coping paradigm within the
larger context of Native women’s status as a colonized people. This unequal distribution
of power leads to large-scale instances of discrimination, which empirical evidence
indicates impacts Native women’s health trajectories (Walters & Simoni, 2002).
Pearson’s (2008) Shine Sociocultural and Structural Framework of Race/Ethnicity and
Health identifies several health valences across a variety of domains, including
ethnoracial assignment, ethnic identity, high-effort coping and social and economic
resources. He suggests that the combination of these positive or negative health valences
produce overall health status across different populations.
There has been some empirical exploration of these hypotheses among immigrant
populations (Haritatos, Mahalingam, & James, 2007; Wildsmith, 2002), yet the specific
barriers and resources that surround Asian immigrants require a unique model. While
these studies were novel in their attempts to expand the immigrants’ stress process to
incorporate the larger context, these hypotheses were developed for specific populations
with their unique histories in mind. For example, a high level of John Henryism is
hypothesized to lead to worse cardiovascular outcomes for Black Americans with fewer
41 material resources. For immigrants, however, the coupling of John Henryism and
material resources may propel immigrants to better health outcomes. Indeed, Haritatos
and colleagues (2007) found that John Henryism was predictive of better reports of self-
rated health, somatic symptoms and physical health functioning among Chinese and
Asian Indian immigrants. They found that high levels of JH mediated perceived stress
that was associated with worse outcomes for their three health measures. While
weathering, John Henryism and the indigenist models may not be fully applicable to
Asian immigrants, we can draw inspiration from their emphasis on the contextual to
develop a stress and coping process that is more directly related to the Asian immigrant
experience.
The health outcomes of varying context of disease are best illustrated in
examples that demonstrate the interconnected nature of economic, social and cultural
forms of integration. For the remainder of the section, I will detail several examples and
hypothesize how health outcomes may emerge.
Economic and Social Integration
The intersection between economic and social integration raises doubts whether
material resources from increasing economic means will confer benefits to groups that
have been historically marginalized. The resources that are assumed to accompany
higher SES may not have the same benefit for some groups if, for example, their social
position limits their access to certain goods or services or if the path to upward social
mobility takes such a toll on their health that it counteracts any resource-related benefits
(Pearson, 2008).
42 As previously discussed, immigrants’ earnings have been shown to increase as
they spend more time in the United States. The human capital theory attributes this
increase to improving job skills that are readily applied to occupational situations. Those
who consider SES a Fundamental Cause of Disease connect this process to better health
outcomes; increasing SES is beneficial for health, as higher SES can create resources that
protect health and promote salubrious behaviors (Link & Phelan, 1995). Higher SES can
provide opportunities to settle in neighborhoods that have better access to health-
promoting resources, including safe neighborhoods, nutritious foods, health services, and
leisure. Higher-income neighborhoods also do not have the toxins and other pollutants
that are direct health risks.
This sequence of events relies heavily on economistic assumptions. Geronimus
and Thompson (2000) describe economism as a deeply entrenched American ideology
that emphasizes the role of personal agency in placing individuals within social
hierarchies that lead to differential material outcomes. According to this view,
“individuals choose to invest in their human capital to best position themselves to engage
the market and fulfill their personal responsibilities” (2000, p. 252). Thus, economic
forces are the primary vehicle by which health is formed and material resources are the
most significant health influences.
When we consider the social integration of Asian immigrants alongside their
economic integration, we see that the road to upward economic status contains barriers
that are unforeseen in the economism narrative. Their high educational and occupational
achievement does not always translate into upward social mobility and proportionate
43 financial compensation. First, there appears to be a limit to how high Asians can advance
through employee ranks. While a large percentage of the male API workforce is
professional (23%), a substantially smaller percentage was in executive-managerial
positions (14%). White male Americans, however, have fewer professionals (14%) but
more of them advance to become executives or managers (17%) (Woo, 1994). In the
National Institutes of Health, Asian scientists make up 21.5% of the tenure-track
researchers, yet only 9.2% are senior investigators (tenured researchers) (Mervis, 2005).
Further, Asians do not appear to be compensated commensurate with their
education. While Asians as a whole have median incomes that are equivalent to White
Americans, their financial standing does not reflect their higher educational attainment.
Asians are often overeducated compared to Whites in the same occupational position
(Barringer, Takeuchi, & Xenos, 1990). Finally, Asians earn less over their lifetime
compared to White employees with the same educational attainment (with the exception
of advanced degrees) (Day & Newburger, 2002). Nativity may factor into the earnings
differential; Iceland found that foreign-born Asian men are disadvantaged relative to
native-born non-Hispanic white men, although the finding vary by nation of origin
(Iceland, 1999). Further delineating this point, Zhen and Xie found that foreign-born
men who were educated in Asia had the highest wage penalty, suggesting a devaluing of
Asian education (2004).
Many of these occupational barriers can be traced back to their social integration.
One contributing factor to blocked occupational mobility are perceptions that Asian
workers are passive and unsuitable for managerial positions (Fernandez, 1998) or better
44 equipped for technical rather than people-oriented work (Woo, 1994). Friedman and
Krackhardt (1997) suggest that social capital is the mechanism that transforms human
capital into workplace gains; the combination of discrimination, preference for other co-
ethnic workers and language factors exclude Asian immigrants from informal networks
that can boost their career mobility.
As Asian immigrants experience barriers in the workplace, they also continue to
encounter discrimination in other areas that can counteract the benefit of material
resources. For example, better health care access is thought to be a benefit of higher
SES, but clinical settings are not escapes from racial profiling and differential treatment.
On average, Asian patients wait longer for transplants and are given fewer analgesics and
they consistently report being less satisfied with their care (Ezenwa, Ameringer, Ward, &
Serlin, 2006; Klassen, Klassen, Ron, Frank, & Marconi, 1998; Lauderdale, Wen, Jacobs,
& Kandula, 2006). Higher income is also thought to provide access to better residential
neighborhoods without harmful environment exposures. Asian immigrants may not have
the same access to these areas, however, as there is evidence to suggest that they
encounter discrimination when trying to purchase a home (Turner, Ross, Bednarz,
Harbig, & Lee, 2003). Further, living racially heterogeneous neighborhoods may also
invite more experiences of interpersonal discrimination.
The positive SES-health relationship is considered one of the most robust in
health, but the pervasiveness of such barriers questions whether increasing
socioeconomic status can produce health-promoting resources for Asian immigrants in
the same way they have been shown to do among non-Hispanic Whites. The SES-health
45 relationship is modest or non-existent for Asian immigrants in BMI (Lauderdale &
Rathouz, 2000; Sanchez-Vaznaugh et al., 2008) and fair or poor self-rated health
(Acevedo-Garcia, Bates, Osypuk, & McArdle, 2010; Kimbro, Bzostek, Goldman, &
Rodriguez, 2008) compared to non-Hispanic Whites. These findings are often attributed
to cultural characteristics serve as protective factors across the socioeconomic spectrum,
but an alternative interpretation is that stressors and discrimination can counteract health
resources among the wealthier and higher educated.
Increasing wages in the face of constant barriers suggests that Asians may employ
high-effort coping over extended periods of time to reach their wage levels. A unique
stressor that may applicable to Asian immigrants’ economic and social integration is
goal-striving stress, which is related to unfulfilled aspirations (W. Kuo, 1976). This
concept is similar to the frustrated expectations model that Vega, Kolody and Valle
(1987, p. 516) apply to depression among Mexican women. They define frustrated
expectations as a stress that arises from circumstances in which “goals of material
success are collectively valued and endorsed, but where the institutional means of
attainment is reduced or unavailable to some people”.
Kuo suggests that as immigrants become more upwardly mobile, they experience
higher degrees of goal-striving stress. As they have higher levels of aspirations due to
socialization experiences in a new society, they are simultaneously unable to overcome
the consequences of discrimination (1976). He measured goal-striving stress as the
discrepancy between an individual’s aspirations and their actual socioeconomic
46 achievements and found it to be a significant predictor of depression among Chinese
Americans.
Since Kuo, there have been few explorations of similar topics among Asian
immigrants. Some researchers have tested the health effects of alternative forms of
aspiration and achievement discrepancy, such as underemployment or economic
opportunity. Underemployment and unemployment have been shown to be positively
associated with depressive disorder (Beiser & Hou, 2001). Shin et al measured the
degree of change in occupational prestige as the result of migration and did not find any
relationship between it and depression in their sample of Korean immigrants (Shin, Han,
& Kim, 2007). In the National Latino and Asian American Study (NLAAS), economic
opportunity was measured by one item, “How do you feel about the economic
opportunity you have had in the U.S.?” de Castro, Gee and Takeuchi (2008a) found that
respondents who reported favorable economic opportunity had significantly higher odds
for better self-rated health, lower odds of smoking and lower BMI.
Social and Cultural Integration
Another context of disease example is the intersection between social and cultural
integration. Social integration considers how immigrants are incorporated into a
racialized social hierarchy and cultural integration considers how immigrants internalize
their experiences in a new country to form new identities. Social-ecological theories
would suggest that the social integration serves as a context to stimulate certain forms of
cultural integration. Nagel describes their relationship this way:
47 “While an individual can choose from among a set of ethnic identities, that set is There are several well-known social constructionist approaches to cultural or
ethnic identity development, such as selective assimilation and reactive ethnicity (Portes
& Zhou, 1993), that acknowledge the interplay between social classification and self-
determined identity. These ideas share the view that, “ethnic boundaries, identities, and
cultures are negotiated, defined and produced through social interaction inside and
outside ethnic communities” (Nagel, 1994, p. 152).
For Asian immigrants, this means making sense of racialized stereotypes related
to the model minority myth and perpetual foreignness. Asian immigrants also encounter
previously unknown classifications, such as a pan-Asian identity or racial minority.
These group distinctions are externally applied to Asian immigrants and contain political
and social implications.
There are several potential outcomes to the social construction of cultural identity.
The first is that immigrants form alternative subgroups that arise from repeated
encounters with discrimination. Pearson’s (2008) ethno-racial assignment and ethno-
racial identity exemplify this view. Ethno-racial assignment involves the external
attribution of characteristics and classifications and their economic, political and social
significance. Ethno-racial identity consists of individually-established beliefs, values and
practices that represent a counter-cultural orientation from external assignment.
According to this model, individuals use ethnic resources to resist and offset the
constraints imposed by racial assignment.
48 Another outcome is identity rejection, in which immigrants create distance
between their external categorization and personal affiliations with them. One key force
in this process is internalized racism, which is the subtle processes by which racial
inequality shapes the way that the oppressed think of themselves and other members of
their group (Pyke & Dang, 2003). Shwalbe and colleagues try to supersede the potential
victim-blaming mentality that internalized racism can provoke by conceptualize it as an
adaptive strategy (Schwalbe et al., 2000). By disassociating with their ethnic identities,
individuals can protect themselves against the negative stereotypes and create a positive
self-identity (Pyke & Dang, 2003).
A final potential outcome is a bicultural identity. Portes and Zhou use the term
“selective assimilation” to describe the outcome by which immigrants choose certain
aspects of their ethnic identity that will provide the best opportunities to build resources
and reflect one’s connections to both American and Asian ethnic identities (Schwartz et
al., 2010). This process is based on traits they perceive to be adaptive and conducive to
social mobility. Bean suggests that selective assimilation occurs among immigrants of
higher socioeconomic status, as they have access to co-ethnic networks that provide
social and economic resources that are not available in other non-ethnic networks (Bean
& Stevens, 2003). The health effects of this process emerge from the intersection between stressors
that arise from social integration and coping resources from cultural identity
development. One of the primary stressors from social integration is experiences of
racial discrimination. Racial discrimination has been repeatedly demonstrated to be
49 associated with poorer health outcomes among Asian immigrant populations. Nearly all
of the 59 studies identified in a recent review paper on reported discrimination and
mental health outcomes among Asian Americans found a negative relationship between
the two; the more discrimination respondents report, the higher their risk for poor mental
health outcomes (Gee, Ro, Shariff-Marco, & Chae, 2009). Discrimination seemed to
have a similar pattern in physical health outcomes, although some studies did not have
significant findings, particularly when birth weight and blood pressure were the outcomes
in question (Brown, 2006; Shiono, Rauh, Park, Lederman, & Zuskar, 1997). Poorer
health behaviors, such as decreased medical utilization, smoking, alcohol use, high-risk
sexual activity, have been shown to associated with higher reports of discrimination
(Chae, Takeuchi, Barbeau, Bennett, Lindsey, & Krieger, 2008; Chae, Takeuchi, Barbeau,
Bennett, Lindsey, Stoddard et al., 2008; Chae & Yoshikawa, 2008).
The resources that emerge from cultural integration can moderate discrimination’s
health effects on Asian immigrants. There is some evidence to suggest that a strong
ethnic identity is directly related to better mental health outcomes (Phinney et al., 2001;
H.C. Yoo & Lee, 2005), but it and other related psychosocial resources arising from
cultural identities may have a more profound health impact by acting as buffers from the
stressors that arise from social integration.
A strong ethnic identity can provide a buffer against racism-related stressors by
reinforcing positive associations with one’s ethnic group after an experience of racial
discrimination. Conversely, individuals with low ethnic identity may not have the
psychological resources (i.e., clarity, knowledge, and pride of their ethnic group) to deal
50 with recurring instances of racial discrimination. On the other hand, a strong ethnic
identity can heighten the negative impact of racism, as it may invoke a stronger reaction
among those with a very salient ethnic identity. Individuals with high ethnic identity may
be more rejection-sensitive than individuals with low ethnic identity because they are
more likely to identify and invest in that particular group affiliation.
Among Asians, there is empirical evidence to support both the positive and
negative buffering effects of ethnic identity. Strong ethnic identity significantly
decreased the relationship between perceived racial discrimination and depression
(Cassidy, O’Connor, Howe, & Warden, 2004; Mossakowski, 2003; Noh, Beiser, Kaspar,
Hou, & Rummens, 1999) and between racial discrimination and adverse coping
behaviors, such as smoking and drinking (Chae, Takeuchi, Barbeau, Bennett, Lindsey, &
Krieger, 2008; Chae, Takeuchi, Barbeau, Bennett, Lindsey, Stoddard et al., 2008). In
contrast, Asians with higher levels of ethnic identity reported more negative affect after
imagining racially discriminatory scenarios than those with lower ethnic identity (H. C.
Yoo & Lee, 2008).
Another important moderator emerging from cultural integration is social
networks and resultant social support. Group affiliation is a key factor underlying
cultural identity and individuals with a strong cultural identity may be more active in co-
ethnic networks that can provide important social resources. Strong social networks can
impact health in three ways: 1) by influencing health-related behaviors; 2) influencing
access to services and amenities; and 3) affecting psychosocial processes. These
influences appear to be protective of health; there are positive associations between social
51 networks and all-cause mortality, stroke and infectious diseases (Kawachi & Berkman,
2000). Another outcome of social networks is social support. Empirical evidence
suggests that social support buffers the effects of stress among Asian immigrants. Social
support has been shown to enhance the well-being of immigrants, especially when they
perceive high levels of discrimination in their new country (Jasinskaja-Lahti, Liekind,
Jaakkola, & Reuter, 2006). Social support, in the form of emotional support, appeared
to buffer the effect of discriminatory stressors among Filipinos (Gee et al., 2006). Ethnic
support has been shown to have an interactive effect between perceived stress on
depressive symptomatology for Koreans living in Canada (Noh & Avison, 1996).
Strong social support may also produce certain types of coping that counteract the
negative effects of discrimination. In Asian immigrants; problem-based coping was more
effective in reducing the mental health impacts of perceived discrimination, but only
among those with strong social support (Noh & Kaspar, 2003).
Different Integration Experiences
As demonstrated in the empirical literature, much of the complexity surrounding
health trajectories is due to variation across groups with different socioeconomic, ethnic
or demographic characteristics. One possible explanation for this heterogeneity is that
groups can differ in their experiences of integration, resulting in discrete health
trajectories. Portes and Zhou’s segmented assimilation theory (1993) posits that
contemporary immigrants can experience different integration paths by virtue of varying
contexts of reception. Some important contextual factors that determine such patterns are
52 government policies, conditions of the host labor market, social context (including
immigrants’ assigned racial attributes, geographical concentration and social mobility
ladders) and co-ethnic communities. These determine where immigrants will find
themselves in the social hierarchy and the subsequent environment in which they will
assimilate towards. Different contexts of reception also avail resources that can hinder or
facilitate certain integration outcomes. The table below provides examples of how three
influential modes of incorporation, governmental policies, societal reception and co-
ethnic communities, may impact immigrants’ economic, cultural and social integration.
Table 2-1. Contexts of Reception and Influences on Integration Processes
Dimensions Economic Social Cultural Contexts of Reception Policies
Determines human Reinforces or reflects sentiment towards Prohibits certain Societal Facilitates or hinders mobility Experiences of racial Reactive cultural Co-ethnic Provides alternative opportunities outside market
Buffers against Promotes cultural Government policies represent federal immigration policy, visa regulations,
government assistance or state-level policies that address undocumented immigration.
Immigration policy can impact economic integration by determining who can enter the
United States and the characteristics they should have. For example, employee-
sponsored (H-IB) visas are issued to employers in certain industries and can lead to high
concentrations of foreign-born workers in such fields as high-tech or engineering. Social
integration can be affected by anti-immigrant policies that attempt to curtail social
53 services for immigrants or criminalize undocumented immigrants. These policies both
validate and encourage larger public sentiments regarding immigration and foster an anti-
immigrant climate. Policies can also directly impact the cultural integration of
immigrants by prohibiting or stigmatizing certain cultural behaviors. For example,
English-only policies can curtail immigrants’ use of native languages.
Societal reception represents the values and prejudices of the receiving society.
Some groups have been exempted from the traditional prejudice aimed at the foreign-
born; Portes and Zhou cite Cuban refugees during 1960 and 1980 as one such group
(Portes & Zhou, 1993). For Asian immigrants, societal reception can impact economic
integration by producing occupational barriers, such as discriminatory hiring practices or
block upward mobility. It can impact social integration by fostering experiences of racial
discrimination. Finally, societal reception can impact cultural integration by encouraging
immigrants to form their cultural identities as they are mindful of what may or may not
be acceptable. Light and Rosenstein (1995) have termed this “reactive ethnicity”, which
is a response to their involuntary designation as outsider, lower-status groups; they seek
to preserve the group’s endangered collective self-esteem by enhancing solidarity.
Co-ethnic communities provide resources that immigrants utilize as they progress
through economic, social and cultural integration. Immigrants who join well-established
and diversified ethnic groups have access to invaluable moral and material resources.
Strong co-ethnic communities with economic diversity can open up immigrants’
occupational options by providing opportunities away from primary labor market. They
can also impact immigrants’ social integration by shielding immigrants from racial
54 discrimination by limiting social and professional contacts to those within the co-ethnic
community. They can also provide tangible means for immigrants to retain their cultural
identity through larger social networks of co-ethnics, access to ethnic foods and
organized cultural activities.
Modes of incorporation are dynamic and can vary across periods of time and
groups of Asian immigrants. I discuss three factors that can alter integration experiences:
entry cohorts, Asian ethnicity and gender. Each of factors not only produce separate
groups that are compositionally varied, but have symbolic meanings that can alter
integration processes by virtue of the kinds of resources that individuals in certain groups
derive from the various modes of incorporation.
Cohorts
Year of entry cohorts signify unique periods of Asian immigrant integration that
differ in the types of people immigrating, countries of origin, pre-migration
characteristics, circumstances of entry and the social and cultural community that await
them. One influential factor in the creation of separate cohorts is immigration policy.
Immigration policy has influenced much of the Asian immigrant population’s
demographic and socioeconomic features, as immigration policy establishes hard-line
criteria for who can enter the United States (Hing, 1993; E. Park & Park, 2005).
Immigration policy can vary in response to the political climate, suggesting that it may be
a distal contributor to health differences across segments of the Asian population by
altering the distribution of pre-migration characteristics that can shape subsequent
integration. While the Asian health literature has long called for disaggregating by Asian
ethnicity to account for the wide variation in cultural and socioeconomic characteristics
within the population (Lin-Fu, 1988), year of entry cohorts not only encompass
differences in these characteristics, but also identifies immigration policy and contexts of
reception as sources of such variation. Furthermore, the different ethnicities are likely
clustered within certain cohorts, as certain periods of immigration were more amenable to
particular countries of origin.
Immigration policy in the early 19th century played an obvious role in controlling
the characteristics of the Asian immigration population by restricting the entry of Asian
women or immigrants from certain countries completely. More contemporary
immigration policy works less obviously, but can still create distinct groups across time.
I identify five post-1965 Asian immigrant cohorts: the First Professional Wave (1966-
1976); the First Family Reunification Wave (1978-1991); the Refugee Wave (1976-
1988); the Second Professional Wave (1992-2005); and the Second Family Reunification
Wave (1998-2005).
First Professional Wave (1966-1976)
The first contemporary wave of Asian immigrants entered the United States
immediately following the enactment of the 1965 Immigration Act that dissolved national
preferences. A defining feature of this cohort is their high educational and occupational
achievement, as required by the newly-established immigration statutes. Asian
immigrants quickly became the largest group to enter under the third preference category
for professionals. Eighty-six percent of Indian immigrants and 74% of Filipino
56 immigrants who entered in the United States between 1965 and 1975 held professional
occupations prior to immigration. In contrast, the total percent of Americans in a
professional occupation during the same time period was between 25 and 29% percent.
The Asian professional immigrants were predominantly health workers, principally
doctors and nurses; 67% of Indians and Filipino and 75% of Korean professional
immigrants were in the health field (Liu, 1992). High-tech personnel, mainly engineers
were also highly represented, among the Chinese-speaking countries in particular (Liu,
1992).
These immigrants entered during a receptive government era and non-prejudiced
social context. The passage of the Immigration Act of 1965 was widely hailed as an
achievement on par with the Civil Rights Act (Zolberg, 2006, pg. 332). The legislation
was thought to better represent American values of equality than the previous national
quotas which favored White European immigrants. Further, the marginal presence of
immigrants contained large-scale anti-immigrant hostility; 1965, the foreign-born
represented only 5% of the population, the lowest level since the 191 century.
As the first substantial cohort of Asian immigrants, the coethnic communities for
these immigrants were weak. The existing Asian American communities were primarily
Japanese and Chinese immigrant stock who had first come to the United States in the
early part of the 19* century. The majority of these professionals arrived in the United
States with their immediately families, however. Immigrants coming in as family
families tend to further minimize dependency upon pre-existing social networks (Liu,
Ong, & Rosenstein, 1991).
57 First Family Reunification Wave (1978-1991)
The second cohort represented the first visible immigration boom after the 1965
Act and was composed of the immediate and extended families of the First Professional
Wave members. As naturalized citizens, members of the first cohort could now sponsor
their family members for family reunification visas, as stipulated in the 1965
Amendments. The family reunification visas facilitated the “chain migration” that drove
the exponential increase in Asian immigrants during this period. Between 1961 and
1970, there were 427,000 Asian immigrants admitted to the United States. From 1971 to
1980, the admitted Asian immigrant population jumped to over 1.5 million, a 250%
increase (INS). While family reunification was also a widely-used entry route in the
previous cohort, the sheer size increase of Asian immigrants during this period made the
family reunification contingent substantially larger.
While most of this cohort still had higher levels of educational and occupational
attainment than the U.S. average, their human capital resources were considerably lower
compared to the First Professional Wave. The percent of Asian Indian immigrants who
held a professional occupation prior to immigration between 1980 and 1984 was 50%,
compared to 86% in 1970-1974. Filipinos also saw a drop from 74% to 30% in this same
time period. Less than 20% of Koreans held professional occupations, the lowest percent
in the 35-year span between 1965 and 2000. Some of the drop may be attributed to
government-imposed restrictions on employment visas enacted just prior to this period
(Min, 2006a). Further, the family reunification visas did not hold any economic or
occupational stipulations, enabling more heterogeneity in human capital characteristics.
58 The government and societal context was decidedly less favorable during this
period. An economic downturn in the early 1970’s precipitated two amendments in 1976
that introduced restrictions on employment preference visas. The Eilberg Act required
immigrants to have a solid job offers before receiving visas and required employers to
demonstrate that the certification of a foreign worker had no adverse effects on
Americans workers (Liu, 1992). The Health Professions Educational Assistance Act
required foreign medical professionals to get job offers from American companies, take
the TEOFL and get U.S. medical licenses. These policies represented the growing
perception that the ever-increasing immigration population threatened American jobs.
The rise of Japanese manufacturing and automobile industries in the face of American
decline further antagonized Asian immigrants, who were perceived to embody the Asian
economic threat. In 1982, Vincent Chin was murdered outside of Detroit by two
unemployed autoworkers who yelled racial slurs while they pummeled him to death.
Despite the rising hostility, Asian immigration continued to expand and co-ethnic
communities strengthened as the population grew and concentrated in certain
metropolitan area. There was a marked increase in immigrant population in along the
coasts, such as in Los Angeles and New York (Min, 2006b). These co-ethnic
communities became important sources of social support, as well as economic-related
resources, as they provided employment opportunities through networks or the ethnic
economy.
59 Refugee Wave (1976-1988)
After the Vietnamese Civil War, millions of Southeast Asian refugees were
displaced in camps throughout Southeast Asia. The U.S. involvement in the war and
other geopolitical activities in the surrounding region including Cambodia and Laos,
ultimately facilitated the entry of millions of Vietnamese, Vietnamese-Chinese, Laotian,
Cambodian and Hmong refugees into the United States. In 1976, 14,000 Southeast Asian
refugees entered the United States and the numbers grew steady with each passing year,
reaching 167,000 at its peak in 1980. 1.4 million refugees were ultimately resettled in the
United States (Haines, 2001).
The earliest refugees came directly into the United States and represented more
educated populations from Vietnam, as they were in positions of influence in the former
pro-Western governments. The later and more numerous refugees, however, were war
exiles from Cambodia, and ethnic Lao and Hmong fleeing government persecution in
Laos and Thailand. Most of these refugees escaped in boats to neighboring countries,
coining the term “boat people”. The group had lower levels of formal education and
suffered from higher levels of post-traumatic stress and had other low levels of human
capital. Immigrants who entered in this cohort continue to have the highest levels of
poverty compared to other Asian ethnic groups.
This cohort received strong government support. As the Vietnam War ended and
the American-supported governments in Cambodia, Laos and Vietnam fell, Congress
acted quickly to ensure that former allies could resettle directly into the United States.
Early acts were passed in 1975, 1977 and 1978 that facilitated easier U.S. entry and
60 subsequent naturalization for refugees and established domestic resettlement programs.
The policies culminated in the comprehensive 1980 Refugee Act, which removed
refugees from the worldwide numerical restrictions and brought the United States refugee
law in accord with international standards (Haines, 2001). The social reception was
mixed, however. Within policy circles, the refugees were viewed as strong allies against
communism in the Cold War. The general public was less supportive; public opinions
polls showed that over half of surveyed Americans opposed Asian resettlement to the
United States, fearing loss of jobs and increased public spending (Bolin, 2005).
The coethnic community for these refugees was weak; resettlement policies
explicitly dispersed the refugees throughout the country to avoid the formation of ethnic
enclaves and to lessen the impact of large numbers of refugees in one geographic area.
The actual resettlement efforts were conducted by voluntary agencies (volags), such as
the United States Catholic Conference, the International Rescue Committee, and Church
World Service, who arranged sponsorships for the refugees and took care of their initial
needs upon arriving in the United States. These volags sought to provide support and
material support for the incoming refugees and incorporate them into the communities in
which they were brought.
Second Professional Wave (1992-2005)
This wave was influenced by an overhaul in immigration policy in 1990 that
expanded employment-based immigration. The Immigration Act of 1990 tripled the
number of employment-based visas from 54,000 to 140,000 and increased the
employment-based preferences from two categories to five. The act also created 195,000
61 temporary work visas (H visas), which proved to be a popular avenue by which to adjust
to permanent resident status. For example, 58% of Indian Hl-B workers adjusted their
status between 2000 and 2003. Not surprisingly, the proportion Asian immigrants who
held professional positions in their home countries increased from the previous cohort,
reaching 46% in 2001-2005 (Min, 2006a).
Asian Indians comprised a large percent of this cohort. Strides in Indian
education, particularly technical training institutes, prepared many Indian computer
programmers, computer technologists and engineers to immigrate under the new H l – B
visas. This cohort saw a moderate decline of immigration from South Korea, Taiwan and
Hong Kong, as significant economic and social improvements in these countries reduced
the motivation for educated, middle-class citizen to emigrate (Min, 2006a). This period
also saw a spike in Chinese status adjusters after Tiananmen Square, as President George
Bush issued an executive order to facilitate the adjustment of Chinese foreign students to
permanent residency between 1993 and 1994.
The human characteristics of this sample are similar to the first professional wave.
Instead of health professionals, however, this wave shifted to more scientific and
technical professionals (Sana, 2010).
The government policies and societal context that surrounded this cohort were
increasingly hostile. At the federal level, two 1996 laws sought to enhance punitive
measures against non-resident immigrants and reduce immigrants’ eligibility for social
programs. The 1996 Illegal Immigration Reform and Immigrant Responsibility Act
(IIRIRA) and increased the number of aliens subject to mandatory detention and
62 increased the crimes for which non-citizens could be deported. The 1996 Personal Work
and Responsibility Act (PWRORA) barred new legal immigrants from federally funded
assistance programs for their first five years in the U. S. State policy was markedly more
severe. California’s Proposition 187 in 1994 proposed ending education, nonemergency
health care, and other public services for undocumented immigrants and required police
and government workers to report suspected undocumented immigrants. While the new
laws were meant to address illegal immigration, they effectively blurred the lines
between “legal” and “illegal” immigrants and reflected the public’s resentment towards
immigrants at large.
Second Family Reunification Wave (1998-2005)
This wave reflects the chain migration that followed the refugee wave. Refugees
were eligible to naturalize two years after their arrival, enabling their sponsorship of
family members. Refugee visas declined since 1994, but the numbers of Vietnamese,
Cambodian and Laotian immigrants grew through family reunification (Haines, 2001).
The human capital characteristics of this cohort are unclear. While the refugee
wave was characterized by low levels of human capital, and the subsequent family
reunification cohorts may have similar characteristics if they were also coming from
displacement camps outside their countries of origin. The government and societal
context of this cohort were similar to those experienced by the concurrent Second
Professional Wave.
The coethnic community surrounding these immigrants is strong. While refugees
were initially settled in disparate parts of the country, a significant amount of secondary
63 migration occurred within a few months, mainly to California and Texas, the two states
that now have the largest Southeast Asian populations. The geographic concentration of
this cohort to these states suggests that they migrate to areas with established co-ethnic
communities.
Integration Differences across Cohorts
While these cohorts have been identified from a historical and policy perspective,
I have not located empirical data that investigates their potential integration differences.
Some work in the economic literature has investigated differences in economic outcomes
across visa status. Jasso and colleagues (1998) examined whether changes in immigration
policy between 1972 and 1995 affected the numbers of employment visas versus spousal
visas and the skill levels of entering immigrants. Using a panel data set constructed from
immigration records obtained from the Immigration and Naturalization Service (INS)
between 1972 and 1995, they found that rising immigrant skill during this period was due
in part to the increase of employment visas and changing immigration policies.
Other research has not considered policy directly, but has examined the impact of
visa status on economic outcomes, such as wage or occupation. Immigrants from the
Eastern Hemisphere (the majority of whom were from Asian counties) who entered under
employment visas had higher wages immediately following immigration compared to
family reunification immigrants. However, with increased time in the United States, this
differential shrinks (Jasso & Rosenzweig, 1995). A similar pattern holds for refugees;
Cortes (2004) found that while refugees had lower wages and work fewer hours in 1980
than other immigrants, this differential disappeared in 1990. Combined, these studies
64 suggest that immigrants who enter under different policy regimes have varied
socioeconomic patterns of integration. None of these studies explicitly examined Asian
immigrants however, so the question of whether Asian immigrant cohorts that have been
shaped by separate policy eras are different in their socioeconomic and health profiles
remains an empirical one.
In general, the role of immigration policy is not widely considered as a factor in
Asian immigrant health trajectories. There is even less discussion of the potential effect
of the most recent changes to immigration policy in the 1990s. Any mention of
immigration law and practice on health outcomes is only discussed in terms of its effect
on Asian Americans’ trust in governmental institutions and the potential ramifications on
Census participation and health-related data (Srinivasan & Guillermo, 2000). Part of the
reason for this absence of research is due to the lack of information on visa status in
datasets with health outcomes. Large, representative datasets such as the Decennial
Census, American Community Survey, the National Latino and Asian American Survey,
the National Health Interview Survey and the California Health Interview Survey do not
include visa information.
While cohort differences have not been explicitly explored, some research has
considered how refugees differ from the rest of Asian immigrants, drawing particular
attention to the poorer socioeconomic status and worse health profile of Laotians, Hmong
and Cambodians. In the 2000 Census, these groups had over three times the odds for a
physical disability and over six times the odds for mental disability compared to the
Japanese (Ro & Gee, 2009). Many studies have documented their higher-than-U.S.
65 average rates of depression, trauma and other mental disorders (Hsu, Davies, & Hansen,
2004; Kinzie et al., 1990; Kroll et al., 1989). Laotians have median incomes levels
around $10,000, far below other groups such as the Japanese. Sixty-three percent of
Hmong live in poverty compared to 6% of Filipinos (Srinivasan & Guillermo, 2000).
Little work has been done to distinguish the family and work visa cohorts in this regard,
however. Further, this work tends to highlight health disparities within the Asian
population over the historical role of immigration policy. While some researchers have
attributed the socioeconomic and health profiles of these groups to their refugee status
(Hsu et al., 2004; Lin-Fu, 1988), they do not expand their explanation to consider how
immigration policies may have influenced the potentially favorable characteristics of
other Asian groups as well.
Gender
The different integration experiences between men and women lie in the separate
social and cultural ideals of gender that organize opportunities and shape life chances
(Hondagneu-Sotelo, 1994). Much like other social categories such as race or ethnicity,
gender classifies individuals within a historically and socially determined unequal power
structure (Llacer, Zunzunegui, del Amo, Mazarrasa, & Bolumar, 2007). Gender is an
important source of differences in overall health patterns among Asian immigrants; men
and women have different prevalence of chronic disease, health care utilization and diets
(Choe, 2009; Park Tanjasiri & Nguyen, 2009). For immigrants, however, gender may
play an even more unique role in their integration processes and subsequent health
66 outcomes as immigrant men and women experience shifting social roles both within the
household and in their new society.
The earliest and most influential immigration studies, developed separately from
gender issues; researchers often viewed the migrant as male or gender-less (Pessar,
1999). More recent work has amended this early omission and has demonstrated that
experiences of migration and gender are closely intertwined. First, women have initiated
and composed the bulk of post-1965 Asian migration. Between 1975-1980, when Asian
immigration was growing most rapidly, working-age women outnumbered men in
immigrants from China, the Philippines, Taiwan, Korean, Burma, Indonesia, Japan and
Thailand (Salazar Parrenas, 2003). This created a chain effect whereby women who had
already secured U.S. residence, such as Korean military brides and Filipina nurses, often
served as visa sponsors for their extended families, making the maternal family more
prominent in the United States (K. Park, 1997).
Secondly, the act of migration modifies gender roles within the family and
domestic sphere. In her study of Korean immigrant business owners, Park (1997) finds
that traditional Korean gender roles are first disrupted in the migration process itself, as
the majority of immigration is female-initiated and maintained. This has shifted the
hierarchies of traditional Korean families, which typically revolve around the husband’s
relatives. Having more maternal relatives enables Korean women to utilize family
resources to share the burden of cooking, childcare and housework. The traditional
arrangement is further upended in business ownership, as women must also participate in
the business and work alongside their husbands. Labor participation provides a stronger
67 sense of independence and satisfaction among the female Korean immigrants. In Korea,
women are not expected to work after child-bearing age, leaving them financially
dependent on their husbands or other male family members. Park concludes that the
employment factor has been revolutionary for Korean immigrant women and has
established new gender consciousness that manifests itself in growing self-esteem,
autonomy, freedom and equality.
More recent research has examined how gendered roles permeate all aspects of
the daily operations of immigrant integration, such as patterns of labor incorporation,
ethnic enclaves, citizenship, sexuality, and ethnic identity (Hondagneu-Sotelo, 2000). In
matters related to economic integration, the labor market has been segmented by gender,
with certain occupations characterized as feminine and masculine. The informal service
sector, such as paid domestic work, child care, garment and electronic assembly has
relied heavily on female employees, particularly immigrant women of color (Espiritu,
1999). Within their social integration, immigrant women may have experiences of
gender discrimination on top of racial discrimination. The relationship between health,
race and gender discrimination is a complex one, as women simultaneously experience
their racial and gender identities and the two forms of discrimination may not be fully
disentangled from one another (Moradi & Subich, 2003). These dual roles can
compound stressors and their negative health effects. Further, immigrant men’s
experiences with racial discrimination and marginalization may introduce additional
68 stressors within marriage, even culminating in domestic abuse (Dasgupta, 2000). Min
recounted a story of marital discord arising from a husband’s social status concerns:
“Five years ago, he left home after a little argument with me and came back two Women are also more likely to utilize their networks within their co-ethnic
communities than are men (Billings & Moos, 1981). These social relationships not only
provide material resources but are also forms of social support to cope with immigration-
related difficulties.
These differences are borne out in the different health trajectories between men
and women. Smoking and drinking have been one of the most studied health outcomes
when examining gender differences, likely because they represent changing ideas about
gender norms. While smoking and drinking prevalence is lower among Asian immigrant
women than men, duration appears to have a more positive effect on smoking and
drinking among Asian immigrant women (Choi, Rankin, Stewart, & Oka, 2008;
Maxwell, Bernaards, & McCarthy, 2005). Duration is associated with more substantial
weight gain among women compared to men (Lauderdale & Rathouz, 2000).
Asian Ethnicity
Ethnicity is a social construct that encompasses personal identity and group
affiliation. It is distinct from racial classifications, which have been developed
historically through systems of social stratification and are often externally applied (Ford
& Harawa, 2010). Different Asian ethnic groups may experience alternative integration
processes on account of their distinct social and lifestyle characteristics, such as common
69 geographic origins, family patterns, language, values, cultural norms, religious traditions,
literature, music, dietary preferences and employment patterns (Williams, 1997). These
factors may be more proximal to health outcomes, as they are influential on attitudes
towards medical services, diet and health-risk behaviors (i.e., violence, substance use,
smoking).
Health differences among Asian ethnic groups have been well-documented.
Filipinos have the highest rates of hypertension among the Asian ethnic groups, even
surpassing the rate for White Americans. Koreans have the highest levels of current
smoking status, smoking at a rate comparable to White Americans (Islam, Trinh-Shevrin,
& Rey, 2009). Rates of cervical cancer incidence among Vietnamese women are more
than two and a half times higher than rates for women of any other racial or ethnic group
(Parker, Davis, Wingo, Ries, & Heath, 1998).
A common refrain within public health research on Asian Americans has been to
disaggregate the population into separate Asian ethnicities when conducting quantitative
analysis to account for such heterogeneity (Srinivasan & Guillermo, 2000). Researchers
have suggested a bimodal distribution of socioeconomic and health characteristics within
the Asian population (Lin-Fu, 1988). Classifying Asians into a single group in statistical
analyses masks such heterogeneity and biases results to the null. Further, when Asians
are combined into a single pan-ethnic group, it suggests similar characteristics and
lifestyles among the Asian respondents. Ultimately, culture is dynamic and what
constitutes broad understandings of the Asian “culture” are continually in flux (Pfeffer,
70 1998). Outside of the shared racialized experience, there are few common “cultural”
characteristics, such as language, social networks, or diet across Asian ethnicities.
Disaggregating by Asian ethnicity may also account for separate immigration
histories. While year-of-entry cohorts most clearly delineate the contexts of immigration
history for subsequent integration and health patterns, ethnicity can also be proxy for this,
as populations from different countries of origin entered in the United within certain time
periods. For example, the Japanese have one of the longest histories of immigration to
the United States, but their immigration peaked in the 1970’s and has declined the
decades since. As a result, this population has low linguistic isolation and is
predominantly American-born (Hing, 1993). This is in contrast to the Vietnamese, many
of whom entered as refugees in the 1970’s and 1980’s, during political unrest in
Southeast Asia. Their incorporation into the United States was heavily governed by
refugee resettlement policies, which determined where they could live and the type of
government support available to them (Hing, 1993). For datasets that lack information
that cannot easily classify by year of entry cohorts, ethnicity or country of origin may
provide a reasonable substitute.
Finally, ethnicity has a strong bearing on the development of a cultural identity, as
Asians tend to self-identify more with their ethnic identity than a pan-ethnic one. In the
debate between using “Latino” or “Hispanic”, Yankauer suggests that the ideal solution is
to ask the members themselves (1987). A similar argument can be made for Asians; self-
identification is important because socially constructed categories are largely applied
externally. Self-identification gauges the extent to which an individual has internalized a
71 label and consequently acquires the resources and drawbacks associated therein. While a
nationally-representative survey has yet to be conducted, Lien and colleagues surveyed
1218 Asian immigrants residing in the metropolitan areas of Los Angeles, New York,
Honolulu, San Francisco and Chicago (Lien, Conway, & Wong, 2003). They found that
when Asian immigrants are given the choice of identifying as ethnic-specific or pan-
ethnic, they tend to identify foremost with their ethnicity. This is not surprising;
throughout the history of Asian immigration, groups from different Asian countries went
through lengths to distinguish themselves from one another, most often when one group
was the target of discriminatory policies (Takaki, 1993).
Conclusion
This review provides an overview of our current knowledge of Asian immigrant
health trajectories and develops a new framework that identifies new economic, social
and cultural influences on health patterns. The framework expands upon popular lifestyle
and behavior explanations for Asian immigrant health patterns in three ways. First, it
incorporates structural influences on health. Second, it identifies specific aspects of
integration that are not typically associated with health and produces health-related
pathways. Third, it attempts to identify sources of group variation in integration
experiences and subsequent health trajectories.
Aspects of the framework have been carefully studied in economics, demography,
sociology and psychology, but it has yet to be considered in public health. The validity
of the framework can be securely established with empirical work that demonstrates the
72 significance of economic, social and cultural factors on Asian immigrant health
trajectories. References Abraido-Lanza, A. F., Armbrister, A. N., Florez, K. R., & Aguirre, A. N. (2006). Toward Acevedo-Garcia, D., Bates, L. M , Osypuk, T. L., & McArdle, N. (2010). The effect of Ager, A., & Strang, A. (2008). Understanding Integration: A Conceptual Framework. Akresh, I. (2007). US immigrants’ labor market adjustment: Additional human capital Alba, R., & Nee, V. (1997). Rethinking assimilation theory for a new era of immigration. Alba, R., & Nee, V. (2003). Remaking the American Mainstream: Assimilation and Barringer, H. R., Takeuchi, D. T., & Xenos, P. (1990). Education, Occupational Prestige, Bean, F., & Stevens, G. (2003). America’s Newcomers and the Dynamics of Diversity. Becker, G. S. (1962). Investment in Human-Capital: A Theoretical Analysis. Journal of Beiser, M., & Hou, F. (2001). Language acquisition, unemployment and depressive Bhatia, S., & Ram, A. (2001). Rethinking ‘acculturation’ in relation to diasporic cultures Billings, A. G., & Moos, R. H. (1981). The role of coping responses and social resources Bolin, T. (2005). Public Opinion on Immigration in America: Merage Foundation. Immigrants. Journal of Labor Economics, 3(4), 463-489. in a Racially Ethnically Diverse Sample of Women. American journal of Cassidy, C , O’Connor, R. C , Howe, C , & Warden, D. (2004). Perceived discrimination Chae, D. H., Takeuchi, D. T., Barbeau, E. M., Bennett, G. G., Lindsey, J., & Krieger, N. 74 Chae, D. H., Takeuchi, D. T., Barbeau, E. M., Bennett, G. G., Lindsey, J. C , Stoddard, Chae, D. H., & Yoshikawa, H. (2008). Perceived group devaluation, depression, and Chang, E. C , Tugade, M. M., & Asakawa, K. (2006). Stress and Coping Among Asian Chiswick, B. R. (1986). Human Capital and the Labor Market Adjustment of Immigrants: Cho, Y. T., & Hummer, R. A. (2001). Disability status differentials across fifteen Asian Choe, J. H. (2009). The Health of Men. In C. Trinh-Shevrin, N. Islam & M. Rey (Eds.), Choi, S., Rankin, S., Stewart, A., & Oka, R. (2008). Effects of Acculturation on Smoking Cohen, S., & Wills, T. A. (1985). Stress, Social Support, and the Buffering Hypothesis. Constantine, M. G., Kindaichi, M., Okazaki, S., Gainor, K. A., & Baden, A. L. (2005). A Cortes, K. E. (2004). Are Refugees Different from Economic Immigrants? Some Dasgupta, S. D. (2000). Charting the Course: An Overview of Domestic Violence in the Day, J. C , & Newburger, E. C. (2002). The Big Payoff: Educational Attainment and de Castro, A. B., Gee, G. C , & Takeuchi, D. T. (2008a). Examining Alternative 75 de Castro, A. B., Gee, G. C , & Takeuchi, D. T. (2008b). Job-related stress and chronic Dey, A., & Wilson Lucas, J. (2006). Physical and Mental Health Characteristics of U.S. Diwan, S., Jonnalagadda, S. S., & Gupta, R. (2004). Differences in the Structure of Dunn, J. R., & Dyck, I. (2000). Social determinants of health in Canada’s immigrant Espiritu, Y. L. (1994). Introduction In P. Ong, E. Bonacich & L. Cheng (Eds.), The New Espiritu, Y. L. (1999). Gender and Labor in Asian Immigrant Families. American Ezenwa, M. O., Ameringer, S., Ward, S. E., & Serlin, R. C. (2006). Racial and Ethnic Fernandez, M. (1998). Asian Indian Americans in the Bay Area and the Glass Ceiling. Folkman, S., & Lazarus, R. S. (1980). An Analysis of Coping in a Middle-Aged Ford, C. L., & Harawa, N. T. (2010). A new conceptualization of ethnicity for social Friedman, R. A., & Krackhardt, D. (1997). Social Capital and Career Mobility. The Frisbie, W. P., Cho, Y. T., & Hummer, R. A. (2001). Immigration and the health of Asian Gee, G. C , Chen, J., Spencer, M. S , See, S., Kuester, O. A., Tran, D., et al. (2006). Gee, G. C , & Ro, A. E. (2009). Racism and Health among Asian and Pacific Islander N. Islam & M. Rey (Eds.), Health Issues in the Asian American Community. San Gee, G. C , Ro, A. E., Shariff-Marco, S., & Chae, D. (2009). Racial Discrimination and 76 Geronimus, A. T. (2000). To mitigate, resist, or undo: addressing structural influences on Geronimus, A. T., & Thompson, J. P. (2004). To Denigrate, Ignore or Disrupt: Racial Glazer, N. (1993). Is Assimilation Dead? Annals of the American Academy of Political Goel, M. S., McCarthy, E. P , Phillips, R. S., & Wee, C. C. (2004). Obesity among US Gordon, M. (1964). Assimilation in American Life: The Role of Race, Religion, and Griffith, D., Johnson, J., Ellis, K., & Schulz, A. (2010). Cultural context and a critical Haines, D. (2001). Southeast Asian Refugees. In J. Ciment (Ed.), Encyclopedia of Haritatos, J., Mahalingam, R., & James, S. A. (2007). John Henryism, self-reported Hazuda, H. P., Stern, M. P., & Haffner, S. M. (1988). Acculturation and Assimilation Hing, B. O. (1993). Making and Remaking Asian America through Immigration Policy Hing, B. O. (1997). To Be an American: Cultural Pluralism and the Rhetoric of Hondagneu-Sotelo, P. (1994). Gendered Transitions: Mexican Experiences of Hondagneu-Sotelo, P. (2000). Feminism and Migration. The ANNALS of the American Hsu, E., Davies, C. A., & Hansen, D. J. (2004). Understanding mental health needs of Hunt, L. M., Schneider, S., & Comer, B. (2004). Should “acculturation” be a variable in Iceland, J. (1999). Earnings returns to occupational status: Are Asian Americans Islam, N., Trinh-Shevrin, C , & Rey, M. (2009). Towards a Contextual Understanding of Jackson, J. S., & Knight, K. (2006). Race and Self-Regulatory Health Behaviors: The 77 Disparities. In K. W. Schaie & L. L. Carstensen (Eds.), Social Structures, Aging, James, S. A. (1994). John Henryism and the health of African-Americans. Cult Med Jang, Y., Kim, G., & Chiriboga, D. A. (2005). Health, healthcare utilization, and Jasinskaja-Lahti, I., Liekind, K., Jaakkola, M., & Reuter, A. (2006). Perceived Jasso, G., & Rosenzweig, M. R. (1995). Do Immigrants Screened for Skills do Better Jasso, G., Rosenzweig, M. R., & Smith, J. (1998). The Changing Skill of New Kandula, N. R., Kersey, M., & Lurie, N. (2004). Assuring the health of immigrants: What Kandula, N. R., & Lauderdale, D. S. (2005). Leisure time, non-leisure time, and Kawachi, I., & Berkman, L. (2000). Social Cohension, Social Capital and Health. In L. Kim, C. J. (1999). The Racial Triangulation of Asian Americans. Politics Society, 27(1), Kim, Y. Y. (2001). Becoming Intercultural: An Integration Theory of Communication Kimbro, R. T., Bzostek, S., Goldman, N., & Rodriguez, G. (2008). Race, ethnicity, and Kinzie, J. D., Boehnlein, J. K., Leung, P. K., Moore, L. J., Riley, C , & Smith, D. (1990). Klassen, A. C , Klassen, D. K., Ron, B., Frank, R. G., & Marconi, K. (1998). Factors Krieger, N. (2001a). A glossary for social epidemiology. Journal of Epidemiology and Krieger, N. (2001b). Theories for social epidemiology in the 21st century: an ecosocial Kroll, J., Habenicht, M., Mackenzie, T., Yang, M., Chan, S., Vang, T., et al. (1989). 78 Kuo, W. (1976). Theories of Migration and Mental-Health – Empirical Testing on Kuo, W. H. (1976). Theories of Migration and Mental-Health – Empirical Testing on Lalonde, R. J., & Topel, R. H. (1991). Immigrants in the American Labor-Market – Lauderdale, D. S., & Rathouz, P. J. (2000). Body mass index in a US national sample of Lauderdale, D. S., Wen, M., Jacobs, E., & Kandula, N. (2006). Immigrant Perceptions of Lee, T. (2000). Racial Attitudes and the Color Line(s) at the Close of the Twentieth Lien, P., Conway, M. M., & Wong, J. (2003). The contours and sources of ethnic identity Light, I., & Rosenstein, C. (1995). Race, Ethnicity andEntrepreneurship in Urban Lin-Fu, J. S. (1988). Population characteristics and health care needs of Asian Pacific Lin, M. H., Kwan, V. S. Y., Cheung, A., & Fiske, S. T. (2005). Stereotype content model Link, B. G., & Phelan, J. (1995). Social Conditions As Fundamental Causes of Disease. Liu, J. M., Ong, P. M., & Rosenstein, C. (1991). Dual Chain Migration: Post-1965 Llacer, A., Zunzunegui, M. V., del Amo, J., Mazarrasa, L., & Bolumar, F. (2007). The Marmot, M. G., & Syme, S. L. (1976). Acculturation and coronary heart disease in Marmot, M. G., Syme, S. L., Kagan, A., Kato, H., Cohen, J. B., & Belsky, J. (1975). 79 Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S. M., & Chun, C. A. (2005). Massey, D. S. (1981). Dimensions of the New Immigration to the United-States and the Maxwell, A. E., Bernaards, C. A., & McCarthy, W. J. (2005). Smoking prevalence and McEwen, B. S., & Seeman, T. (1999). Protective and Damaging Effects of Mediators of Mervis, J. (2005). A glass ceiling for Asian scientists? Asian scientists are a major Min, P. G. (2006a). Asian Immigrants: History and Contemporary Trends. In P. G. Min Min, P. G. (2006b). Settlement Patterns and Diversity. In P. G. Min (Ed.), Asian Misra, R., Patel, T. G., Davies, D., & Russo, T. (2000). Health promotion behaviors of Moos, R. H. (1979). Social-ecological perspectives on health. In G. Stone, F. Cohen & N. Moradi, B., & Subich, L. M. (2003). A Concomitant Examination of the Relations of Mossakowski, K. N. (2003). Coping with Perceived Discrimination: Does Ethnic Identity Mossakowski, K. N. (2007). Are immigrants healthier? The case of depression among Moyerman, D. R., & Forman, B. D. (1992). Acculturation and Adjustment – a Meta- Mutchler, J. E., Prakash, A., & Burr, J. A. (2007). The demography of disability and the Nagel, J. (1994). Constructing Ethnicity – Creating and Recreating Ethnic-Identity and 80 Noh, S., & Avison, W. R. (1996). Asian immigrants and the stress process: a study of Noh, S., Beiser, M., Kaspar, V., Hou, F., & Rummens, J. (1999). Perceived racial Noh, S., & Kaspar, V. (2003). Perceived discrimination and depression: moderating Omi, M., & Winant, H. (1994). Racial Formation in the United States from the 1960s to Parikh, N. S., Fahs, M. C , Shelley, D., & Yemeni, R. (2009). Health behaviors of older Park, E., & Park, J. (2005). Probationary Americans. New York: Routledge. York City. Ithaca, NY: Cornell University Press. sociology, 33(6), 881. N. Islam & M. Rey (Eds.), Health Issues in the Asian American Community. San Park, Y., Neckerman, K. M., Quinn, J., Weiss, C , & Rundle, A. (2008). Place of birth, Parker, S. L., Davis, K. J., Wingo, P. A., Ries, L. A. G., & Heath, C. W. (1998). Cancer Pearson, J. A. (2008). Can’t Buy Me Whitenss: New Lessons from the Titanic on Race, Pessar, P. R. (1999). The Role of Gender, Households and Social Networks in the Pfeffer, N. (1998). Theories of race, ethnicity and culture. Bmj, 317(7169), 1381-1384. Immigration, and Weil-Being: An Interactional Perspective. Journal of Social Portes, A., & Zhou, M. (1993). The New Second Generation: Segmented Assimilation Pyke, K., & Dang, T. (2003). “FOB” and “Whitewashed”: Identity and Internalized 81 Redfield, R., Linton, R., & Herskovits, M. J. (1936). Memorandum for the Study of Ro, A., & Gee, G. C. (2009). Disability status differentials across 18 Asian and Pacific Rogler, L. H., Cortes, D. E., & Malgady, R. G. (1991). Acculturation and mental health Roshania, R., Venkat Narayan, K. M., & Oza-Frank, R. (2008). Age at Arrival and Risk Salant, T., & Lauderdale, D. S. (2003). Measuring culture: a critical review of Salazar Parrenas, R. (2003). Asian Immigrant Women and Global Restructuring, 1970s- Sana, M. (2010). Immigrants and natives in U.S. science and engineering occupations, Sanchez-Vaznaugh, E. V., Kawachi, I., Subramanian, S. V., Sanchez, B. N., & Acevedo- Schoeni, R. F. (1997). New evidence on the economic progress of foreign-born men in Schwalbe, M., Godwin, S., Holden, D., Schrock, D., Thompson, S., & Wolkomir, M. Schwartz, S. J., Unger, J. B., Zamboanga, B. L., & Szapocznik, J. (2010). Rethinking the Seeman, T., Singer, B., Rowe, J. W., Horwitz, R. I., & McEwen, B. S. (1997). Price of Shibutani, T., & Kwan, K. M. (1965). Ethnic Stratification: A Comparitive Approach. Shin, H. S., Han, H.-R., & Kim, M. T. (2007). Predictors of psychological well-being Shiono, P. H., Rauh, V. A., Park, M., Lederman, S. A., & Zuskar, D. (1997). Ethnic 82 Singh, G. K., & Miller, B. A. (2004). Health, life expectancy, and mortality patterns Singh, G. K., & Siahpush, M. (2002). Ethnic-immigrant differentials in health behaviors, Smith, T. W. (2001). Intergroup Relations in a Diverse Society: Data from the 2000 Srinivasan, S., & Guillermo, T. (2000). Toward improved health: disaggregating Asian Suzuki, B. H. (1977). Education and the Socialization of Asian Americans: A Revisionist Syme, S. L. (1979). Psychosocial Determinants of Hypertension. In G. Onesti & C. Klimt Takaki, R. (1993). Strangers from a Different Shore: A History of Asian Americans. New Takeuchi, D. T., Hong, S., Gile, K., & Alegria, M. (2007). Developmental Contexts and Taylor, V. M., Yasui, Y., Tu, S. P., Neuhouser, M. L., Li, L., Woodall, E., et al. (2007). Turner, M., Ross, S., Bednarz, B., Harbig, C , & Lee, S. (2003). Discrimination in Vega, W. A., Kolody, B., & Valle, J. R. (1987). Migration and mental health: an Walters, K. L., & Simoni, J. M. (2002). Reconceptualizing Native Women’s Health: An Waters, M. (1999). Black Identities: West Indian Immigrant Dreams and American Wildsmith, E. M. (2002). Testing the weathering hypothesis among Mexican-origin Wilkinson, R. G., & Marmot, M. (2003). Social Determinants of Health: The Solid Facts, Williams, D. R. (1997). Race and health: basic questions, emerging directions. Ann Woo, D. (1994). The Glass Ceiling and Asian Americans. Department of Labor
83 Worth, R. M., Kato, H., Rhoads, G. G , Kagan, A., & Syme, S. L. (1975). Yankauer, A. (1987). Hispanic/Latino—what’s in a name? Am JPublic Health, 77(\), 15- Yoo, H. C , & Lee, R. M. (2005). Ethnic Identity and Approach-Type Coping as Yoo, H. C , & Lee, R. M. (2008). Does Ethnic Identity Buffer or Exacerbate the Effects Yoon, E., Lee, D., Koo, Y. R., & Yoo, S. K. (2010). A Qualitative Investigation of Zhang, W., & Ta, V. M. (2009). Social connections, immigration-related factors, and Zhen, Z., & Xie, Y. (2004). Asian-Americans’ Earnings Disadvantage Reexamined: The Zhou, M., & Kamo, Y. (1994). An Analysis of Earnings Patterns for Chinese, Japanese, 84 CHAPTER 3 – EMPIRICAL PAPER 1
Cohort Differences in Health Trajectories
Introduction Scholarship on immigrant integration into the United States has long been
influenced by classic definitions of assimilation that assume a unidirectional progression
towards American lifestyles. Gordon’s early work on Anglo-Conformity (1961)
describes change on the part of an immigrant group in the direction of middle-class
Anglo culture. This assumes that as immigrants interact more with American host
society, they will shed their ethnic origins and conform in language, culture and identity
towards an Anglo-Protestant core culture. Anglo-Conformity shaped subsequent
scholarship and became the prevalent framework for understanding integration in the
social sciences (Alba & Nee, 2003). This viewpoint has also been applied to studying the
health consequences of integration. Changes in immigrant health over duration are
believed to be the result of lifestyle and behavior changes that reflect the progression
towards dominant American culture (Salant & Lauderdale, 2003).
Other work, however, has proposed a more complex picture of integration that
acknowledges heterogeneity across experiences in the United States. Most recognizable
among these is segmented assimilation theory, which suggests that the circumstances
surrounding migration, the resources that immigrants bring with them and the conditions
85 of the host country can shape the social standing of immigrants. Consequently,
immigrants proceed along integration paths that reflect their social standing; they may
display progression towards the White middle class, or they can display “downward
assimilation” patterns that mirror those of marginalized groups (Portes & Rumbaut, 1990;
Portes & Zhou, 1993).
There have been other similar arguments for complex integration experiences that
depend on how an immigrant is received and the resources available to them as they
adjust to American society (Alba & Nee, 2003; Nee, Sanders, & Sernau, 1994; Waters,
1999). Common across these views is the emphasis on structural constraints and
contextual influences on the nature of immigrant integration. More specifically, they
identify aspects of the circumstances of migration and contexts of reception that set
immigrants on an integration path that reflects the stratified nature of American society.
As the scholarship on immigrant integration develops, public health research has
also demonstrated heterogeneity in immigrants’ physical health trajectories. Some
groups have displayed worsening physical health with duration, while others do not show
any duration effect or only display effects among certain outcomes (Cho & Hummer,
2001; Lauderdale & Rathouz, 2000; Mutchler, Prakash, & Burr, 2007). The inconsistent
relationship between duration and physical health outcomes aligns well with emerging
work that argues for divergent integration experiences. Bridging these strands of
research, it would appear that disparate health trajectories arise from separate integration
experiences.
86 The pathways by which integration impacts health trajectories can be understood
through the stress and coping framework. Migration and subsequent integration are
inherently stressful experiences that encompass both major life events and daily hassles.
Several scholars have identified unique migration-related stressors that impact
immigrants in addition to general life stressors, such as racial discrimination, language
difficulties, cultural adjustment and goal-striving stress (Kuo, 1976; Noh & Avison,
1996; Takeuchi et al., 2007). The physical effects of stress exposure have been well-
documented (McEwen & Seeman, 1999; Seeman, Singer, Rowe, Horwitz, & McEwen,
1997). Certain factors can mitigate or exacerbate the impact of stress among immigrants,
such as co-ethnic social support, material resources or cultural identity (Chae et al., 2008;
Noh, Beiser, Kaspar, Hou, & Rummens, 1999; Noh & Kaspar, 2003). Throughout their
integration processes, immigrants must encounter and cope with stressors; health
trajectories represent the accumulation of this process.
Divergent integration experiences can create differential stress and coping
processes. I argue that two underlying factors that drive separate integration paths,
circumstances of migration and contexts of reception, can impact the stress and coping
process in two ways. First, changing circumstances of migration can determine the
resources immigrants bring with them and their baseline health upon entry to the United
States. This is primarily seen through changing immigration policy and geopolitical
circumstances. Immigration policy sets criteria for who can enter the United States; as
the stipulations of immigration policy change, so can the characteristics of incoming
immigrants (Gee & Ford, 2011). Immigration policies that favor the highly-skilled
87 ensure that immigrants enter the United States with high human capital resources, such as
education and professional skills. Such policies may also be indirectly preferencing
healthier migrants, as high educational and occupational achievement is conditional on
health. Further, geopolitical changes in the sending countries in areas such as access to
medicine, better nutrition, or the presence or absence of widespread conflict, can alter
population-level health patterns (Jasso, Massey, Rosenzweig, & Smith, 2004). Incoming
migrants’ health can reflect such shifts. Selective migration has been well-studied in
immigration health, but it has not been considered as a factor in health trajectories.
Second, contexts of reception can alter the types of integration-related stressors
immigrants encounter and resources available to them. Some important contexts of
reception in this regard are the societal reception of immigrants, domestic policies of the
host country, labor market conditions and co-ethnic communities (Portes & Rumbaut,
1990). Contexts of reception reflect the host country’s larger views towards immigrants
and can determine immigrants’ interpersonal interactions, as well as the nature of
domestic policies and labor market conditions (Ager & Strang, 2008). If immigrants are
negatively received, this may result in discriminatory hiring or similarly closed labor
markets and compel restrictive domestic policies that limit immigrants’ resources.
Taken together, selective migration and the disparate stress and coping process
can produce unique health trajectories among different groups of immigrants. For
example, positively health-selected immigrants who enter the United States with a
favorable societal reception and a robust labor market may have an easier time securing
financial stability and experience higher upward social mobility. If immigrants can
88 utilize such material and social resources to improve medical access and avoid certain
health risks, they can experience improving health trajectories. Conversely, positively
health-selected immigrants who enter the United States under negative societal reception
and closed labor markets may have more difficulty securing upwards social mobility and
the associated resources that can translate to better health outcomes. The strength to
overcome such barriers may exact a physical toll on their health, ultimately resulting in
worsening trajectories. While these immigrants may have better physical health at
baseline, the cumulative assaults on health will not enable the same health gains over
time as immigrants entering under more favorable contexts of reception.
Cohorts One useful way to study the health impacts of divergent integration paths is
through separate year of entry cohorts. Cohorts encompass historical changes in
migration circumstances as well as changing contexts of reception. Asian immigrants
may be a particularly useful group to study in this regard, as there are several distinct
cohorts who have entered after the 1965 Immigrant Act. I identify four cohorts of Asian
immigration during this modern era of immigration. Each is briefly described below.
First Professional Wave (1966-1976) The 1965 Immigration Act dissolved national preferences and ushered in a new
wave of Asian immigration. A defining feature of these immigrants is their high
educational and occupational achievement, as required by the newly-established
immigration statutes. This was particularly seen among Asian Indian and Filipino
immigrants; 86% of Indian immigrants and 74% of Filipino immigrants who entered in
89 the United States between 1965 and 1975 held professional occupations prior to
immigration (Liu, 1992). These immigrants entered during a receptive government and
social context. The passage of the Immigration Act of 1965 was widely hailed as an achievement on par with the Civil Rights Act. The legislation was thought to better
represent American values of equality than the previous national quotas which favored
White European immigrants. Further, the marginal presence of immigrants contained
large-scale anti-immigrant hostility; in 1965, the foreign-born represented only 5% of the
population, the lowest level since the 19th century (Zolberg, 2006).
Family Reunification Wave (1978-1991) This was the first visible immigration boom and was composed of the immediate
and extended families of the immigrants of the First Professional Wave. This cohort
gained entry through family reunification visas, which were not subject to worldwide
quotas. While most incoming migrants still had higher levels of educational and
occupational attainment than the U.S. average, their human capital resources were
considerably lower compared to their predecessors (Min, 2006).
The government and social context was decidedly less favorable during this
period. An economic downturn in the early 1970’s precipitated two amendments in 1976 that introduced restrictions on employment preference visas, the Eilberg Act and the
Health Professions Educational Assistance Act (Liu, 1992). These policies represented
the growing perception that the increasing immigration population threatened American
jobs. Southeast Asian Refugees (1976-1988)
The U.S. involvement in the Vietnamese Civil war and other geopolitical
activities in the surrounding region ultimately facilitated the entry of millions of
Vietnamese, Vietnamese-Chinese, Laotian, Cambodian and Hmong refugees into the
United States during this wave. The earliest refugees came directly into the United States
and represented more educated populations from Vietnam, as they were in positions of
influence in the former pro-Western governments. The later and more numerous
refugees, however, were war exiles and had lower levels of formal education and suffered
from higher levels of post-traumatic stress and other disorders (Nicholson, 1997).
Refugees received strong government support. The 1980 Refugee Act removed
refugees from the worldwide numerical restrictions and brought the United States refugee mixed, however. Public opinions polls showed that over half of surveyed Americans
opposed Asian resettlement to the United States, fearing loss of jobs and increased public
spending (Bolin, 2005). The Immigration Act of 1990 represented an overhaul in immigration policy
whose aim was to encourage more high-skill migrants; the act tripled the number of
employment-based visas, increased the employment-based preferences, and created the
temporary work visas (H visas) (Jasso, Rosenzweig, & Smith, 2000). The H-visa proved
to be a popular avenue by which Asian immigrants adjusted to permanent resident status,
Asian Indian workers in particular. Strides in Indian education, particularly technical
91 training institutes, prepared many Indian computer programmers, computer technologists
and engineers to immigrate under the new Hl-B visas. Conversely, there was a moderate
decline of immigration from South Korea, Taiwan and Hong Kong, as significant
economic and social improvements in these countries reduced the motivation for
educated, middle-class citizen to emigrate (Min, 2006).
The contexts of reception during this era were increasingly hostile. At the federal
level, two 1996 laws sought to enhance punitive measures against non-resident
immigrants and reduce immigrants’ eligibility for social programs, the Illegal
Immigration Reform and Immigrant Responsibility Act and the Personal Work and
Responsibility Act (PWRORA) (Fix & Passel, 2002). State policy was markedly more
severe. California’s Proposition 187 in 1994 proposed ending education, nonemergency and government workers to report suspected undocumented immigrants (Hing, 1997).
While the new laws were meant to address illegal immigration, they reflected the public’s
resentment towards immigrants at large.
Aims and Hypotheses
I assume that health trajectories are driven by the stress and coping process and
that the relationship between duration and health exposes the health impacts of this
process. Changing circumstances of migration and contexts of reception can alter the
stress and coping process across different cohorts of immigrants. The aim of this paper is
to explore the health impact of divergent integration experiences among separate cohorts
of Asian immigrants.
92 Hypothesis 1. The First and Second Professional Waves will have higher levels
of education and lower levels of self-employment compared to other cohorts, reflecting
stipulations of concurrent immigration policy. I also expect the Second Professional
Wave to have higher proportions of Asian Indian and Filipino immigrants, as these
immigrants are more likely to be able to secure employment visas because of their
stronger command of English (Min, 2006).
Hypothesis 2. Both the First and Second Professional Waves will have better
baseline health than other cohorts, reflecting health selectivity during these periods.
Hypothesis 3. Longer duration will be associated with worsening health. The
majority of cohorts have encountered negative social reception that can produce stressors
and barriers to upward mobility that take a cumulative toll on health.
The stress and coping view of the health impact of integration is a departure from
the majority of public health research, which attributes changing health trajectories to
behaviors that result from more Westernized lifestyles. While behaviors are certainly
proximal influences on health, they are not sole determinants of health trajectories. I
additionally control for health behaviors to examine whether health influences arise from
duration over and above health behaviors.
Hypothesis 4. The relationship between longer duration and worsening health
will grow stronger from earlier to more recent cohorts, reflecting growing negative social
reception. Methods
An ideal exploration of cohort and duration effects would follow distinct cohorts
of immigrants over the course of many years and examine differences both within and
across cohorts (Lauderdale, 2001). While there is no dataset currently available that
contains a large enough sample size of Asian immigrants to test the duration effect
longitudinally, there are methods that enable a quasi-cohort analysis using multiple waves
of cross-sectional data. While the subjects are not interviewed repeatedly, a sample of a
cohort of immigrants that entered the U.S. in a certain year and are in a certain duration
group in the first dataset can be reproduced in the following datasets.
This method has precedent in economics and demography (Borjas, 1985; Myers
& Lee, 1996), but has not been used widely in the public health literature. Two
exceptions are Antecol and Bedard (2006) and Kaushal (2009). They combined multiple
waves of the National Health Interview Survey to create cohorts of immigrants and
follow them through several survey iterations. Antecol and Bedard examined self-rated
health, health conditions, activity limitation and BMI among Latino immigrants and
Kaushal analyzed obesity among Asian immigrants. I used these studies to inform my
analytic plan.
Data and Sample
The sample was all single-race Asian adults over the age of 18 from the 1995-
2005 waves of the National Health Interview Surveys (NHIS). The NHIS is an annual
nationwide in-person survey of approximately 40,000 households conducted by the
National Center for Health Statistics (NCHS) (CDC, 2010). The NHIS was the most
94 suitable dataset for this analyses because it is the only nationally-representative and
repeated cross-sectional dataset with a sizeable Asian sample.
In the publicly-available data, some of the Asians respondents can be further
identified by their specific Asian ethnicity: Chinese, Filipino or Asian Indian. Koreans,
Japanese, Vietnamese and smaller subgroups are classified into an “Other Asian”
category. This analysis examined Asian as an aggregated sample, controlling for the
available ethnicities. I did not disaggregate Asians into individual ethnicities, as I
hypothesized that different ethnicities are clustered by cohorts.
The dataset was downloaded from the Integrated Health Interview Series (IHIS),
which provides harmonized data and documentation for the NHIS. The IHIS facilitates
cross-time comparisons of the NHIS by coding variables identically across time and re-
weighting the survey weights according to the waves included in a given sample
(Ruggles et al., 2010). All analyses were matched to the appropriate samples and
weights, depending on the availability of the variables across survey waves and the
sample universe.
Measures
Outcomes There were three general physical health outcomes measured in this paper:
disability, self-rated health, and obesity. Because I suggested that structural factors
impact the entire health profile of Asian immigrant cohorts, my measures were
accordingly broad enough to include a range of possible illnesses that can reflect the
overall state of population health. I chose to focus on overall measures of well-being to
95 align with the World Health Organization (WHO) definition of health as a “state of
complete physical, emotional and social well-being, and not merely the absence of
disease or infirmity,” (WHO, 1946). Like all health measures in the NHIS, each outcome measure was obtained
through self-report. While this may raise validity concerns about the measures, other
work has established their validity with objectively measured health outcomes among
other Asian American samples (Brunner Huber, 2007; Ro, 2010).
Disability- This outcome refers to limitations in tasks and roles that one is
expected to be able to do that are caused by one or more health conditions (Pope &
Tarlov, 1991). It is a useful measure of overall health because it encompasses specific
health problems (disease or condition, a missing extremity or organ, or any type of
impairment), as well as disorders not always thought of as health-related problems (i.e.,
alcoholism, drug dependency or reaction, senility, depression, retardation) (IHIS, 2010).
Disability is detrimental to one’s quality of life and is predictive of mortality (Scott,
Macera, Cornman, & Sharpe, 1997). Disability was analyzed as a binary variable that indicated whether a person is
limited in any way. This was a recoded variable from a series of questions about
limitations in working, mobility and memory, and the presence of physical conditions.
An affirmative response to any of these questions indicated that the person had a
limitation. This question wording was changed after 1996; to account for the effect of
potential question wording differences, I included only the 1997-2005 waves of the
survey in analyses with this measure.
96 Fair/Poor Self-Rated Health – Self-rated health assesses health across a broad
range of illnesses and is understood as “a summary statement about the way in which
numerous aspects of health, both subjective and objective, are combined within the
perceptual framework of the individual respondent,” (Tissue, 1972). It has been found to
be a predictor of mortality, health utilization behaviors, and disability (Benyamini &
Idler, 1999; Ferraro, Farmer, & Wybraniec, 1997; Idler & Benyamini, 1997; Idler &
Kasl, 1995). Self-rated health measured respondents’ self-reported general health on a five-
point Likert scale that had the following responses: “Excellent”, “Very good”, “Good”,
“Fair” and “Poor”, along with an unrated “unknown” category. The question wording
was consistent throughout 1995 to 2005. This outcome was dichotomized; respondents
who answered fair or poor were coded as 1, all others 0.
Obesity – This is a measure of body composition that is a strong risk factor for osteoarthritis (Must et al., 1999).
Obesity was calculated by self-reported heights and weights using the standard
formula (weight in kilograms divided by the square of the height in meters). In
accordance to the suggested guidelines by IHIS, I restricted the height range to 59 and 76
inches and the weight range to 98 to 289 pounds to account for the changing top and
bottom codes across different survey waves of the NHIS. I categorized BMI according
to the CDC-issued guidelines for obese.
97 Key Independent Variables
Cohorts – Because of data limitations on visa status and country of origin, I
identified cohorts only through years of entry. This was a series of indicator variables
that represented the years an immigrant entered the United States. There were six
different year-of-entry cohorts that were examined in the analyses: Pre-1980, 1981-1985,
1986-1990, 1991-1995, 1996-2000, 2001-2005. Respondents were categorized into these
cohorts by their years of U.S. residence in a given survey year.
The table below details how the cohort coding corresponds to the historical Asian
immigrant cohorts I previously discussed.
Table 3-1. Historical Cohorts and Corresponding Year of Entry Cohorts
First Professional Pre-1980
Family 1981-1985 Refugee Wave
1981-1985 Second Professional 1991-1995 The year of entry cohorts did not exactly match the historical cohorts, but they
offer a rough approximation of their boundaries. While this coding scheme contains
some limitations in examining historical waves of Asian immigration, it enables an
examination of overall health trends across different time periods.
Nativity/Duration – This variable designated the nativity and years of U.S.
residence for the sample. The variable was divided into the following categories: US-
born, 0-4 years, 5-9 years, 10-14 years and over 15 years duration. This coding scheme
was used in previous studies (Cho & Hummer, 2001; Frisbie, Cho, & Hummer, 2001).
98 The inclusion of a US-born comparison group separates age trends from duration
trends. I used US-born Asians as a reference group because of similarities in educational,
employment, economic and residential characteristics with the Asian foreign-born.
Similar patterns across these common health confounders can narrow down differences
between the foreign-born and US-born comparison groups to migration-related factors.
Because US-born Asians may also experience the consequences of negative societal
reception, I re-ran my analyses with a US-born, non-Hispanic White comparison group
and obtained similar results.
Health Behaviors
I included three health behavior variables, smoking, alcohol use and exercise.
Smoking was included as a binary variable that indicated whether a person was current
smoker. Alcohol was a binary variable that indicated whether a respondent was a
moderate or heavy drinker. I used the CDC guidelines for alcohol use and categorized
moderate or heavy drinkers as current drinkers who drank more than one drink per sitting
for women and two drinks for men (USDA & DHHS, 2005). Exercise was a binary
variable that indicated whether a respondent engaged in the CDC-recommended levels of
physical activity (moderate physical activity at least 5 times a week for 30 minutes or
vigorous physical activity at least 3 times a week for 20 minutes) (CDC, 2005).
Sociodemographic variables
Sociodemographic variables were first examined as outcomes in Hypothesis 1.
Indicator variables for Chinese ethnicity, Filipino ethnicity, Asian Indian ethnicity,
99 college graduate and self-employed/working without pay for a family business were
tested as outcomes.
For the remaining multivariate models, I included ethnicity, gender and age as
sociodemographic controls. Because of the quasi-cohort design, I controlled for
characteristics that either remained constant through the survey waves (i.e, gender) or did
not have a differential effect through time; for example, everyone in the sample aged at
the same rate and thus had the same age effect.
Cohort Coding
I was not able to recreate the same five-year year-of-entry cohorts across every
survey year from 1995-2005 due to the categorical coding of years of U.S. residence in
the NHIS (0-4 years, 5-9 years, 10-14 years, 15 plus). To classify respondents into
cohorts, I utilized a weighting strategy whereby I calculated the likelihood that a
respondent was in a cohort (pre- 1980, 1981-1985, 1986-1990, 1991-1995, 1996-2000,
2001-2005) based on their years of U.S. residence in a given survey year. I derived the
weights using the Current Population Survey (CPS), which contains information on an
immigrant’s year of entry in single or double year intervals. For each NHIS survey year
between 1995-2005,1 used the CPS to calculate the percent of Asian immigrants who
entered the U.S. in a given year.
Table 3-2 demonstrates my weighting process with an example. In the NHIS
survey year 2002, an immigrant who is categorized as having 5-9 years of U.S. residence
entered in the United States between 1993 and 1997. This interval straddles the 1991-
1995 and 1996-2000 cohorts. According to the CPS, 15% of Asian immigrants with 5-9
100 years duration in 2002 entered in 1997, 20% of these immigrants entered in 1996, 22% in
1995 and so on. To calculate the likelihood that the respondent was in the 1991-1995
cohort, I summed the prevalence for 1993, 1994 and 1995, the three years of overlap
between the actual year-of-entry interval and the analysis cohort (in gray). I then created
a duplicate copy of the observation. One observation received a weight of .65 to
correspond to the likelihood of being in the 1991-1995 cohort. The second copy received
a weight of .35 to represent its likelihood of being in the 1996-2000 cohort. This cohort
weight was multiplied by the person weight in the complex survey weighting scheme for
a new person weight. For the full weighting scheme, see Appendix A.
Table 3-2. Weighting Example for NHIS Survey Year 2002, 5-9 years of U.S. Residence Years in the US 5 7 M l ‘
8 12 Year of Entry 1997 1995 1990 Weight for 1991-1995 cohort Distribution 0.15
0.2
0.22
0.25 , – 0 Actual years of k Analvsis Table 3-3 displays the sample sizes and cohorts represented in the 11-year period
included in this analysis, weighted by the CPS-derived cohort weights.
101 To check the robustness of the findings among this sample, I performed the
analyses across an additional sample that used the 1995-2005 NHIS waves, but did not
use CPS weights to classify respondents into cohorts. Instead, a duration category for a
given cluster of survey waves was coded in same cohort group. For example, all
respondents with 0-4 years duration during the 1995, 1996, 1997 and 1998 waves were
coded as entering the United States between 1991 and 1995. As a result, neighboring
cohorts have overlapping years, but the general pattern across cohorts should remain the
same. This method has been used in previous research examining cohort effects
(Antecol & Bedard, 2006; Kaushal, 2009). This additional sample produced similar
results for the analyses presented.
Analyses
All analyses were conducted on Stata version 11.2. I also accounted for the ACS
complex survey design using Stata’s svy function that accounted for person weights,
strata and cluster design effects.
Model 1- Sociodemographic differences across cohorts
This model examined differences in sociodemographic characteristics across
cohorts. I conducted separate regression models for each sociodemographic outcome
using the following model:
Y i = p , X i + p2Ci + + (33Ni + si
Where Y was the log odds of having a college degree, being Chinese, Filipino, or
Asian Indian or being self-employed or an unpaid family worker. X represented a vector
of covariates (age, gender, US-born, nativity by gender interaction), C represented
102 dummy variables for each of the cohorts, with the 1986-1990 cohort as baseline. Using
this reference group enabled comparisons between cohorts representing the Family
Reunification/Refugee waves versus the First and Second Professional waves. N was a
series of dummy variables for the nativity/duration categories. With the addition of the
duration indicator variables, the cohort regression coefficients provided the cohort’s
demographic profile at baseline (0-4 years duration) compared to the 1986-1990 cohort.
The regression coefficients for N represent the relative comparison of each duration
group to the 0-4 year group across the entire foreign-born sample.
Model 2 – Baseline health differences across cohorts and duration effects
This model was nearly the same as the previous one, except with disability, self-
rated health or obesity as the outcome. It provided estimates for baseline health across
cohorts as well as the effects of years in the United States across the foreign-born sample,
controlling for cohort baseline health differences. Y was the predicted health outcome, X
was a vector of covariates and C represented dummy variables for each of the cohorts,
with the 1986-1990 cohort as the reference group. N was a series of dummy variables for
the nativity/duration categories.
Y1=p1X1 + p2C, + p3N1 + e1
Additional models included health behavior variables of smoking, alcohol use and
exercise. Model 3 — Duration difference across cohorts
The final model examined the duration effect among different cohorts.
Y1=p,X, + p2N1 + s,
103 Where Y represented the predicted physical health outcomes and N was the
available duration effects for each cohort. I conducted the model separately for each
cohort. To examine differences in duration effects across cohorts, I compared the
strength and direction of the duration coefficients to one another.
Results
Sample Characteristics
Table 3-4 illustrates the sample’s demographic and health characteristics by
cohort. While the percent of high school graduates across all cohorts is above the
national average of 84% in the same period (Newburger & Curry, 2000), the most recent
cohorts had the highest percentages with over 90% with a high school education. The
same was also true for college graduation; the most recent cohorts had well over 50%
college graduates. There were some occupational patterns as well; the earliest cohorts
had the highest rates of self-employment and this decreased with more recent cohorts.
Table 3-5 provides the prevalence of health outcomes for each cohort and
duration sample, along with the prevalence for a gender and age-matched comparison
group from the US-born Asian sample. These matched comparison groups enable some
distinction between age and duration patterns among the foreign-born, as age is
confounded with duration. If the ratio of the US-born to foreign-born prevalence remains
constant across duration categories, we can assume that differences among the duration
groups are due to aging.
Within each cohort, the prevalence of each health condition rises with longer
duration. For example, the prevalence of disability for the cohort entering between 1991
104 and 1995 grew from 1.8%, 4.0% to 4.4% over the respective duration groups. The
corresponding matched comparison groups also rose within cohorts across all outcomes,
suggesting that some of this upward trend is due to age. For disability and obesity,
however, the ratio of the US-born and foreign-born prevalence decreases within each
cohort, implying that duration may increase prevalence over and above the aging effect.
For self-rated health, however, the ratios remain consistent, suggesting that the upward
trend in reporting fair/poor health across duration categories may be due to increasing
age. Regression Results
Demographic Characteristics
The regression results for the demographic characteristics confirmed the bivariate
findings that cohorts differ across Asian ethnicity, education and occupational status
(Table 3-6). These patterns coincide with the hypothesized effects of immigration policy.
Two of the cohorts corresponding to the Second Professional Wave (1996-2000, 2001-
2005) were more likely to have a college education and were less likely to be self-
employed than the cohort representing the Family Reunification/Refugee waves (1986-
1990, reference). These cohorts were also more likely to be Asian Indian and less likely
to be Filipino or Chinese, reflecting changes in countries of origin as occupation
concentration in employment visas shifted from healthcare to the high-tech industry.
105 Cohort Baseline Health Status and Duration Effects
Disability. The odds for baseline disability status relative to the cohort
representing the latter Family Reunification/Refugee waves (1986-1990, reference) did
not differ across cohorts.
Among the duration categories, the odds of disability increased compared to the
0-4 year reference group. The odds ratios for the 5-9 and 10-14 year categories were 1.70
and 1.69, respectively, and the 15+ year odds was the highest at 1.9. Table 3-7 provides
the regression results for this model.
Self-Rated Health. There were only minor baseline health differences in fair/poor
self-rated health. The cohorts representing the Second Professional Wave (1991-1995,
1996-2000 and 2001-2005) had lower odds for fair/poor self-rated health compared to the
1986-1990 reference group, but only the 1996-2000 cohort was significantly lower.
There was no duration pattern across the cohorts. None of the duration categories
had a significantly different odds ratio for fair/poor self-rated health than the 0-4 year
reference group.
Obesity. The cohorts corresponding to the First Professional Wave (Pre-1980)
and the beginning of the Family Reunification/Refugee wave (1981-1985) had
significantly lower odds for obesity compared to the 1986-1990 reference group. Other
cohorts displayed higher odds, but were not significantly different. The duration
categories displayed an upward trend whereby the longest term duration category had the
highest odds for being overweight or obese relative to the 0-4 year group.
106 To determine whether the cohort and duration patterns were driven by health
behaviors, I included health behaviors in the previous analyses (results not shown).
While the health behaviors themselves were related to the health outcomes, their
inclusion did not change the cohort and duration patterns. This is particularly important
for the duration results, which suggests that there are other health-related factors that
progress with longer residence in the United States over and above changing health
patterns. Duration Differences across Cohorts
I was not able to examine full duration patterns across all of the cohorts because
of the time period of the NHIS survey waves. Instead, I constructed partial duration
analyses for the 1981-1985, 1985-1990, and 1991-1995 and 1996-2000 cohorts. The first
two cohorts corresponded to the Family Reunification/Refugee wave (1981-1985, 1986-
1990) and the latter two corresponded to the Second Professional wave (1991-1995,
1996-2000). The results are listed in Table 3-9.
Disability. In the previous set of results, the odds of disability increased with
longer duration. This pattern was present across all of the examined cohorts, yet did not
reach significance. One exception was the 1991-1995 cohort, in which 5-9 year group
was significantly higher than the 0-4 year reference group.
Self-Rated Health. The only cohort that displayed a significant duration effect
was the 1986-1990 cohort. Longer-term immigrants reported lower odds for fair/poor
self-rated health compared to more recently arrived immigrants. Both the 10-14 year and
107 15 years plus categories had lower odds for reporting fair/poor self-rated health than the
5-9 year baseline group (OR=0.79, 0.75, respectively).
Obesity. For all cohorts, the odds for obesity increased with longer duration. The
only exception was the 1996-2000 cohort, in which the obesity odds for the 0-4 year and
5-9 year group did not significantly differ from one another.
Discussion
This paper examined differences in health trajectories among cohorts of Asian
immigrants. I contended that changing circumstances of migration and contexts
reception would impact immigrants’ stress and coping processes that proceed with
integration. I first argued that circumstances of migration would change the characteristics of
incoming migrants. This could impact the stress and coping process by altering potential
coping resources immigrants bring with them and their baseline health status. My results
supported this, as some cohorts appeared to have unique demographic and health profiles.
Both the First and Second Professional Waves were shaped by immigration
policies that preferenced the highly-skilled. The 1965 Immigration Act created visa
preference categories for certain occupations and the 1990 Immigration Act increased
employment-based visas and created a temporary visa for high-skilled workers. The
results pointed to a stronger impact of the 1990 Act in demographic characteristics,
however. Cohorts corresponding to the Second Professional Wave were more likely to
be college educated and less likely to be self-employed compared to Family
Reunification and Refugee waves. The only cohort corresponding to the Second
108 Professional Wave that did not have significantly higher college attainment or lower self-
employment was the 1991-1995 cohort. This group straddled the Family
Reunification/Refugee Wave and the Second Professional Wave and their characteristics
may reflect a lag between enactment of the policy and resulting shift in immigrant
characteristics. The First Professional Wave did not show any significant differences in
college graduation compared to the reference group.
While the 1990 Act coincided with demographic differences, it did not appear to
impact cohort health selectivity to the same extent. In fair/poor self-rated health, there
was some indication that the Second Professional Wave had lower odds for this outcome,
yet only one of the three corresponding cohorts had significantly lower odds than the
reference group. Cohorts did not differ in their baseline disability status. The “healthy
immigrant effect” has argued that immigrants are positively selected on health compared
to their native country counterparts, as the act of migration requires physical robustness
(Abraido-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999). Perhaps immigrants across all
cohorts have already been undergone positive health selection to such a degree that
changes in immigration policy may not have noticeably affected their disability or self-
rated health profiles.
There were baseline differences in obesity, but these seem to point to the salience
of geopolitical circumstances in the sending countries over immigration policy influence.
Earlier cohorts displayed significantly lower odds of obesity and odds steadily increased
with more recent cohorts. This finding coincides with other research that has
documented a global increase in BMI in the past 30 years (Caballero, 2007). Such an
109 increase is often attributed to urbanization and the globalization of food production and
marketing (Caballero, 2007). These changes characterize Asian countries particularly
well. Common sending countries, such as India, China, Korea and Taiwan, have seen
accelerated economic growth , accompanied by equally rapid dietary shifts in the past
fifty years (Yoon et al., 2006). The rise of obesity across cohorts suggests that the health
effects of obesity have yet to pose a barrier to migration.
I also argued that contexts of reception were a driving force of integration
experiences and that the accumulated impact of associated stressors would result in
worsening health with duration. Negative societal reception may give rise to stressors
such as racial discrimination, blocked labor market opportunities or nativist domestic
policies that can accumulate over US residence and take a physiological health toll. This
duration analysis was more rigorous than traditional duration analyses, as I controlled for
baseline cohort effects as well as considered the potential mediating effect of health
behaviors. In both disability and obesity, groups with longer duration displayed higher
odds compared to the most recently arrived immigrants, even after controlling for
smoking, alcohol use and exercise. This finding implies that regardless of different
baseline health status, factors related to integration negatively impact health over and
above changing health behaviors.
When coupled with other previously published research, this finding reveals the
salience of stress and coping processes in shaping immigrant health trajectories.
Uppaluri et al. (2001) found that Asian immigrants report more stress as they live longer
in the United States. Potential immigration-related stressors, such as racial
110 discrimination, adjustment stress, and language use are regularly associated with negative
health outcomes (Gee, Ro, Gavin, & Takeuchi, 2008; Takeuchi et al., 2007). This
viewpoint can provide a useful counter point to the widespread assumption that health
trajectories are driven by changing health behaviors. Instead, it appears that societal
stressors also have a direct influence on immigrant health patterns.
Finally, I suggested that changes in reception would create differential stressors
and resources across cohorts, which would be seen in dissimilar health trajectories. In
disability and obesity, there were no clear differences across cohorts. While not all of the
duration patterns reached significance, they maintained the same pattern throughout. The
lack of significant effects within cohorts could be due to smaller sample sizes and not to
any true differences in the duration patterns. The similar disability and obesity
trajectories indicate that stressors are consistent across all cohorts and that all immigrants
experience their negative effects. Immigrants in the Second Professional Wave should
have better theorized resources against stressors due to their higher educational and
occupational characteristics, but the limited datas preclude any definitive conclusions. I
was only able to examine duration patterns among two cohorts corresponding to this
wave, the 1991-1995 and 1996-2000 cohorts. Of these, only the latter showed
significantly higher college attainment or occupational patterns. Within this cohort, there
were no significant differences between more recent and older duration groups, although
it is unclear whether this is due to the protective effect of their more favorable
demographic characteristics or because of their relatively short tenure in the United
States. I l l
Asian Americans. Washington, D.C.: Pew Research Center,
2002;39(1):34–41. doi:10.1080/00224490209552117.
and sex equity. TCA J 1995;23(2):1.
adolescent communication about sex in Filipino American families: a
demonstration of community-based participatory research. Ambul Pediatr
2005;5(1):50–5. doi:10.1367/A04-059R.1.
differences in mother-daughter communication about sex. J Adolesc Health
2006;39(1):128–31. doi:10.1016/j.jadohealth.2005.08.005.
among Asian American emerging adults. J Adolesc Res 2007;22(1):3–31.
doi:10.1177/0743558406294916.
socialization. Psychol Women Q 2009;33(3):334–50. doi:10.1111/j.1471
-6402.2009.01505.x.
the Movement: Sexual and Reproductive Justice and Asian Pacific American Women.
Washington, D.C.: National Asian Pacific American Women’s Forum,
adolescents and health care providers about sexual activity, sexually transmitted
infections, and pregnancy prevention: a qualitative study. J Adolesc Health
2012;50(2):S66–7. doi:10.1016/j.jadohealth.2011.10.176.
intercourse: gender and acculturation differences. Perspect Sex Reprod Health
2006;38(1):28–36. doi:10.1111/j.1931-2393.2006.tb00056.x.
among Asian American/Pacific Islander high school students. J Adolesc Health
2000;27(5):322–30. doi:10.1016/S1054-139X(00)00093-8.
in health risk behaviors among Asian/Pacific Islander high school students. J
School Health 2009;79(8):347–54. doi:10.1111/j.1746-1561.2009.00420.x.
among Asian American and Pacific Islander high school students in the US,
2001–2007. Public Health Rep 2011;126(1):39–49.
and Pacific Islander high school students. J Adolesc Health 1998;23(4):221–31.
doi:10.1016/S1054-139X(97)00210-3.
transmitted infections (STIs): a review of reviews into the effectiveness of non-
clinical interventions. Liverpool, England: Liverpool John Moores University,
and reproductive health of adolescents: patterns, prevention, and potential.
Lancet 2007;369(9568):1220–31. doi:10.1016/S0140-6736(07)60367-5.
content and process of mother – adolescent communication about sex in Latino
families. Soc Work Res 2006;30(3):169–81. doi:10.1093/swr/30.3.169.
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
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.”
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.
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
DOI: 10.1080/1040265042000237680
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.
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).
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.
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.
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.
Leadership Summit in 1991. Over 600 delegates met and passed the 17
Principles of Environmental Justice. According to Hofrichter, the preamble
reads,
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.
the concept that members of this movement were linked through the pollution
and harm they experience as a result of racism.
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.
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
this is the main way Asian immigrant organizations have defined their issues as
environmental justice concerns.
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.
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.
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.
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
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
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
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-
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
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
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
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
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
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
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.
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-
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.
24–30. � http://www.asianweek.com/2000 11 24/news1 nophillieschinatown.html � .
Movement Ezine. � http://www.aamovement.net/community/aaej.html � .
Sierra Club.
New Society.
Movement.” AsianWeek.com, October 4–10. � http://www.asianweek.com/2002 10 04/
home.html � .
in Hofrichter, R. (ed.), Toxic Struggles: The Theory and Practice of Environmental Justice. Philadel-
phia: New Society.
the Fight against Institutional Expansion and Environmental Racism.” Amerasia Journal 21(3):
99–119.
New York Times, February 20: 23.
Pellow, D.N. & L. Park. 2003. The Silicon Valley of Dreams: Environmental Injustice, Immigrant Workers
Tai, S. 1999. “Environmental Hazards and the Richmond Laotian American Community: A Case
Taylor, D.E. 2002. Race, Class, Gender and American Environmentalism. Seattle: U.S. Forest Service.
United Church of Christ, Commission for Racial Justice. 1987. Toxic Wastes and Race in the United
Waste Sites. New York.
Correspondence: Department of American Studies, University of California, Davis, Mart Hall, Davis,
CA, 95616, USA. Email: jsze@ucdavis.edu
September 2013 Vol. 14, Suppl 1, 40S –47S
DOI: 10.1177/1524839913484762
© 2013 Society for Public Health Education
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.
munity-based participatory research;
health research; Pacific Islander; tobacco
prevention and control
ealth Promotion Practice / MonthTanjasiri et al. / Short Title
2013
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
Asian American and Pacific Islander 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.
“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.
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).
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).
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
and advocacy efforts.
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.
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.
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.
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.
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).
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
interest in the incentive items.
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.
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)
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).
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).
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.
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
outlet (figure 1) and described it as promoting youth
smoking via youth-targeted advertisements and sales
by stating,
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.
described a photograph depicting the poor physical
quality of the city as part of the reason why youth also
smoke. according to this youth,
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.
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,
types of Pro- and anti-tobacco locations Influencing
Tobacco
Tobacco
and Anti
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
1 — 3
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
associations between Proximity (in Miles) to Pro-
Proximity to Pro-
Yes 1.49 *
no 2.06
Smoked 100+ cigarettes
no 1.98
Participated in leader-
no 1.70
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.
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
(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).
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.
features had a substantial influence on aaPI youth
smoking risk and behaviors. Data from all three mixed-
methods (survey, Photovoice, and GIS mapping) identified
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.
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.
arose from this study, we also faced many challenges
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.
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
logistic regression of self-reported 100-cigarette and Past 30-day smoking (n = 298)
Lifetime
Past 30 Days
Ratio p
Odds Ratio p
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
policy makers, they become advocacy tools that can con-
tribute to community-wide tobacco policy change.
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.
n. (2012). Patterns of alcohol and tobacco use in cambodia. Asia-
Pacific Journal of Public Health. advance online publication.
doi:10.1177/1010539512464649
Sorensen, G. (2012). The relationship between diet and perceived
and objective access to supermarkets among low-income housing
residents. Social Science & Medicine, 75, 1254-1262. doi:10.1016/
j.socscimed.2012.05.014
to prevent the sale of tobacco products to minors. International
Quarterly of Community Health Education, 13, 77-86.
Legislative efforts to protect children from tobacco. Journal of the
American Medical Association, 257, 3387-3389.
a., forouzesh, M., & Kuoch, K. (2012). Socioepidemiology of ciga-
rette smoking among cambodian americans in Long beach,
california. Journal of Immigrant and Minority Health, 14, 272-280.
doi:10.1007/s10903-011-9478-1
Review of community-based research: assessing partnership
approaches to improve public health. Annual Review of Public
Health, 19, 173-202.
E. (2009). Monitoring the future national survey results on drug
use, 1975-2008: Vol. 1. Secondary school students. bethesda, MD:
national Institute on Drug abuse.
association between neighborhood context and smoking preva-
lence among asian americans. American Journal of Public
Health, 99, 885-892.
Tobacco availability and point of sale marketing in demographi-
cally contrasting districts of Massachusetts. Tobacco Control,
11(Suppl. 2), ii71-ii73.
use among asian americans and Pacific Islanders. American
Journal of Public Health, 93, 764-768.
M. (2008). The spatial distribution of underage tobacco sales in
Los angeles. Substance Use & Misuse, 43, 1597-1617.
perception-based and geographic information system (GIS)-based
characterizations of the local food environment. Journal of Urban
Health, 85, 206-216. doi:10.1007/s11524-008-9259-x
Targeting of asian americans and Pacific Islanders by the tobacco
industry: Results from the Minnesota Tobacco Document
Depository. Tobacco Control, 11, 201-209.
Davis, R. M. (1989). Trends in cigarette smoking in the united
States: Projections to the year 2000. Journal of the American
Medical Association, 261, 61-65.
b., berry, c. c., & farkas, a. J. (1998). Has the california tobacco
control program reduced smoking? Journal of the American
Medical Association, 280, 893-899.
(2002). collaborative research as an essential component for
addressing cancer disparities among Southeast asian and Pacific
Islander women. Health Promotion Practice, 3, 144-154.
using Photovoice to assess and promote environmental
approaches to tobacco control in aaPI communities. Health
Promotion Practice, 12, 654-665. doi:10.1177/1524839910369987
ogy, and use for participatory needs assessment. Health Education
& Behavior, 24, 369-387.
fiske, K. E., & Sharp, E. (1992). cigarette point-of-sale advertising
in ethnic neighborhoods in San Diego, california. Health Values,
16, 23-28.
tobacco, and other drug use among asian american and Pacific
Islander adolescents in california and Hawaii. Addictive
Behaviors, 29, 127-141.
beliefs about tobacco, health, and addiction among adults in
cambodia: findings from a national survey. Journal of Religion
and Health. advance online publication. doi:10.1007/s10943-
011-9537-x
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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.
encouraged, and guided me through every step of this process.
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.
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.
very lucky to have such encouraging and supportive friends.
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.
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.
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.
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.
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.
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.
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.
University, Ph.D., September 2010.
Problem of Statement …………………………………………………………………………………………………… 1
Significance of the Proposed Study for Social Work ……………………………………………………….. 5
Health Conseqeunces ……………………………………………………………………………………………….. 7
Measurement of alcohol Significance of Alcohol Consumption …………………………………….. 9
Chinese …………………………………………………………………………………………………………………. 12
Vietnamese ……………………………………………………………………………………………………………. 13
Relevant Contributory Factors to Alcohol Use ………………………………………………………………. 19
Socio-cultural Factors …………………………………………………………………………………………….. 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 ………………………………………………………………………………………….
Discrimination………………………………………………………………………………………………… 37
Family cultural conflict ……………………………………………………………………………………. 38
Social support…………………………………………………………………………………………………. 41
Religiosity ……………………………………………………………………………………………………… 42
Data Source and Sample …………………………………………………………………………………………….. 51
Measures ………………………………………………………………………………………………………………….. 53
Acculturative stress ……………………………………………………………………………………………. 54
Family cultural conflict ………………………………………………………………………………….. 55
Social support …………………………………………………………………………………………………… 55
Religiosity ………………………………………………………………………………………………………… 55
Demographic Variables ……………………………………………………………………………………… 57
Ethical Issues ……………………………………………………………………………………………………………. 61
Alcohol use ………………………………………………………………………………………………………….. 65
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
Acculturation…………………………………………………………………………………………………………….. 96
Acculturative Stress …………………………………………………………………………………………………… 97
Filipino Americans ……………………………………………………………………………………………….. 98
Chinese and Vietnamese Americans ……………………………………………………………………… 100
The Relationship between Acculturation and Acculturativstress ……………………………………. 100
Social Support/Religiosity ………………………………………………………………………………………… 101
Filipino Americans ……………………………………………………………………………………………… 103
Vietnamese Americans ……………………………………………………………………………………….. 104
Implications…………………………………………………………………………………………………………….. 107
Social work policy ……………………………………………………………………………………………… 111
Rcommendatiosn for Future Study ……………………………………………………………………………. 113
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
Alcohol use measure Sample/design Findings Statistical Model
Iwamoto
(2007)
Revised (AVS-R:
Kim & Hong,
2004)
(alcohol use,
binge drinking
behavior,
marijuana use,
cocaine, other
illicit drug use) in
the last month
college students.
Convenience sampling
Sample size=154
Vietnamese (n=31)
Filipino (n=23)
Korean (n=17)
Asian Indian (n=14)
Japanese (n=12)
other Asians (n=17)
with higher
adherence to Asian
values drank less
alcohol
Friedman
(2007)
of Marin, Sabogal,
Marin, Otero-
Sabogal, & Perez-
Stable(1987)
Three subscales:
media, and ethnic
social relations
Alcohol per week
Binge drinking
Asian (n=153)
African (n=69)
Hispanic (n=138)
other (n=51)
Sample size=521
with high
acculturation
reported to drink
more than those with
lower acculturation
(2007)
born vs. Foreign
Born)
English-language
the past month
& Vietnamese Adults
in Washington D.C.
metropolitan area
Sample size=4
born in U.S. were
more likely than
those who were
foreign born drink
alcohol
(2006)
at home
Preference for
Checklist (19
items)
private university in
East Coast city.
watching American
TV/Movie were
food and watching
American
TV/movie
Place of birth (US
born)
in lifetime and in
the past 30 days
Asian American and
Pacific Islanders.
alcohol
Foreign born Asians
drink beer than U.S.
born.
No association
home and current
drinker
MacPherson,
Myers, Carr,
& Tamara
(2005)
Self-Identity
Acculturation (SL-
ASIA)
in lifetime
Used alcohol in
Heavy drinking in
Southern California
Sample size=428
Korean (n=205)
Longitudinal study
Asian Americans
were more likely to
drink heavily.
Takeuchi,
Agbayabi-
Siewert, &
Tacata
(2003)
US
Age at immigration
English
dependence (Short
form of the
University of
Michigan’s
version of the
Composite
International
Diagnostic
Interview)
Filipino American
Epidemiological Study
in San Francisco or
Honolulu.
Sample size= 1,818
Probability sampling
immigrated at early
age were more likely
to have alcohol
dependence disorder
than those who
immigrated at older
age.
(2002)
(U.S born vs.
Foreign born)
consumption –
average daily
ethanol intake
(current drinker,
ex-drinker, &
Abstainer)
Chinese-, Japanese-,
Sample size=704
Secondary data –
Alcohol
consumed more
alcohol than foreign
born Asians.
dependence
(lifetime)
Alcohol
Binge drinking
Socially
drinking
(NLAES) data of 1992
(2001)
of the Suinn-Lew
Asian Self-Identity
Acculturation
Scale
current uses or
nonuse
University of Houston
Vietnamese
Sample size=412
Cross-sectional design
more acculturated
were more likely to
drink than those with
less acculturation
Zane, &
Nakamura
(1989)
Survey (60-items)
(Conner, 1977)
Quantity of
(Abstainer,
infrequent drinker,
light drinker,
moderate drinker,
and heavy
drinker)
Chinese (n=49)
Caucasian (n=96)
not related to
alcohol consumption
regression
Nagoshil,
Ahern,
Wislon, &
Yuen (1987)
born vs. Foreign
born)
Number of years of
Hawaii
Quantity of
alcohol use
(Abstainer, former
drinkers, and
current drinkers)
Filipino, Hawaiian,
Hapa- Haoles, and
Caucasian
Sample size=3,714
Cross-sectional design
and Filipinos who
were born in Hawaii
were more likely to
drink alcohol
compared to those
who were born in
their home country.
& Ito (1979)
proficiency
Quantity of
Chinese (n=23)
related to increase
American friends
Generation
grandparents – U.S
born vs. Foreign
born)
(5 categories:
abstainer/light,
mild, moderate,
heavy, and very
heavy)
Caucasian (n=77)
Cross-sectional design
Americans
Size
Americans
Americans
Americans
Weighted N 2,234,825 1,681,420 1,007,086
discriminationa F (2, 40)=15.98***
b: chi-square test
df=degrees of freedom
treatment
discrimination
cultural conflict
R2: changes of pseudo-R2 to make coefficients comparable.
Controlling variables
Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair treatment
racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans with a higher
discrimination and, as a result, drink less than Asian Americans with weaker religiosity.
Americans who are less acculturated experience more unfair treatment and perceive more
racial/ethnic discrimination than Asian Americans who are more acculturated.
treatment
Perceived Racial/ethnic
discrimination
Family
cultural conflict
Controlling variables Beta Beta Beta
B: logistic regression unstandardized coefficients. b: OLS regression unstandardized coefficients.
R2: changes of pseudo-R2 to make coefficients comparable.
Controlling variables
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.
hypothesized that Asian Americans who are less acculturated drink more because they
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 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
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
Americans who are less acculturated experience more unfair treatment and perceive more
racial/ethnic discrimination than Asian Americans who are more acculturated.
treatment
Perceived Racial/ethnic
discrimination
Family
cultural conflict
Controlling variables Beta Beta Beta
R2: changes of pseudo-R2 to make coefficients comparable
Hypothesis 2.1 Yes Partially Partially
Hypothesis 3.1
Hypothesis 3.2
No
No
No
Hypothesis 4.2
No
No
No
No
No
Hypothesis 5.2
Hypothesis 5.3
No
No
Partially
Partially
No
No
Hypothesis 6.2
Hypothesis 6.3
No
Yes
No
No
Partially
Hypothesis 7.1
Hypothesis 7.2
No
No
Partially
No
Acculturation
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Less than once a year
(3) A few times a year
(4) A few times a month
(5) At least once a week
(6) Almost every day
(2) Rarely
(3) Sometimes
(4) Often
(2) Rarely
(3) Sometimes
(4) Often
(2) Rarely
(3) Sometimes
(4) Often
(2) Sometimes
(3) Often
family.
(2) Sometimes
(3) Often
(2) Sometimes
(3) Often
(2) Sometimes
(3) Often
(2) Sometimes
(3) Often
squares (OLS) regression
University Committee on Activities Involving Human Subjects
665 Broadway, Suite 804
New York, NY 10012
Telephone: 212-998-4808 / Fax: 212-995-4304
Internet: www.nyu.edu/ucaihs
Initial Review
HS#: (10-0041) “Socio-Cultural Factors Related to Alcohol Use Among Asian Americans”
Sponsor:
Number of Subjects Approved for enrollment: 2095
Devices:
category(s): 4.
Expiration Date: 25-Jan-2013
concerning your research protocol.
additional information, require further modifications, or monitor the conduct of your research
and the consent process.
help, please contact the IRB office at (212) 998-4808 or email ask.humansubjects@nyu.edu
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sample size.
1. Alcohol use 1
1. Alcohol use
2. Age
3. Gender
4. Income
5. Education
6. Marital Status
7. Protestantism
8. Catholicism
9. Other religion
10. No religion
11. English proficiency 1
*p < .05, **p < .01, ***p < .001
1. Alcohol use 1
1. Alcohol use
2. Age
3. Gender
4. Income
5. Education
8. Catholicism
9. Other religion
10. No religion
11. English proficiency 1
2
estimated by product of the direct
2
2.
generation
treatment
use
2
of the requirements for the degree of
(Health Behavior and Health Education)
201
Professor John Bound
Assistant Professor Derek Griffith
Associate Professor Gilbert Gee, University of California, Los Angeles
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List of Tables
List of Appendices viii
References
Aims and Hypotheses 1
and Gender to US Born Asians 1
Model 1
153
Ethnicity for Chapter 4
3
self-rated health and mortality – Additional studies, 1995 to 1998. Research on
Aging, 21(3), 392-401.
reproductive age. Maternal and Child Health, 11, 137-144.
Origin in Current and Constant (2008) Dollars. National Statistical Abstract:
Current Population Survey, Census Bureau
DC: Census Bureau.
the literature. Journal of Midwifery & Women’s Health, 48(5), 338-345.
dynamics among Black and White adults. Journal of Health and Social Behavior,
38(1), 38-54.
Origin: 2010. Washington DC: Census Bureau.
twenty-seven community studies. Journal of Health and Social Behavior, 38(\),
21-37.
in Functional Ability. Journals of Gerontology Series B-Psychological Sciences
and Social Sciences, 50(6), S344-S353.
NHIS Codebook, 2010, from http://www.ihis.us/ihis-action/variables/FLGOOUT
1523-1529.
Statistics.
from http://www.omhrc.gov/tcmplates/browse.aspx?lvl=2&lvlid=53
the 1990s. New York: Routledge.
for Prevention. Washington, DC: National Academies Press.
Behavioral, Health, and Social Differentials of Adult Mortality. San Diego, CA:
Harcourt Press.
status as a predictor of mortality in men and women over 65. Journal of Clinical
Epidemiology, 50(3), 291-296.
problem is real – Anthropological and historical perspectives on the social
construction of race. American Psychologist, 60(\), 16-26.
Gerontology, 27(1), 91-94.
by the International Health Conference, New York, 19-22 June, 1946; signed on
22 July 1946 by the representatives of
Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
previously taken-for-granted self-concepts and collective ethnic
identity and bring the anxiety of temporary rootlessness.
Strangers in a new environment are confronted with situations
in which their mental and behavioral habits are called into
question, and they are forced to suspend or even abandon their
identification with the cultural patterns that have symbolized
who they are and what they are. (2001, p. 50)
generally limited to socially and politically defined ethnic categories with varying
degrees of stigma or advantage attached to them.” (1994, p. 156)
of Integration
Integration
Integration
Integration
Governmental
capital characteristics
larger public
immigrants
cultural practices
Reception
occupational
discrimination
identity development
communities
employment
the primary labor
hostile experiences
identity development
55
weeks later. He wanted to get respect from me. But a real source of the problem
was not me but his frustration over low status.”
73
a theory-driven model of acculturation in public health research. Am J Public
Health, 96(8), 1342-1346.
immigrant generation and duration on self-rated health among US adults 2003-
2007′. Social Science & Medicine, 77(6), 1161-1172.
Journal of Refugee Studies, 21(2), 166-191.
investment and earnings growth. Demography, 44(A), 865-881.
International Migration Review, 37(4), 826-874.
Contemporary Immigration Cambridge: Harvard University Press.
and Income of Asian Americans. Sociology of Education, 63(1), 27.
New York, NY: Russell Sage Foundation.
Political Economy, 70(5), 9-49.
disorder among Southeast Asian refugees: a 10-year study. Social Science &
Medicine, 53(10), 1321-1334.
and postcolonial identities. Human Development, 44(\), 1-18.
in attenuating the stress of life events. Journal of Behavioral Medicine, 4(2), 139-
157.
Borjas, G. J. (1985). Assimilation, Changes in Cohort Quality, and the Earnings of
Brown, C. (2006). The Relation between Perceived Unfair Treatment and Blood Pressure
epidemiology, 164(3), 257-262.
and psychological distress: The role of personal and ethnic self-esteem. Journal of
Counseling Psychology, 51(3), 329-339.
(2008). Unfair treatment, racial/ethnic discrimination, ethnic identification, and
smoking among Asian Americans in the National Latino and Asian American
study. American Journal of Public Health, 98(3), 485-492.
A. M., et al. (2008). Alcohol disorders among Asian Americans: associations with
unfair treatment, racial/ethnic discrimination, and ethnic identification (the
national Latino and Asian Americans study, 2002-2003). Journal of Epidemiology
and Community Health, 62(11), 973-979.
HIV-Risk behavior among Asian gay men. Health Psychology, 27(2), 140-148.
Americans: Lazarus and Folkman’s Model and Beyond. In P. T. P. Wong & L. C.
J. Wong (Eds.), Handbook of Multicultural Perspectives on Stress and Coping
(pp. 439-447). Dordrecht, Netherlands: Kluwer Academic Publishers.
Testing Alternative Hypotheses. Migration, Human Capital and Development, 4,
1-26.
and Pacific Islander groups and the effect of nativity and duration of residence in
the U.S. Soc Biol, 48(3-4), 171-195.
Health Issues in the Asian American Community (pp. 162-198). San Francisco:
Jossey-Bass.
Behavior in Asian Americans: A Meta-Analysis. Journal of Cardiovascular
Nursing, 23(1), 67-73 10.1O97/1001JCN.0000305057.0000396247.fO000305052.
Psychological Bulletin, 98(2), 310-357.
Qualitative Investigation of the Cultural Adjustment Experiences of Asian
International College Women. Cultural Diversity and Ethnic Minority
Psychology, 11(2), 162-175.
Empirical Evidence on the Heterogeneity of Immigrant Groups in the United
States. Review of Economics and Statistics, 86(2), 465-480.
South Asian Community in the United States. Journal of Social Distress and the
Homeless, 9(3), 173-185.
Synthetic Estimates of Work-Life Earnings. Publication P23-210. Washington
DC: US Bureau of the Census,
Measures of Social Disadvantage Among Asian Americans: The Relevance of
Economic Opportunity, Subjective Social Status, and Financial Strain for Health.
Journal of Immigrant and Minority Health.
health conditions among Filipino immigrants. JImmigr Minor Health, 10(6), 551-
558.
and Foreign-Born Adults: United States 1998-2003. Advance Data, no. 369,
Hyattsville, MD. National Center for Health Statistics.
Depression Among Older Asian Indian Immigrants in the United States. Journal
of Applied Gerontology, 23(4), 370-384.
population: results from the National Population Health Survey. Social Science &
Medicine, 57(11), 1573-1593.
Asian Immigration in Los Angeles and Global Restructuring. Philadelphia:
Temple University Press.
Behavioral Scientist, 42(4), 628-647.
Disparities in Pain Management in the United States. Journal of Nursing
Scholarship, 38(3), 225-233.
Sociological Perspectives, 41(1), 119.
Community Sample. Journal of Health and Social Behavior, 21(3), 219-239.
epidemiologic and health equity research. Social Science & Medicine, 71(2), 251-
258.
Journal of Applied Behavioral Science, 33(3), 316-334.
and Pacific Islander adults in the United States. American Journal of
Epidemiology, 153(4), 372-380.
Social support as a buffer for perceived unfair treatment among Filipino
Americans: differences between San Francisco and Honolulu. Am J Public
Health, 96(4), 677-684.
Americans: Historical Roots and Contemporary Evidence. In C. Trinh-Shevrin,
Francisco, CA: Jossey-Bass.
Health Among Asian Americans: Evidence, Assessment, and Directions for
Future Research. Epidemiologic Reviews, 31(1), 130-151.
the health of urban populations. Am J Public Health, 90(6), 867-872.
Inequality in Health and the Impact of a Policy-Induced Breakdown of African
American Communities. Du Bois Review, 7(2), 247-279.
and Social Science, 530, 122-136.
immigrant subgroups by duration of residence. Jama, 292(23), 2860-2867.
National Origins. New York: Oxford University Press.
approach to eliminating health disparities. Ethnicity and Disease, 20(1), 71-76.
American Immigration. Armonk, NY: Sharpe.
physical health indicators, and the mediating role of perceived stress among high
socio-economic status Asian immigrants. Social Science & Medicine, 64(6), 1192.
among Mexican Americans: Scales and Population-Based Data. Social Science
Quarterly, 69(3), 687-706.
1850-1990. Stanford: Stanford University Press.
Assimiliation. New York: New York University Press.
Immigration. Berkeley: University of California Press.
Academy of Political and Social Science, 571(1), 107-120.
Southeast Asian refugees: Historical, cultural, and contextual challenges. Clinical
Psychology Review, 24(2), 193-213.
health research? A critical review of research on US Hispanics. Social Science &
Medicine, 59(5), 973-986.
disadvantaged? Social Science Research, 28(1), 45-65.
Asian American Health. In C. Trinh-Shevrin, N. Islam & M. Rey (Eds.), Health
Issues in the Asian American Community. San Francisco, CA: Jossey-Bass.
Role of the Stress Reponse and and the HPA Axis in Physical and Mental Health
and Self-Regulation in the Elderly New York, NY: Springer Publishing.
Psychiatry, 18(2), 163-182.
satisfaction with service: barriers and facilitators for older Korean Americans. J
Am GeriatrSoc, 53(9), 1613-1617.
discrimination, social support networks, and psychological well-being among
three immigrant groups. Journal of Cross-Cultural Psychology, 37(3), 293-311.
Than Family Reunification Immigrants? International Migration Review, 29(1),
85-111.
Immigrants to the United States: Recent Trends and their Determinants. National
Bureau of Economic Research.
the leading health indicators tell us. Annual Review of Public Health, 25, 357-376.
occupational physical activity in Asian Americans. Ann Epidemiol, 15(A), 257-
265.
Berkman & I. Kawachi (Eds.), Social Epidemiology (pp. 174-190). New York,
NY: Oxford University Press.
105-138.
and Cross-cultural Adaptation. Thousand Oaks, CA: Sage Publications.
the education gradient in health. Health Affairs, 27(2), 361-372.
The prevalence of posttraumatic stress disorder and its clinical significance
among Southeast Asian refugees. Am J Psychiatry, 147(1), 913-917.
Influencing Waiting Time and Successful Receipt of Cadaveric Liver Transplant
in the United States 1990 to 1992. Medical Care, 36(3), 281-294.
Community Health, 55(10), 693-700.
perspective. International Journal of Epidemiology, 30(4), 668-677.
Depression and posttraumatic stress disorder in Southeast Asian refugees. Am J
Psychiatry, 146(12), 1592-1597.
Chinese-Americans. Social Science & Medicine, 10(6), 297-306.
Chinese-Americans. Social Science & Medicine, 10(6), 297-306.
Quality, Assimilation, and Distributional Effects. American Economic Review,
81(2), 297-302.
Asian Americans: effects of nativity, years since immigration and socioeconomic
status. lnt J Obes Relat Metab Disord, 24(9), 1188-1194.
Discrimination in Health Care: The California Health Interview Survey 2003.
Medical Care, 44(10), 914-920.
Century. In P. Ong (Ed.), The State of Asian Pacific America: Transforming Race
Relations, A Public Policy Report (Vol. 4). Los Angeles: LEAP, Asian Pacific
American Public Policy Institute and UCLA Asian American Studies Center.
choices among Asian Americans. Social Science Quarterly, 84(2), 461-481.
America. Hawthorne, NY: Aldine De Gruyter.
Americans. Public Health Rep, 103(1), 18-27.
explains prejudice for an envied outgroup: Scale of anti-Asian American
stereotypes. Personality and Social Psychology Bulletin, 37(1), 34-47.
Journal of Health and Social Behavior, 35, 80-94.
Filipino Immigration to the United States. International Migration Review, 25(3),
487-513.
contribution of a gender perspective to the understanding of migrants’ health.
Journal of Epidemiology and Community Health, 67(Suppl 2), ii4-iil0.
Japanese-Americans. Am J Epidemiol, 104(3), 225-247.
EPIDEMIOLOGIC STUDIES OF CORONARY HEART DISEASE AND
STROKE IN JAPANESE MEN LIVING IN JAPAN, HAWAII AND
CALIFORNIA: PREVALENCE OF CORONARY AND HYPERTENSIVE
HEART DISEASE AND ASSOCIATED RISK FACTORS. Am. J. Epidemiol.,
102(6), 514-525.
Mental health of Cambodian refugees 2 decades after resettlement in the United
States. Jama, 294(5), 571-579.
Prospects for Assimilation. Annual Review of Sociology, 7, 57-85.
correlates among Chinese- and Filipino-American adults: Findings from the 2001
California Health Interview Survey. Preventive Medicine, 41(2), 693-699.
Stress: Elaborating and Testing the Concepts of Allostasis and Allostatic Load.
Annals of the New York Academy of Sciences, S96(Socioeconomic Status and
Health in Industrial Nations: Social, Psychologcal, and Biological Pathways), 30-
47.
presence in U.S. biomedical research tabs. So why do so few hold leadership
positions?(News Focus). Science, 370(5748), 606(602).
(Ed.), Asian Americans: Contemporary Trends and Issues, Second Edition.
Thousand Oaks: Sage Publications.
Immigrants: History and Contemporary Trends. Thousand Oaks, CA: Sage
Publications.
Gujurati Asian Indian immigrants in the United States. JImmigr Health, 2(4),
223-230.
E. Adler (Eds.), Health Psychology: A Handbook (pp. 523-548). San Francisco:
Jossey-Bass.
Perceived Racist and Sexist Events to Psychological Distress for African
American Women. The Counseling Psychologist, 37(4), 451-469.
Protect Mental Health? Journal of Health and Social Behavior, 44(3), 318-331.
Filipino Americans. Social Psychology Quarterly, 70(3), 290-304.
Analytic Study. Hispanic Journal of Behavioral Sciences, 14(2), 163-200.
effects of immigrant history: older Asians in the United States. Demography,
44(2), 251-263.
Culture. Social Problems, 41(1), 152-176.
Koreans in Canada. J Health Soc Behav, 37(2), 192-206.
discrimination, depression, and coping: a study of Southeast Asian refugees in
Canada. J Health Soc Behav, 40(3), 193-207.
effects of coping, acculturation, and ethnic support. Am J Public Health, 93(2),
232-238.
the 1990s. New York: Routledge.
Chinese adults living in New York City. J Community Health, 34(\), 6-15.
Park, K. (1997). The Korean American Dream: Immigrants and Small Business in New
Park, R. E. (1928). Human Migration and the Marginal Man. The American journal of
Park Tanjasiri, S., & Nguyen, T.-U. (2009). The Health of Women. In C. Trinh-Shevrin,
Francisco, CA: Jossey-Bass.
duration of residence, neighborhood immigrant composition and body mass index
in New York City. Int J Behav Nutr Phys Act, 5, 19.
statistics by race and ethnicity. CA: A Cancer Journal for Clinicians, 48(1), 31-
48.
Ethnicity and Health. Du Bois Review, 5(1), 27.
Migration Process: A Review and Appraisal. In C. Hirschman, P. Kasinitz & J.
DeWind (Eds.), The Handbook of International Migration: The American
Experience. New York, NY: The Russell Sage Foundation.
Phinney, J. S., Horenczyk, G., Liebkind, K., & Vedder, P. (2001). Ethnic Identity,
Issues, 57(3), 493-510.
and Its Variants. Annals of the American Academy of Political and Social Science,
530, 74-96.
Racism Among Second Generation Asian Americans. Qualitative Sociology,
26(2), 147-172.
Acculturation. American Anthropologist, 38(1), 149-152.
Islander ethnic groups in the U.S. : The added dimensions of immigration. Paper
presented at the Population Association of America, Detroit, MI.
status among Hispanics. Convergence and new directions for research. Am
Psychol, 46(6), 585-597.
of Obesity Among US Immigrants. Obesity (Silver Spring).
acculturation and health in Asian immigrant populations. Soc Sci Med, 57(1), 71-
90.
1990s. In S. Hune & G. M. Nomura (Eds.), Asian/Pacific Islander American
Women. New York, NY: New York University Press.
1994-2006. Demography, 47(3), 801-820.
Garcia, D. (2008). Differential effect of birthplace and length of residence on
body mass index (BMI) by education, gender and race/ethnicity. Social Science &
Medicine, 67(8), 1300-1310.
the 1970s and 1980s. Journal of Human Resources, 32(4), 683-740.
(2000). Generic Processes in the Reproduction of Inequality: An Interactionist
Analysis. Social Forces, 79(2), 419-452.
Concept of Acculturation Implications for Theory and Research. American
Psychologist, 65(A), 237-251.
adaptation—allostatic load and its health consequences: MacArthur studies of
successful aging. Archives of internal medicine, 157(19), 2259.
New York: The Macmillan Company.
amongst Korean immigrants to the United States: A structured interview survey.
International Journal of Nursing Studies, 44(3), 415-426.
differences in birthweight: the role of lifestyle and other factors. Am J Public
Health, 87(5), 787-793.
among immigrant populations in the United States. Can J Public Health, 95(3),
114-21.
morbidity, and cause-specific mortality in the United States: an analysis of two
national data bases. Hum Biol, 74(\), 83-109.
General Social Survey. GSS Topical Report No. 32. National Opinion Research
Center, University of Chicago.
American and Native Hawaiian/Pacific Islander data. Am J Public Health, 90(\ 1),
1731-1734.
Analysis of the “Model Minority” Thesis. Amerasia, 4(2), 23-51.
(Eds.), Hypertension Determinants, Complications and Intervention. New York:
Grune & Stratton.
York, NY Little, Brown and Company.
Mental Disorders among Asian Americans. Research in Human Development,
4(\&2), 49-69.
Heart disease prevention among Chinese immigrants. J Community Health, 32(5),
299-310.
Metropolitan Housing Markets. Retrieved, from.
empirical test of depression risk factors among immigrant Mexican women. Int
MigrRev, 27(3), 512-530.
“Indigenist” Stress-Coping Model. Am J Public Health, 92(4), 520-524.
Realities. Cambridge: Harvard University Press.
women. Ethn Dis, 12(4), 470-479.
2nd Edition. Copenhagen: Denmark: World Health Organization Regional Office
for Europe.
Epidemiol, 7(5), 322-333.
EPIDEMIOLOGIC STUDIES OF CORONARY HEART DISEASE AND
STROKE IN JAPANESE MEN LIVING IN JAPAN, HAWAII AND
CALIFORNIA: MORTALITY. Am. J Epidemiol, 102(6), 481-490.
17.
Moderators of the Racial Discrimination/Well-Being Relation in Asian
Americans. Journal of Counseling Psychology, 52(A), 497.
of Frequent Racial Discrimination on Situational Well-Being of Asian
Americans? Journal of counseling psychology, 55(1), 63.
Korean Immigrant Women’s Lives. Counseling Psychologist, 38(4), 523-553.
self-rated physical and mental health among Asian Americans. Soc Sci Med,
68(12), 2104-2112.
Role of Place of Education. The American Journal of Sociology, 109(5), 1075.
and Non-Hispanic White Males in the United-States. Sociological Quarterly,
35(4), 581-602.
90
law in accord with international standards (Haines, 2001). The social reception was
Second Professional Wave (1992-2005)
health care, and other public services for undocumented immigrants and required police
93
chronic diseases, including Type II diabetes, gallbladder disease, high blood pressure and
Wave
Reunification Wave
1986-1990
1986-1990
Wave
1996-2000
2001-2005
3
4
6
9
10
11
13
14
1999
1998
1996
1994 i
199 V”
1992
1991
1989
1988
Weight for 1996-2000 cohort
from CPS
0
0
0.18 , ,
0
0
0
0
0.65
0.35
entry
Cohort
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