Acculturation and Health in Asian American Communities: Time for a Reset

Abstract

To date, public health literature has treated acculturation as a static determinant of health in Asian American communities without offering actionable recommendations. Four limitations exist in current research: use of proxies for acculturation, focusing on cultural practices (not values and identity), not considering the context of reception for Asian American individuals in the receiving country, and ignoring time and digitalization. We recommend researchers use validated scales, contextualize findings in time and the global context, and consider multi-level influences in sending/receiving countries. A nuanced approach will allow for the unpacking of associations with the acculturation process and ultimately translation into actionable research.

Acculturation is a key social determinant of health frequently studied in Asian American health research,^1–3 owing in part to the large proportion of the Asian American population that is born outside the U.S. and the interplay of the perpetual foreigner and healthy immigrant stereotypes ⁴ that facilitate the use of acculturation as a way to explain health differences. Acculturation may be understood as changes that occur when two cultural groups interact and the exchange of social influences that follow.^5,6 This definition has evolved from a unidimensional model—a linear process from less to more acculturated to one’s receiving country (often referred to as “westernization”), to bidimensional—one’s association with heritage and receiving country cultures, to a multidimensional model, which involves assessment of multiple attitudes and values to understand the impacts of different cultural contexts. Salient constructs within the acculturation process have included cultural practices (language use, social affiliations), cultural values (individualism/collectivism), or cultural identification (attachments to cultural groups). ⁵

Despite these advances in the social sciences and globalization, epidemiological research on the acculturation process has not consistently kept pace, despite a call 18 years ago by public health experts for a more theory-based approach. ⁷ First, epidemiological studies continue to use unidimensional definitions and/or proxies of acculturation versus validated scales. In a review of the conceptualization of acculturation, half of the studies that used scales (n = 62) used unidimensional scales (n = 31) and nearly half of the studies utilized proxies—especially population-based (62%) versus smaller health surveys (25%). ⁶ Moreover, 33 acculturation proxies have been identified that fall under the domains of language, migration history, ethnicity or race, and social environment/culture and, while convenient and widely available, fail to capture the complexity of the acculturation process. ⁶ Second, research has typically focused on cultural practices only and ignored cultural values and identification. The context of reception—how immigrant groups, their heritage country, and their cultural practices and values are viewed in the receiving country—has also been largely overlooked.^6,8,9 Perceptions by the public and “othering” can strongly shape one’s identity and the relationship between identity and well-being, ¹⁰ particularly in the current climate of discrimination and anti-immigrant sentiment.

A final but critical aspect of the acculturation dialogue in public health research pertains to time. The temporal aspect is partially accounted for by asking about “time spent in the U.S.” but only focuses on changes at the time at arrival in the receiving country and not pre-migration context. Individuals who are “born outside the U.S.” are treated as a homogenous group regardless of when they migrated. There is an inherent assumption that the social determinants of health, the environments of sending countries and the U.S., the characteristics of migrating individuals, and transnational communication have remained static over time. The enactment of the Immigration and Nationality Act in 1965 resulted in substantial waves of immigrants from Asia, Latin America, and Eastern Europe to the U.S. ¹¹ Concurrently, there have been major shifts in economic development and globalization impacts in Asian sending countries. For example, China and India have undergone rapid urbanization; diet, sedentary lifestyle, and increased alcohol consumption have contributed to explosive increases in type 2 diabetes. ¹² South Korea transitioned from a developing country post-Korean War in the 1950s, to a developed country in 1996, to now being recognized as a modern economic and cultural power. Fast food has become a global phenomenon—first taking hold in the 1970s and rapidly expanding to more than an $800 billion dollar industry today. ¹³ Lastly, technological advances have significantly changed communication and increased exposure to social media among transnational family members/peers, shaping the adoption or maintenance of health beliefs or behaviors. In contrast, in the 1960s, international phone calls were expensive, and ethnic media were geographically limited to urban areas with large, racialized populations. Advances in communication and information exchange internationally therefore underscore the need to account for time of migration in our framing, measurement, or analyses of health.

The implications of these practices are twofold. We cannot confidently make statements about the directionality of the relationship between acculturation and health, ⁵ and we lack the necessary understanding of the acculturative process to provide evidence-based guidance for immigrant communities. What aspects of acculturation drive health behaviors or outcomes: day-to-day practices, value systems, or cultural identity? How has the sociopolitical climate shaped the reception of Asian immigrants? Which aspects of acculturation are modifiable through public health interventions or education? Our current knowledge is insufficient to answer these important questions.

It may be impossible to enumerate all aspects of the acculturation process, but this should not be our primary goal. We propose the following feasible and tangible recommendations for the public health community to move towards a deeper understanding of the acculturation process of Asian American communities:

• 1.

Utilize validated acculturation scales and include plausible causal pathways.

Include a definition of acculturation supported by theory (e.g., Berry—bidimensional) and use validated scales. When possible, utilize multi-dimensional measures of acculturation that enumerate practices, values, and identity (e.g., Schwartz), ⁵ and/or scales that have been validated in Asian American communities.

The use of proxies is not recommended. However, in cases where proxies are used, they should be named as what they measure (e.g., state “nativity” instead of using an umbrella term “acculturation”), and a causal pathway a priori should be elucidated in the Methods (e.g., see Morey et al.). ¹⁴

State a plausible causal pathway between acculturation and the health outcome, focusing on modifiable factors. For example, as opposed to examining the relationship between acculturation and quality of life amongst Chinese American breast cancer survivors, researchers theorized and found evidence for mediators of the relationship (i.e., more acculturated → less self-stigma → better quality of life). Targeting self-stigma is an actionable path forward to improve health outcomes in this population. ¹⁵

Work in multi-disciplinary teams with expertise in the social sciences, mediation analyses, causal inference, and translational research to propose plausible mechanisms and eventual application to practice.

2.

Provide context on the population being examined and for interpreting findings.

Describe cultural context and/or pre-migration environments of the participant sample from the extant literature guided by tools such as the ECLECTIC framework (Education, Culture, Language, Economic issues, Communication, Testing [data collection] situation, Intelligence, Context of immigration) ¹⁶ paired with measures on transnational ties and social media exposure. In this way, public health practitioners can consistently report standardized elements of cultural context across different immigrant groups by ethnicity and/or time of migration.

Provide the prevalence of the health outcome of interest in the sending country.

If possible, describe cultural practices, values, and identity; include measures of enculturation (e.g., Enculturation Scale for Filipino Americans-Short; Asian Values Scale—Revised; Traditional cultural beliefs scale in Mediators of Atherosclerosis in South Asians Living in America);^17–20 and/or temporal characteristics, including year of migration, age of migration (e.g., as a child vs. as older adult), migration circumstances (e.g., family reunification, economic opportunity), and discuss the interplay between these factors (e.g., dynamic nature of restrictive/open immigration policies).

3.

Enumerate acculturative influences beyond the individual level.

Incorporate multiple levels of influence in both sending and receiving countries: interpersonal, community, and societal levels, and different domains of determinants such as food, physical/built and sociocultural environments, health care infrastructure, or government type (e.g., see LeCroy et al.). ²¹ This is particularly salient when we consider chain migration, whereby established support systems for housing, food, and employment enable continued and specific migration by one group to that geographic community within the U.S. ²²

Contextualize findings to what is happening in both sending and receiving countries on appropriate time horizons in the manuscript conceptualization and in the introduction, methods, and discussion sections.

If possible, conduct in-depth interviews with your community of interest to gather information at the time of migration on their sending country environment and/or the context of reception of their community in the U.S.

4.

Be specific of the community of interest/under study.

Understand what migrating community you are studying and the sociopolitical relationship with the U.S. (e.g., context of migration, visa type), and consider including children of migrants (i.e., second generation in the U.S.) in research, as there is evidence that these individuals experience acculturative stress despite not having gone through the migration process;^10,23

If conducting primary data collection, apply inclusive research practices, including tailoring materials to health/reading literacy levels and preferred language/dialect of the local community; providing bilingual support in all participant interactions; ensuring cultural salience of materials, messaging, and survey tools; ²⁴ and utilizing survey measures that have been validated in Asian American populations, where possible.

Acknowledge that acculturation experiences can be distinct across and within ethnic groups if examining Asian American groups in aggregate.^2,5

By focusing on acculturation as an isolated, atheoretical variable without considering the context or causal pathways, we inadvertently yet blatantly put the onus on individuals regarding their ‘acculturation status’ rather than understanding the systems and identifying multi-sector solutions to better support immigrant health and well-being. By evaluating and shifting our current practices of conceptualization and analysis of acculturation in research, we too can progress towards a more informed place for public health action.

Authors’ Contributions

Conceptualization: S.S.Y. Writing—original draft: S.S.Y. Writing—review and editing: L.N.Đ., S.C.K., and S.S.Y.