DEBORAH J. MORTON, E. PERClL STANFORD, CATHERINE J. HAPPERSETF, AND CRAIG A. MOLGAARD

ACCULTURATION AND FUNCTIONAL IMPAIRMENT AMONG OLDER CHINESE AND VIETNAMESE IN SAN DIEGO COUNTY, CALIFORNIA ABSTRACT. Level of acculturation and the relationship to functional impairment was examined among a group of Chinese (n = 50) and Vietnamese (n = 50) 45 years and older in San Diego County, California. Prevalence of functional impairment and level of acculturation, one-way analysis of variance and Pearson correlations were utilized to examine differences between ethnicity, gender and age groups, as well as significant relationships between various dimensions of impairment and levels of acculturation. Findings indicated that lack of English language skills and lack of use and exposure to English were associated with social and economic resource impairment, mental and physical health impairment, and ADL impairment, as measured by a modified OARS instrument. Data suggested that the visibility and extensiveness of the Vietnamese community may serve to buffer the negative effects associated with the acculturation process for the Vietnamese. Key Words: acculturation, functional impairment, OARS instrument, older Chinese, older

Vietnamese

INTRODUCTION F r o m a broad perspective, culture is a major determinant o f social, psychological, economic, and political behavior, as well as physical and mental health. It creates the evaluative standard o f "normal" response to changes in the environment. The process o f acculturation m a y be seen as the channel through which change and adaptation are manifested. In the process o f either voluntary or forced migration, where it is usually necessary to adapt to various aspects o f a new cultural environment, the effects o f acculturation can be pervasive. Moreover, in any analysis o f health status and patterns o f illness among ethnic minority groups, it is often very difficult to uncover which health behaviors and resultant effects are due to cultural variation and which are due to other variables. Therefore, in any study which investigates health status or health behaviors among ethnic minority groups, an essential component is a measure o f acculturation. Level o f acculturation among various ethnic minority groups has been shown to be a major factor in relation to a variety o f physical and mental health assessments, as well as in help-seeking behaviors. In general, most studies support the tenet that low levels o f acculturation are associated with higher stress levels, higher prevalences o f physical and mental illness, and less use o f services. More specifically, studies have shown acculturation levels associated with prevalence o f various psychiatric disorders (Bumam, Hough, K a m o , Journal of Cross-Cultural Gerontology 7: 151-176, 1992. © 1992 Kluwer Academic Publishers. Printed in the Netherlands.

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Escobar, and Telles 1987), depression (Salgado de Snyder 1987), gender (Tran 1988), age (Krause, Bennett and Tran 1989), psychological assessment (Hoffman, Dana and Bolton 1985), stress and coping behaviors (Wong and Reker 1985; Yu 1984; Lin, Masuda and Tazuma 1982; Yu and Harburg 1981), subjective health status (Angel and Worobey 1988; Angel and Thoits 1987), meaning and structure of eating habits (Pasquali 1985), service and physician utilization patterns (Wells, Golding, Hough, Bumam, and Kamo 1989; Die and Seelbach 1988; Cox 1986; Boyce and Boyce 1983), and physical health (Angel and Worobey 1988; Marmot and Syme 1976). The majority of these studies appear to have been concerned with psychological stress associated with relocating to radically different cultures where migrants must learn to speak a new language, as well as adjust to cultural differences in social, political, psychological, and economic environments. This emphasis is further evident in the literature concerning refugees, who must endure forced migration and, in many cases, extreme psychological trauma prior to and during their departure. The remainder of the above mentioned studies appear to have been primarily focused on very specific issues and their relationship to acculturation. Further, few studies attempt to concern themselves solely with the older portions of migrant populations, and if so, the concentration and concern is principally with social service needs and not health assessment or the effects of acculturation (Chambon 1989; Cheung 1989; Die and Seelbach 1988; Lee 1987; Wong and Reker 1985; Yu and Wu 1985; Brown 1982). No studies were located in the literature that have attempted to examine from a broad or multidimensional perspective, the relationship between acculturation and health status among any older ethnic minority groups. The purpose of the present study was to address the relationship of acculturation with general health status, more specifically, functional impairment, among two older ethnic minority groups. Older ethnic migrants and refugees are particularly vulnerable during the acculturation process because they must also simultaneously face the difficulties associated with the natural aging process. It is very difficult to age physically and learn a new language, handle the emotional trauma associated with the possibility of never returning to their homeland, accept the devastating losses of relatives and friends, fear possible retaliation from the government, and accept the substantial shift from traditional to American values among younger family members (Freeman 1989; Ikels 1983). Communities investigated in the present study represent two older migrant populations, one consisting of relatively recent immigrants and refugees, the Vietnamese, and one consisting of an immigrant group with a longer history in the United States, the Chinese. In an attempt to discern whether or not acculturation is related to functional health status, several main research questions were investigated. These were: (a) are there differing levels of acculturation within and between the two groups; (b) do the levels and dimensions of functional impairment differ within and between the two groups; (c) is there a relationship between level of acculturation and functional impairment, and does this relationship remain constant when controlling for other factors; and finally, (d)

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what aspects of the relationship between acculturation and functional impairment have potential for preventive intervention among the Vietnamese and Chinese. METHODOLOGY

Selection of Sample Respondents The sampling frame consisted of non-institutionalized persons aged 45 and older of Vietnamese and Chinese descent in San Diego County. Nonprobability sampling methods were utilized to obtain the study group. Although random probability samples produce the most generalizable results, it is not always the most cost effective method when identifying ethnic minority populations, especially when specifying the age criteria of 45 years and older. Additionally, while the Vietnamese in San Diego County live in geographic clusters, the geographic distribution of the Chinese is very diffuse, making screening costs substantial. Many Chinese have been in California for more than one generation and have become very integrated with respect to residence patterning. Consequently, random digit dialing telephone screening in randomly selected census tracts or census tracts with high ethnic clustering, a preferred method of probability sampling, was rejected.

Chinese Chinese health, social service agencies and religious organizations were identified in the community with the assistance of the director of the Union of Pan Asian Communities (UPAC). UPAC is a community based umbrella organization that provides and administrates social and health services to the Chinese, Indochinese (including Vietnamese, Hmong, Cambodian, Lao, and Thai), Japanese, Filipino, Korean, Samoan, and Guamanian communities in San Diego County. All organizations were contacted, informed of the project, and asked to provide lists of clients. One list was obtained from the Chinese Senior Social Service Center, and another from a Chinese nutrition program. These two lists contained 118 names. This list was augmented with names chosen through a random process of sampling by surname from the telephone directory. There are a finite number of Chinese surnames and a list of approximately 200 Chinese surnames was prepared utilizing the Standard Romanized Dictionary of Popular Japanese and Chinese Names (Chen 1972). These 200 names served as the basis for sampling from the telephone directory. The final sampling list contained 285 names. A translated letter informing potential respondents about the project was mailed to all on the list. Additionally, an announcement about the project, targeted at potential respondents, was placed in the Chinese newspaper. The final list was then divided equally and given to interviewers. Of the 285 names, interviewers attempted to contact by telephone a total of 233 people, 60 of

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which were not eligible, 32 refused, 91 were never reached and 50 completed the interview. Using Kalton's (1983) definition of response rate, the ratio of completed surveys to the total number of identified eligibles, the response rate for the Chinese group was 61%.

Vietnamese None of the Vietnamese agencies and organizations identified by UPAC provided client lists. The Vietnamese are known as "Tram Ho", or "the people of 100 names", hence a reasonable alternative was to draw a random sample from the 1990-1991 telephone directory utilizing the list of 100 names (Weeks and Rumbaut 1988). This procedure yielded 474 names. Again, a translated letter was sent to all on the list, an announcement was placed in the Vietnamese newspaper, and the list was divided equally among interviewers. From the total list, interviewers attempted to contact by telephone 401 potential respondents, of which 162 were not eligible, 48 refused, 141 were never reached, and 50 completed the interview. The response rate for the Vietnamese group was 51%, slightly lower than for the Chinese. In essence, these two variations of nonprobability sampling yielded two available groups for study. Although results cannot be generalized to the total populations of these two groups, the data remain valuable in that the final product consists of well-informed knowledge about predisposing and correlated variables, which serve to augment the success of future intervention processes.

Survey Instrument The survey instrument collected a broad spectrum of data including demographics, residential, medical, occupational and educational histories, current housing information, nutritional risk assessment, Alzheimer's risk factors such as head trauma due to accidents or boxing, and exposure to heavy metals and/or pesticides, depression data, and attitudes and use of alcohol. In addition, major portions of the instrument were focused on acculturation and functional impairment. Measurement of acculturation was accomplished through the use of several scales developed by Hazuda, Stem and Haffner (1988a) from a project conducted among Mexican Americans. Hazuda and colleagues defined acculturation as a multidimensional process where individuals acquire attitudes, behavior and values from the host culture. Additionally, individuals acculturate at differing rates along various aspects of the culture. Hazuda et al. (1988a) constructed a set of scales that measure acculturation and structural assimilation. Their work, based on Gordon's (1964, 1975) seven dimensions of assimilation, views acculturation and structural assimilation as two of the seven dimensions, with marital assimilation, identificational assimilation, attitude receptional assimilation, behavior receptional assimilation, and civic assimilation making up the other five dimensions. Hazuda et al. (1988a) accepted Gordon's model that defines acculturation as the changing of cultural behavior to match that of the

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host society, and added that this process is not unidirectional but reciprocal, with the dominant force generally in the direction of the host culture. Structural assimilation, according to Gordon (1964), occurs when there is large-scale membership by ethnic minorities in clubs and institutions of the mainstream culture. Additionally, structural assimilation, with or without acculturation, is the primary precursor of the other five dimensions of assimilation as identified by Gordon. Due to Gordon's notion that structural assimilation is critical to the overall assimilation process, Hazuda and colleagues (1988a) felt it important to develop measures of both acculturation and structural assimilation. While the scales developed by Hazuda et al. (1988a) were tested for use among Mexican Americans, due to their adherence to a general theoretical background the seven dimensions measured by the scales appear to be appropriate for use among older Asian minority groups. A literature search identified one measure of acculturation specifically developed for use with Asians, the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA) (Suinn, Rickard-Figueroa, Lew and Vigil 1987). Despite the fact that the SLASIA measures essentially the same dimensions of acculturation and was very similar to the work of Hazuda and colleagues (1988), it was not chosen for use in the present study for two reasons. First, the SL-ASIA does not provide a structural assimilation component. Second, the SL-ASIA was validated on two small groups (n = 35, n = 47) of young university students (mean age = 19), whereas Hazuda's work was validated on four sets of criterion groups that included members of the migrant population and members of the host, or mainstream population. These criterion groups ranged in age from 25 to 64 years and had varying levels of income, occupation and education. Additionally, the Hazuda scales were validated on three generationally variant groups within the migrant population. The Hazuda acculturation and structural assimilation measures are additive scales which collapse into four homogeneous strata ranging from one to four, representing the lowest to highest level of acculturation. The four strata are constructed by summing the response scores of the total number of questions in each of the scales. The seven scales consist of the following: Scale A1 "Early Childhood Experience with English vs. Other Language" Scale A2 "Adult Proficiency in English" Scale A3 "Adult Pattern of English vs. Other Language Usage" Scale A4 "Value Place on Preserving Ethnic Cultural Origin" Scale A5 "Attitude Toward Traditional Family Structure and Sex Role Organization" Scale S1 "Childhood Interaction with Members of Mainstream Society" Scale $2 "Adult Interaction with Members of Mainstream Society"

2 items, 2--6 points 3 items, 3-12 points 10 items, 10-50 points 3 items, 3-15 points 7 items, 7-35 points 3 items, 3-9 points 3 items, 3-9 points

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No missing data were permitted for two-item scales, the case was removed. Missing data were permitted on one item only for three or more item scales, and replaced by the mean score of non-missing items for that case (Hazuda, Stem, and Haffner 1988b). Cutpoints for each of the four strata were taken from Hazuda and colleagues' work which were originally obtained by applying Lazarsfeld's property-space reduction technique (Hazuda et al. 1998a). These Likert type scale scores are statistically treated as interval level data, although one may argue that technically, the data axe ordinal (Hazuda 1990). For the present study, only minor modifications in the Hazuda et al. (1988a) scales were made. Questions that referred to specific cultural holidays were changed to generic holidays, and the word "Mexican" was substituted with the appropriate ethnic group name. Functional impairment was measured through use of the assessment portion of the Older Americans Resources and Services (OARS) instrument developed at Duke University (1978). This instrument has been utilized in hundreds of studies across the country and, therefore, provides a large comparative base. It has also been used outside the U.S. among Chinese elderly in Singapore (Kua 1990). The OARS instrument measures functional impairment in five areas: social and economic resources, mental and physical health, and activities of daily living (ADL). The five scales range from one to six, with the higher numbers representing higher levels of impairment. The five scales, although technically ordinal, have been historically treated as interval level data in other studies (Stanford, Happersett, Morton, Molgaard, and Peddecord 1991; Nakamura, Molgaard, Stanford, Peddecord, Morton, I_x~ckery, Zuniga, and Gardner 1990; Ailinger 1989; Gatz, Pederson, and Harris 1987; Gerson, Jarjoura, and McCord 1987; and Harel and Deimling 1984) and will be treated as such for this analysis. The translation of the instrument into Chinese was completed by a Chinese physician from the mainland. His education and medical training produced a very precise and accurate translation, easily comprehended by the interviewers, regardless of the dialect spoken. The Vietnamese translation was completed by a professional translator and journalist specializing in television and radio translations. Both translations were back translated and verified by two interviewers.

Interviewer Recruitment and Training Chinese and Vietnamese interviewers were solicited from the community-atlarge through newspaper ads. These ads were translated and placed in the Chinese and Vietnamese community newspapers which have county-wide circulation. Several community leaders were made aware of the available positions. Response to these efforts was overwhelming. All applicants were interviewed to prevent possible offense to the community. Four Chinese and four Vietnamese interviewers (2 females and 2 males in each group) were selected. All were bilingual, two were trilingual (Chinese and Vietnamese), and

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one spoke four Chinese dialects. For the Chinese interviewers, it was an absolute necessity to have a variety of language skills among the group. Along with people from mainland China who may speak one of several dialects, there are also a large number of ethnic Chinese from Vietnam in San Diego County. It was difficult to anticipate what language or dialect would be spoken based on name alone. All eight interviewers received 15 hours of training before going into the field, although the four Vietnamese interviewers had previous field experience from a similar project. Training consisted of the following: (a) instruction in response rates and the importance of recording accurate telephone screening data; (b) how to convince eligibles to participate and how to handle refusals during telephone screening; (c) general field techniques, such as a project overview, issues in confidentiality, familiarity with respondents, interviewer attitude and rapport, how to avoid survey bias, privacy during the interview, probing for answers without bias, and accuracy and precision in the recording of answers; (d) instruction in the OARS methodology; (e) reading through all questions in English, Chinese and Vietnamese in order to thoroughly understand what was being asked as well as to again verify the translations; and (f) practice interview sessions with role playing. Within one month of the initial interview, 60% of the completed Chinese interviews were validated by telephone, as were 58% of the Vietnamese interviews. RESULTS

Demographic Characteristics Final sample sizes were 50 respondents for both the Chinese and Vietnamese groups (see Table I). Gender breakdown within each group exhibited identical distributions, with males comprising 46% and females 54%. The age grouping of the total sample was well distributed among four ten-year categories: 22% fell between 45 and 54 years of age, 19% were between 55 and 64, 32% were between 65 and 74 years, and 27% were 75 or older. However, there was great variation in age distribution between the two ethnic groups. The Vietnamese (mean age = 61) were comparatively younger than the Chinese (mean age = 71), of which only 22% were under age 65. In contrast, 60% of the Vietnamese were under age 65. This age distribution may have occurred due to the sampling procedure, since one list of Chinese names was provided by an agency serving mainly seniors. Over half of the total sample was married (62%), with a slightly higher marital rate among the Vietnamese (64%), compared to the Chinese (60%). The Chinese had the highest prevalence of widowhood, 28% versus 20% for the Vietnamese, while disrupted marriages for both groups was very low (8% for the Chinese and 10% for the Vietnamese).

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DEBORAH J. MORTONET AL. TABLE I Selected demographics by ethnicity: Health Status and Lifestyles of Asians project, San Diego, CA 1990

Demographic characteristic

Total sample n % ,~

Chinese n %

Total

100

100

50

50

50

50

Gender M~e Female

46 54

46 54

23 27

46 54

23 27

46 54

Age group 45-54 years 55--64 years 65-74 years 75+ years

22 19 32 27

22 19 32 27

2 9 18 21

4 18 36 42

20 10 14 6

40 20 28 12

Ma~talstatus Never married Married Widowed Divorced Separa~d

5 62 24 5 4

5 62 24 5 4

2 30 14 1 3

4 60 28 2 6

3 32 10 4 1

6 64 20 8 2

Education 0--4years 5-8years 9-12 years 13+ years

23 19 29 28

23 19 29 28

6 10 15 19

12 20 30 38

17 9 14 9

35 18 29 18

Income $0-$9,999 $10-$14,999 $15-$19~99 $20-$29~99 $30-$49,999 $50,000+

49 22 6 3 4 5

55 25 7 3 4 6

23 13 1 2 1 4

52 30 2 5 2 9

26 9 5 1 3 1

58 20 11 2 7 2

Employment Unemployed Employed Retired

30 16 54

30 16 54

22 4 24

44 8 48

8 12 30

16 24 60

Place of Birth United States Vietnam China Other

6 52 36 6

6 52 36 6

6 3 36 5

12 6 72 10

0 49 0 1

65.7

.~

Vietnamese n % .~

70.8

9.5

60.6

11.4

$14,076

7.5

$15,900

$12,292

98 2

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ACCULTURATIONAND FUNCTIONALIMPAIRMENT TABLE I (continued)

Length of time in U.S. Residentialhist. Urban Rural Mixed

13 yrs

69 4 6

16 yrs

87 5 7

35 0 2

95

9.5 yrs

34 4 4

5

81 10 10

(Please note all variables do not sum m total ' n ' due to missing data)

TABLE II Proportion (%) of Chinese (C) and Viemamese (V) in each stratum of acculturation and structural assimilation scales: Health Status and Lifestyles of Asians project, San Diego, CA 1990 Strata level

Acculturation Childhood experience with English versus other language (A1) Adult proficiency in English (A2) Adult pattern of English versus other language usage (A3) Adult value placed on preserving cultural origin (A4) Adult attitude towards traditional family structure and sex-role organization (A5)

Structural assimilation Childhood interaction with members of mainstream society (S1) Adult interaction with members of mainstream society ($2)

Ethnic group

Lowest 1

C V

92 80

2

2 8

6 10

(50) (50)

C V

36 54

30 34

18 6

16 6

(50) (50)

C V

68 94

5 3

10 3

16

(38)

C V

38 72

34 20

20 2

C V

54 68

32 24

14 8

C V

84 90

2 2

12 4

2 4

(49) (50)

C V

46 69

20 23

27 3

7 6

(41) (35)

2

Highest 4 (n)

3

(33)

8

(50)

6

(50) (50) (50)

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DEBORAHJ. MORTONET AL.

Education varied markedly between the two groups. Almost two-thirds of the total sample had acquired at least some high school education, with the highest prevalence among the Chinese (68%), compared to the Vietnamese (47%). Moreover, the average number of years of education among the Vietnamese (7.5 years) was considerably lower than the Chinese (11.4 years). The absence of formal education was most prevalent among the Vietnamese, where 35% had 4 or less years of education. This may be explained by the fact that the majority of this subgroup were females (83%), who were probably less likely to have received a formal education prior to their migration. Regarding income levels, over half of the total sample reported less than $10,000 per year (53%). The Vietnamese had a higher proportion of membership in this group (58%) compared with the Chinese (52%). Further analysis revealed that among those in the lowest income group, 96% of the Vietnamese were either retired or unemployed. Among the Chinese in this low income group, none were earning wages from employment and 65% were receiving some type of public assistance. About one-third of the total sample (32%) earned between $10,000 and $20,000. Only a very small portion (13%) earned more than $20,000 per year, with the Vietnamese having the lowest number for this group (11%), as compared with the Chinese (16%). Employment status for over half of the total sample was retired (54%), both for males and females. Retirement was more common among the Vietnamese (60%), than the Chinese (48%). One in four Vietnamese (24%) were working in either a full or part-time capacity, as compared with less than one in ten Chinese (8%). The very low employment level of the Chinese is probably again a reflection of the older age distribution of this sample group. The Chinese have a considerably longer history in the United States than the Vietnamese. Chinese "sojourners" started migrating to the U.S., especially California, just prior to the Gold Rush of 1849, and have well-established Chinatowns in most of the major U.S. cities. In San Diego, however, although a Chinatown was established in 1870, there has been no visible Chinatown since the early 1950's (Palinkas 1989). The Vietnamese, on the other hand, began coming to the U.S. in two "waves" (pre and post-1978) after the fall of Saigon in 1975, and have a very distinct and visible community in San Diego (Ring 1987; Rumbaut and Weeks 1986). Although it was expected that the Chinese group would most probably have been American born, or at least would have been in the U.S. most of their lives considering their mean ages, almost three out of four Chinese (72%) were born in China, 16% were born in Vietnam, Taiwan, Hong Kong, Macao or Burma, and the small remainder (12%) were born in the United States. Those born in Vietnam (n = 3) were considered Chinese in the statistical pooling of groups for this study due to their self-identification as Chinese and their preference to speak Chinese during the interview process. All but one of the Vietnamese were born in Vietnam, one was born in Laos. Additionally, 75% (n = 37) of the Vietnamese spent an average of eight months in a refugee camp prior to entering the United States, with ten of those people

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having spent more than one year in a camp. Although it was hypothesized that those who had spent time in a refugee camp would have higher levels of impairment, particularly physical and mental health, and ADL, a oneway analysis of variance revealed no significant differences with those who had not been in a camp. However, this may simply be due to a lack of variation among the second group due to its statistically small size (n = 13). All Vietnamese interviews were conducted in the Vietnamese language. Among the Chinese, 40% (n = 20) were conducted in Mandarin, 32% (n = 16) in Cantonese, 12% (n = 6) in Toisan, and the remainder in English (16%, n = 8). Of those Chinese who preferred to be interviewed in English, six were American born, the other two migrated to the U.S. in 1936. Average age of this subgroup was 67 years. The most similar demographic characteristic between the two groups in this study was that the majority of the Chinese (95%) and the Vietnamese (81%) have spent the largest portion of their lives in urban areas.

Acculturation Characteristics Table II reports the percentages of those falling into each of the four strata for the various dimensions of acculturation and structural assimilation. The Vietnamese reported higher levels of acculturation with respect to Childhood Experience with English (Scale A1) than the Chinese (18% of the Vietnamese were in the top two strata as opposed to only 8% of the Chinese). Yet interestingly, only 12% of the Vietnamese fell into the top two strata of Adult Proficiency in English (Scale A2), as opposed to 34% of the Chinese. Although the Vietnamese reported more exposure to English at a younger age than the Chinese, they still did not consider their adult selves as competent as the Chinese. The reason for this may be illuminated partially by the third language scale, Adult Pattern of English Usage (Scale A3). For the Chinese, 26% fell into the top two strata, as opposed to only 3% for the Vietnamese. It appears this sample of Vietnamese do not use English as much as the Chinese, possibly due to two reasons. First, it may be a reflection of less time in the United States. Eleven percent of the Vietnamese in this sample have been here less than 2 years, as compared to only 2% of the Chinese. Conversely, 86% of the Chinese have been in the U.S. more than five years, and 58% have been here more than 10 years, as opposed to 70% and 41%, respectively, for the Vietnamese. Although these proportions were not significantly different between the Chinese and Vietnamese, a oneway analysis of variance showed there was a significant difference (F = 8.0, P < 0.01) between the average length of time in the U.S. (Chinese = 16 years, Vietnamese = 9.5 years). Additionally, Pearson correlations computed between the length of time in the U.S., and the seven scales, indicated that among the Chinese significant correlations were found only with Scales A2 (0.52, P < 0.01) and A3 (0.68, P < 0.01), and with Scale A2 (0.28, P < 0.05) for the Vietnamese. Both Scales A2 and A3 are concerned solely with English language usage. These correla-

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DEBORAH J. MORTON ET AL.

tions indicate that while the number of years in the U.S. does affect proficiency and use of English, it does not necessarily pervade all aspects of the acculturation process. Secondly, as previously discussed, differences in use of English between the two groups may also be due to the geographic nature of the two communities in San Diego. The Vietnamese tend to cluster residentially, whereas the Chinese are widely dispersed throughout the county, and there is no Chinatown per se. Due to secondary migration, the Vietnamese tend to reside in the Vietnamese community. In San Diego this geographic area offers Vietnamese owned restaurants, grocery and clothing stores, leisure activities, and professional services. It is conceivable that living in a Vietnamese neighborhood in San Diego requires little, if any, use of English. For the scale that measured Value Attributed to Preservation of Cultural Origin (Scale A4), the Vietnamese had the largest proportion (72%) of those in the lowest strata. The Chinese were more evenly distributed across the entire range, with only 38% in the lowest strata. As expected, the Vietnamese reported great value placed on maintenance of their culture, which appears to be in line with the large prevalence of those who spoke primarily Vietnamese. Comparatively, the Chinese seem to represent a more varied attitude on preservation of cultural origin. Again this possibly may be due to their longer cultural and residential history in the U.S. as an ethnic group, as well as a significantly longer average length of time in the U.S. for the individuals in this sample. The scale which measured Adult Attitude Towards Traditional Family Structure and Sex-role Organization (Scale A5) was made up of seven questions that examined beliefs concerning extended family relationships, family ancestry and remembrance of those who have died, males protecting females, females respecting male authority, and eldest son responsibilities. For each group, the largest percentages fell in the lowest strata (68% for Vietnamese and 54% for Chinese) indicating majority agreement for traditional family roles and relationships. Regarding structural assimilation, both groups had low levels of assimilation, as measured by the Childhood Interaction with Mainstream Society scale (Scale S1). For both groups, less than 5% fell into the highest strata. As expected, the scale which measured Adult Interaction with Mainstream Society (Scale $2) revealed the Vietnamese to be the least acculturated, with 92% falling in the two lowest strata, as compared to the Chinese with 66%. In general, the Hazuda et al. (1988a) acculturation and assimilation scales appear to be an appropriate measure for use with older Vietnamese and Chinese for a number of reasons. Table 11I presents reliability coefficients for both groups compared with Hazuda's data on Mexican Americans (1988b). Cronbach's alpha coefficients for the Chinese were virtually identical to those obtained in the San Antonio study. Among the Vietnamese, coefficient values for Scales A2, A3, A4, A5, and S1 were highly comparable to the Mexican American values. Scales A1 and $2 had the lowest values as compared to those obtained from Hazuda's work, but remained acceptable. The lower reliability

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163

TABLE III Acculturation and structural assimilation scales reliability coefficients: Comparative data Health Status and Lifestyles of Asians project, San Diego, CA 1990 ALPHA COEFFICIENTS San Diego Study

San Antonio Heart Studya

Chinese

Vietnamese

Mexican Americans

0.88

0.51

0.82

0.97

0.91

0.94

0.94

0.75

0.87

0.77

0.86

0.63

0.75

0.77

0.62

0.82

0.60

0.85

0.75

0.50

0.78

Acculturation

Childhood experience with English versus other language (A 1) Adult proficiency in English (A2) Adult pattern of English versus other language usage (A3) Adult value placed on preserving cultural origin (A4) Adult attitude towards traditional family structure and sex-role organization (A5) Structural assimilation

Childhood interaction with members of mainstream society (S 1) Adult interaction with members of mainstream society ($2)

a Hazuda, HP, Stem, MP, and Haffner, SM 1988 San Antonio Heart Study Acculturation and Assimilation Scales: Reliability Data from the Final Replication Sample, unpublished. coefficients for Scales A1 and $2 among the Vietnamese was most probably due to a combination of factors; the low number of items in each scale, and the small sample size which contributed to the lack of variation in the raw responses for each o f the items in the scales. Along with high levels of statistical reliability, the cross cultural application of the Hazuda scales appears reasonable due to important differences revealed within and between the two groups, largely explained by the community structure in San Diego and the difference in the average length of time since migration. Additionally, as expected, the scales demonstrated the Vietnamese to have the largest proportions of those in the lowest acculturation strata.

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DEBORAHJ. MORTONET AL.

Functional Impairment Characteristics Functional impairment was assessed by utilizing the OARS instrument, which consists of five interviewer rated scales. Each of the five scales measure one dimension of impairment, including social and economic resources, mental and physical health, and ADL. A subsequent refinement of the impairment scales by the OARS methodologists was the development of objective ratings, (as opposed to subjective ratings) for the five dimensions of functional impairment based on algorithms from objective questions (George, Landerman, and FiUenbaum 1982). The objective ratings are scored as follows: 1 = excellent, 2 = good, 3 = mildly impaired, 4 = moderately impaired, 5 = severely impaired, and 6 = totally impaired. Detailed definitions for each of these levels are the same as the original OARS functional impairment ratings (Duke University 1978). For a summarized description of the logic used to create the algorithms for the five functional ratings, see Stanford et al. (1991). Three of the five objective functional impairment ratings derived from the data for the present study, namely social resources, mental health and ADL, were computed exactly as outlined by the OARS methodology. The economic resource rating was modified slightly by increasing the government issued budget standards (no longer available) by the Consumer Price Index for the current year. The physical health rating was also modified to include a more extensive list of possible illness conditions.

Prevalence of Functional Impairment Each of the five functional summary ratings were collapsed into two categories, by combining the categories of excellent and good resources into the nonimpaired category, and the four categories of mild, moderate, severe and total impairment into the impaired category. Among each group, prevalences of overall impairment ranged from 40% (ADL) to as high as 96% (.physical health) (see Table IV). Regarding social resources, approximately half of the total sample was impaired (52%). The Chinese exhibited the highest prevalence (60%) compared to the Vietnamese (44%). In both groups, more women than men experienced social resources impairment. The higher proportion of impairment found among the Chinese may partially be explained by the fact that 30% of the Chinese live alone, as opposed to only 4% of the Vietnamese. Economic resources were impaired in three out of four subjects (75%), with the highest proportion of impairment found in the Vietnamese group (78%). Again, females as compared to males in both ethnic groups exhibited a higher prevalence of economic impairment. This difference was statistically significant among the Vietnamese. Half the sample (51%) was impaired with regard to the mental health rating. The Vietnamese exhibited significantly higher levels of impairment (62%), as opposed to the Chinese (40%). Once again, impairment was higher among the females (56%) than the males (46%), with the greatest gender difference among

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165

TABLE IV Prevalence of functional impairment based on OARS objective functional summary ratings by ethnicity and gender: Health Status and Lifestyles of Asians project, San Diego, CA 1990 Objective functional summary rating Total sample Total males Total females

Total sample

Chinese

Viemamese

n

%

n

%

n

%

100 46 54

100 100 100

50 23 27

100 100 100

50 23 27

100 100 100

52 20 32

52 44 59

30 11 19

60 48 70

22 9 13

44 39 48

75 31 44

75 67 82

36 16 20

72 70 74

39 15 24

78 65 b 89 b

51 21 30

51 46 56

20 7 13

40a 30 48

31 14 17

62 a 62 63

91 41 50

91 89 93

48 22 26

96 96 96

43 19 24

86 83 89

46 16 30

46 35 b 56 b

23 9 14

46 39 52

23 7 16

46 30 b 59 b

Social resources

Overall impaired Males Females Economic resources

Overall impaired Males Females Mental health

Overall impaired Males Females Physical health

Overall impaired Males Females ADL Overall impaired Males Females

"Impaired" includes mild, moderate, severe and total impairment (values 3-6 of rating). a Chi-Square p < 0.05 between ethnic groups. b Chi-Square p < 0.05 between gender groups. the Chinese (48% for females versus 30% for males). However, results in this dimension must be considered rather tenuous due to the difficulties associated with the measurement o f mental health complaints utilizing an instrument that was developed for use with A n g l o populations, not Asian immigrants. The highest prevalences o f impairment were found in the area o f physical health. Nine out o f ten subjects (91%) registered impairment, with slightly higher levels found among the Chinese (96%), as c o m p a r e d to the Vietnamese (86%), possibly due to the more advanced ages o f the Chinese group. Gender differences were small for both groups. A l m o s t half o f both the Chinese and Vietnamese groups registered A D L impairment (46% for each), with the highest rates among the women. F o r the Vietnamese, the relationship between gender and A D L impairment was statistically significant (59% for females versus 30% for males).

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DEBORAHJ. MORTONET AL.

Mean Scores of Functional Impairment Analysis of mean scores for the objective functional impairment ratings can provide additional information not available when stratifying the groups into impaired versus non-impaired status and examining prevalences. Analysis of variance can be utilized to uncover statistically significant differences between groups. Table V illustrates mean scores and results from the one-way anova procedure for ethnic, gender, and age groups. Clearly, economic resources was the dimension with the highest impairment scores. All groups had scores above 3 (mild impairment) with most being closer to 4 (moderate impairment), except the Chinese females (2.9). Vietnamese females exhibited the highest mean score of economic impairment (4.4). The older Vietnamese groups had a significantly lower mean score (3.2) than the younger group (4.8), possibly a reflection of benefits received at age 65. It should be noted that the algorithm for the economic rating adjusts for income level, number of people in the household, age, and economic assistance. Despite these adjustments, and the similarity of income levels for both groups, there was still a significant difference between mean scores for the Vietnamese (4.16) and for the Chinese (3.12), as indicated by the F ratio (p < 0.01). We speculate the reasons for this may be due to differences in responses to other questions which are also included in the algorithm. For example, the algorithm adjusts for respondent's assets, and 36% of the Chinese indicated they own their own home as compared to only 8% of the Vietnamese. Other questions, which are also a part of the algorithm and are more subjective in nature, showed differing response rates between the two groups. More specifically: (a) 59% of the Vietnamese stated they needed additional financial assistance as compared to only 36% of the Chinese; and (b) only 14% of the Vietnamese indicated they had enough to buy those little extras as compared to 28% of the Chinese. It is logical that these differing response rates to subjective questions may be interpreted as reflective of cultural variations in material attitudes. Physical health mean scores highlighted the second most impaired area of the five dimensions, although there were no significant differences between the two ethnic or gender groups. Scores were all within the 3.0 to 3.7 range, which indicate mild impairment. The Vietnamese had statistically significant higher levels of mental health impairment (mean score = 3.04) than the Chinese (mean score = 2.28), which was consistent across gender and age groups. Again, these results should be considered within the context that although this is a composite rating of mental health impairment, which includes a measure of cognitive impairment, the OARS Psychiatric Evaluation Scale, self-reported mental health status, and ratings of enjoyment and excitement about life, it is probably the most difficult dimension to assess cross culturally. Regarding social resources, both groups exhibited the same trends and had minimal levels of impairment. Females were consistently more impaired than males, with a significant difference found between Chinese females (3.19) and

resources

health

Males Females Under 65 65 and over

Mental

-

-

-

Total

Total

Total

resources

Males Females Under 65 65 and over

Economic

Males Females Under65 65andover

Social

Objective functional summary rating

100 46 54 41 59

100 46 54 41 59 2.66 2.50 2.80 2.80 2.56

3.64 3.59 3.69 4.34 c 3.15 c 50 23 27 11 39

50 23 27 11 39

50 23 27 11 39

n

2.63 2.26 b 2.94 b 2.44 2.76

.~

n

100 46 54 41 59

Chinese (n = 50)

Total sample (n = 100)

2.28 2.04 2.48 2.09 2.33

3.12 3.35 2.93 3.09 3.13

2.78 2.30 b 3.19 b 2.27 2.92

£"

50 23 27 30 20

50 23 27 30 20

50 23 27 30 20

n

Vietnamese (n = 50)

3.04 2.96 3.11 3.07 3.00

4.16 3.83 4.44 4.81Y 3.20 c

2.48 2.22 2.70 2.50 2.45

./

11.41"**

9.08**

1.54

F ratio a

TABLE V Mean scores and one-way analysis of variance for objective functional summary ratings by ethnicity, gender and age group: Health Status and Lifestyles of Asians project, San Diego, CA 1990

o~ ....i

t-

z

100 46 54 41 59

100 46 54 41 59

A D L - Total

2.69 2.65 2.72 2.39 d 2.90 d

3.39 3.33 3.44 3.22 3.51 50 23 27 11 39

50 23 27 11 39 2.70 2.83 2.59 2.45 2.77

3.34 3.30 3.37 3.09 3.41 50 23 27 30 20

50 23 27 30 20

2.68 2.48 2.85 2.37 d 3.15 d

3.44 3.35 3.52 3.27 3.70

a F ratios were obtained from a oneway ANOVA between ethnic groups, * = p < 0.05, ** = p < 0.01, *** p < 0.001. b Significant differences between Males and Females for total group, F ratio = 8.51"*; for Chinese, F ratio = 6.01". c Significant differences between Under 65 and 65 and over for total group, F ratio = 11.76"**; for Vietnamese, F ratio = 11.52"*. d Significant differences between Under 65 and 65 and over for total group, F ratio = 8.37**; for Vietnamese, F ratio = 12.84"**.

Males Females Under 65 65 and over

Males Females Under 65 65 and over

P h y s i c a l h e a l t h - Total

TABLE V ( c o n t i n u e d )

0.01

0.23

~r

OO

ACCULTURATIONAND FUNCTIONALIMPAIRMENT

169

Chinese males (2.30). This may partially be due to the high number of Chinese females that lived alone (48%) as compared to the low number of Chinese males (9%) that lived alone. Finally, mean scores of ADL impairment were not significantly different between ethnic or gender groups, and all were less than 3 (mild impairment). However, as expected among the Vietnamese, there was a statistically significant difference between the older group (3.15) and the younger group (2.37). This is possibly a reflection of the higher levels of physical impairment also exhibited among the older Vietnamese group. Although it was expected the same relationship would be exhibited among the Chinese, it did not occur, even though the Chinese sample was an older group. To summarize, there was a great deal of variation between the ethnic, gender, and age groups regarding prevalence and level of functional impairment for the two groups in this study sample. In general, mean functional impairment levels were in the 2.0 to 5.0 range, indicating the sample to be mildly to severely impaired. The highest proportions of impairment were found in the dimensions of physical health and economic resources, with the lowest prevalences of impairment in the ADL dimension. In general, females exhibited higher proportions of impairment. One-way analysis of variance revealed significant ethnic differences in the areas of mental health and economic resources. Mean score analysis also showed significant differences in gender scores among the Chinese in the dimension of social resources, with females exhibiting higher levels of impairment. Analysis of the under and over age 65 groups showed no differences between the Chinese age groups. For the Vietnamese age groups, the highest impairment was found in the area of economic resources for the under age 65 group (mean score = 4.8). The only other significant age group differences were among the Vietnamese, where the older group displayed higher levels of ADL impairment.

Acculturation and Functional Impairment The association between levels of acculturation, structural assimilation, and functional impairment were examined through correlation analysis. Table VI presents zero order Pearson correlations of the five functional impairment ratings with the five acculturation scales (A1 to A5) and the two structural assimilation scales (S 1 and $2). The general expectation was that higher levels of acculturation and structural assimilation would be associated with less impairment. Please note the functional impairment ratings range from 1--6, with higher values indicating higher levels of impairment, and the acculturation scales range from 1-4, with higher values indicating higher levels of acculturation.

C V

C V

C V

C V

C V

Social resources

Economic resources

Mental health

Physical health

ADL

-0.2159 -0.1268

-0.3070* -0.0424

-0.1888 -0.1266

-0.2806* 0.0353

-0.2931" 0.1026

-0.2736* -0.5046***

-0.3845** -0.3567**

-0.6882*** -0.2662*

-0.4985*** -0.2946*

-0.4862*** -0.1643

A2

-0.4093** -0.2678

-0.3996** -0.2404

-0.5547*** -0.2614

-0.6878*** -0.0869

-0.4510"* -0.0355

A3

-0.0738 0.0513

0.0337 -0.0050

0.0611 -0.1102

0.0274 -0.0890

0.1888 -0.0722

A4

-0.1764 0.3559**

-0.1388 0.0316

-0.0588 0.1213

0.0068 0.1917

-0.0084 0.1309

A5

-0.2088 -0.1872

-0.2376* 0.0987

-0.1628 -0.1417

-0.3716"* 0,0199

-0.3048* 0.0193

S1

-0.3784** -0.3623*

-0.2023 -0.2193

-0.4857*** -0.0382

-0.5363*** -0.1761

-0.3113" 0.2545

$2

C = Chinese, V = Vietnamese. * p < 0.05, ** p < 0.01, *** p < 0.001. Acculturation scales: A1: Childhood experience with English versus other language, A2" Adult proficiency in English, A3: Adult pattern of English versus other language usage, A4: Adult value placed on preserving cultural origin, A5: Adult attitude towards traditional family structure and sex-role organization. Assimilation scales: S 1: Childhood interaction with members of mainstream society, $2: Adult interaction with members of mainstream society. Acculturation and structural assimilation scales range from 1-4, with higher values indicating higher levels of acculturation and assimilation. OARS objective functional summary ratings range from 1--6, with higher values indicating higher levels of functional impairment.

Ethnic Group

OARS objective functional ratings

AI

Acculturation and structural assimilation scales

TABLE VI Zero order correlations of OARS objective functional summary ratings with acculturation and structural assimilation scales by ethnicity: Health Status and Lifestyles of Asians project, San Diego, CA 1990

.t--

ACCULTURATION AND FUNCTIONAL IMPAIRMENT

171

Chinese

For the Chinese, significant associations were found for all of the functional impairment ratings with three of the acculturation scales and both of the structural assimilation scales. The significant associations with the acculturation scales were all related to language. There were no significant associations found with the two acculturation scales that measured preservation of culture or attitudes towards family. Scales A1, A2, and A3 were all, as anticipated, negatively associated with social (r = - 0 . 3 0 ; r = - 0 . 4 9 ; r = - 0 . 4 5 ) and economic resources (r = - 0 . 2 8 ; r = - 0 . 5 0 ; r = - 0 . 6 9 ) and physical health ( r = - 0 . 3 1 ; r = - 0 . 3 8 ; r = - 0 . 4 0 ) . More social, economic, and physical health impairment was related to less exposure to English, poorer English proficiency, and less use of English in everyday life. The strongest association of these three dimensions (r = - 0 . 6 9 ) , was between economic impairment and limited adult use of English. This suggests English language skills are most probably indicative of occupational success. Further, this may suggest that the stresses of being economically impaired, or living in poverty, affect the quality of physical health status in later life, leading to impairment at an earlier age. Scales A2 and A3 were also negatively correlated with mental health (r = - 0 . 6 9 ; r = - 0 . 5 5 ) , and ADL (r = - 0 . 2 7 ; r = - 0 . 4 1 ) . Again, more impairment in these areas was associated with poor English skills and limited use of English. The strongest associations of mental health impairment were with scales A2 and A3 (r = -0.69 and r = -0.55, respectively). As previously stated, cross cultural assessment of mental health impairment utilizing instruments developed for mainstream society may be marginal, so these strong correlations may be a function of the instrument itself. However, these associations are logical and may be due to problems of social, physical and mental isolation that result from poor communication skills. Scale S1, Childhood Interaction with Members of Mainstream Society was negatively correlated with social and economic resources (r = -0.30; r = -0.37) and physical health (r = - 0 . 2 4 ) among the Chinese. Again, these associations were in the expected direction, the strongest correlation being with economic impairment. It appears that the more exposure to the host society as a child, the less physical, social and economic impairment as an adult. Scale $2, Adult Interaction with the Mainstream group, was negatively associated with all the impairment ratings to a significant degree, except for physical health. As with the other scales, the strongest correlation was with economic resources (r = - 0 . 5 4 ) , again probably a reflection of occupational status and success. Logically, more interaction with members of Anglo society would increase social and economic success, thus contributing to better mental health. This process, in turn, would help provide better quality of life and hence less ADL problems during the later years. For the Chinese, these results point out how crucial the need is for well developed English language skills. Lack of such skills appears to contribute to

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D E B O R A H J. M O R T O N ET AL.

impairment in all five dimensions. Moreover, interaction as an adult with members of the dominant society was also correlated with four areas of impairment, and it is surmised that more proficient English skills would buffer these interactions and improve impairment scores.

Vietnamese Among the Vietnamese group, only two of the acculturation scales and one of the structural assimilation scales achieved a significant level of correlation with the impairment measures. Scale A2, Adult Proficiency in English, was negatively associated with economic resources (r =-0.29), mental and physical health (r = - 0 . 2 7 ; r = - 0 . 3 6 ) and ADL (r =-0.50). All of these were in the expected direction, indicating that lack of English skills was associated with higher levels of impairment. Scale A5, Adult Attitude Towards Traditional Sex-Roles and Family Structure, revealed a positive association (r = 0.36) with ADL, meaning that lower levels of impairment were associated with more value placed on traditional beliefs and behaviors. This may be indicative of the close family ties and caretaking of extended family that is part of traditional Vietnamese culture. For structural assimilation, scale $2, Adult Interaction with Members of Mainstream Society, there was a significant negative association with only the ADL rating (r = -0.36). Greater involvement with Anglos was associated with less ADL impairment. This may reflect the idea that being more familiar and experienced with mainstream society enables one to have more knowledge of available services, and thus be able to easily secure benefits and help when needed. Most interesting about the results among the Vietnamese was that although better English language skills were associated with less functional impairment, the strongest association was with ADL, not economic impairment as with the Chinese. Moreover, there were no associations with the social impairment rating, and there were no associations found for the other two scales that measure exposure to and use of English, in contrast to the Chinese. Additionally, structural assimilation was only associated with ADL, again in contrast to the Chinese where associations were found with all the dimensions of functional impairment. These correlations support findings already discussed that English language skills and interaction with Anglos are not as crucial to the Vietnamese as they are to the Chinese in San Diego. One of the most important variables that needs consideration in any analysis among ethnic groups is that of income. Many times it is difficult to determine whether group differences are actually due to cultural variation, or are a result of the stresses of low income, or are an interaction between the two. Therefore, even though the groups in this study tended to have relatively the same level of income, all of the Pearson correlations between acculturation, structural assimilation and functional impairment were computed a second time while controlling for income. For the Vietnamese, all correlations between the acculturation scales and functional impairment ratings that achieved significance

ACCULTURATIONAND FUNCTIONALIMPAIRMENT

173

in the first analysis (Table VI), were significant in this secondary analysis, even though the strength of the associations decreased slightly. Among the Chinese, all correlations remained stable, except for one slight variation. The structural assimilation scale S1 no longer achieved any significant relationships with functional impairment. Further, the same Pearson correlations were computed a third time while controlling for the number of years in the U.S., since this variable was found to correlate with Scales A2 and A3 among the Chinese, and Scale A2 among the Vietnamese. Once again, all significant correlations for both groups remained stable with only slight variations in the strengths of those correlations. Therefore, it can be inferred from both of these secondary analyses that the results discussed in Table VI were due to actual cultural differences and were not confounded by income or number of years since migration. SUMMARY AND DISCUSSION Overall, results from this study indicated there were significant differences in the prevalence of functional impairment between older Chinese and Vietnamese, and gender and age groups within each of these two ethnic groups. Levels of acculturation and structural assimilation were identified as major contributors to variation in degrees of impairment between and within the two groups. More specifically: (a) both groups exhibited substantially high prevalences and levels of economic resource and physical health impairment; (b) in general, the highest prevalences and levels of impairment were found among females and those over 65 years of age, regardless of ethnicity; and (c) correlation analysis revealed statistically significant associations between levels of functional impairment with acculturation and assimilation, that were not confounded by the effects of low income status or years since migration. Lack of English language skills and lack of use and exposure to English were associated with functional impairment in all five areas to some degree for both the Chinese and Vietnamese. Additionally, the analyses suggested English language skills may be of less importance to the Vietnamese than the Chinese in San Diego, due to the effectiveness and extent of the Vietnamese community. Taking this interpretation further, the Vietnamese data generally revealed fewer assocations between acculturation and impairment than the Chinese. This suggests the Vietnamese community may act as an effective buffer to the stress associated with the acculturation process. Without a large community structure for support, it is probable that impairment levels would increase. Further support for this idea is evident in the work of Matsuoka and Ryujin (1989-90) from a project conducted among 125 Vietnamese families in San Diego. Their data revealed the most difficult resettlement adjustment problems concerned language, cultural differences, employment, missing support from other Vietnamese, and missing the Vietnamese way of life. They found the ethnic community to be of vital importance to the successful adaptation of the Vietnamese, Many of the people in the study indicated they had sacrificed a

174

DEBORAHJ. MORTONET AL.

great deal in order to live among other refugees. Through secondary migration, they had given up the economic security provided by federal resettlement programs in order to be near those with similar language and cultural background. The ethnic community was found to be a reservoir of collective support for economic and psychological adjustment. Secondary migration patterns for virtually the same reasons have also occurred in the United Kingdom (Dalglish 1989). One major importance of this study is that the data clearly show the process of acculturation, manifesting itself in the overall mental and physical functioning of immigrants, can be quantitatively measured. There were very strong quantitative indications that improvement in English language skills would have positive effects in all five dimensions of functional impairment for both the Chinese and Vietnamese in the study sample. Second, although it may be acutely obvious to the well-informed that these two groups are culturally distinct and that programs, services and interventions designed for these groups must reflect those inherent characteristics, many times data, funding, services, programs and policy lump many distinct groups together under the heading of "Asian". The data from this study help to clearly emphasize the importance of recognizing and defining cultural differences. Further, the data suggest that programs designed to reinforce and preserve traditional cultural beliefs and practices, and promote respect for cultural differences, would have a favorable impact on all five dimensions of functional impairment. Intervention programs designed with the present study data in mind would serve to improve the quality of life for these two older immigrant groups during the course of the aging process, and, hopefully, provide a model for other immigrant groups. AC~O~E~E~NT This study was supported in part by the AARP Andrus Foundation. REFERENCES CITED Ailinger, R. 1989 Functional Capacity of Hispanic Elderly Immigrants. Journal of Applied Gerontology 8(1):97-109. Angel, R. and P. Thoits 1987 The Impact of Culture on the Cognitive Structure of Illness. Culture, Medicine and Psychiatry 11 (December): 23-52. Angel, R. and J.L. Worobey 1988 Acculturation and Maternal Reports of Children's Health: Evidence from the Hispanic Health and Nutrition Examination Survey. Social Science Quarterly 69:707-721. Boyce, W.T. and J.C. Boyce 1983 Acculturation and Changes in Health Among Navajo Boarding School Students. Social Science Medicine 17(4):219-226. Brown, G. 1982 Issues in the Resettlement of Indochinese Refugees. Social Casework: The Journal of Contemporary Social Work (March): 155-159. Burnam, M.A., R.L. Hough, M. Kamo, J.I. Escobar, and C.A. Telles 1987 Acculturation and Lifetime Prevalence of Psychiatric Disorders Among Mexican Americans in Los Angeles. Journal of Health and Social Behavior 28(March):89-102. Chambon, A. 1989 Refugee Families' Experiences: Three Family Themes - Family

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175

Disruption, Violent Trauma and Acculturation. Journal of Strategic and Systemic Therapies 8(bonus issue):3-13. Chen, C.K.H. 1972 A Standard Romanized Dictionary of Chinese and Japanese Popular Surnames. Hanover, New Hampshire: Oriental Society. Chenng, M. 1989 Elderly Chinese Living in the United States: Assimilation or Adjustment? Social Work (September):457-461. Cox, C. 1986 Physician Utilization by Three Groups of Ethnic Elderly. Medical Care 24(8):667-676. Dalgiish, C. 1989 Refugees from Vietnam. London: The Macmillan Press, LTD. Die, A.H. and W.C. Seelbach 1988 Problems, Sources of Assistance, and Knowledge of Services Among Elderly Vietnamese Immigrants. The Gerontologist 28(4):448-452. Duke University Center for the Study of Aging and Human Development 1978 Multidimensional Functional Assessment: The OARS Methodology. Durham, North Carolina (2nd Edition, #27): Duke University. Freeman, J.M. 1989 Hearts of Sorrow. Stanford, California: Stanford University Press. Gatz, M., Pederson, N.L., and Harris, J. 1987 Measurement Characteristics of the Mental Health Scale from the OARS. Journal of Gerontology 42(3):332-335. George, L., R. Landerman, and G.G. Fillenbaum 1982 Developing Measures of Functional Status and Service Utilization: Refining and Extending the OARS Methodology. Durham, North Carolina: Center for the Study of Aging and Human Development, Duke University. Gerson, L.W., D. Jarjoura, and G. McCord, 1987 Factors Related to Impaired Mental in Urban Elderly. Research on Aging 9(3):356--371. Gordon, M.M. 1964 Assimilation in American Life. New York: Oxford University Press. Gordon, M.M. 1975 Toward a General Theory of Racial and Ethnic Group Relations. In Ethnicity: Theory and Experience. N. Glazer and D.P. Moynihan, eds. Pp. 84-1 I0. Cambridge: Harvard University Press. Harel, Z. and G. Deimling 1984 Social Resources and Mental Health: An empirical Refinement. Journal of Gerontology 39(6):747-752. Hazuda, H.P. 1990 Personal Communication. Hazuda, H.P., M.P. Stern, and S.M. Haffner 1988a Acculturation and Assimilation Among Mexican Americans: Scales and Population-Based Data. Social Science Quarterly 69:707-721. Hazuda, H.P., M.P. Stern, and S.M. Haffner 1988b San Antonio Heart Study Acculturation and Assimilation Scales: Reliability Data. Unpublished. Hoffman, T., R.H. Dana, and B. Bolton 1985 Measured Acculturation and MMPI-168 Performance of Native American Adults. Journal of Cross-Cultural Psychology 16(2):243-256. Ikels, C. 1983 Aging and Adaptation: Chinese in Hong Kong and the United States. Connecticut: Archon Books. Kalton, G. 1983 Introduction to Survey Sampling. Sage University Paper Series on Quantitative Applications in the Social Sciences 07-035. P. 66. Beverly Hills and London: Sage Publications. Krause, N., J. Bennett, and T. Van Tran 1989 Age Differences in the Acculturation Process. Psychology and Aging 4(3):321-332. Kua, E.H. 1990 The Health of Elderly Chinese Living in the Community. Singapore Medical Journal 31:111-115. Lee, J. 1987 Asian American Elderly: A Neglected Minority Group. Journal of Gerontological Social Work 9(4):103-117. Lin, K., M. Masuda, and L. Tazuma 1982 Adaptational Problems of Vietnamese Refugees Part III. Case Studies in Clinic and Field: Adaptive and Maladaptive. The Psychiatric Journal of the University of Ottawa 7(3): 173-183. Marmot, M.G. and L. Syme 1976 Acculturation and Heart Disease in Japanese Americans. American Journal of Epidemiology 104:225-247.

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Matsuoka, J.K. and D.H. Ryujin 1989-90 Vietnamese Refugees: An Analysis of Contemporary Adjustment Issues. The Journal of Applied Social Sciences 14(1):23-45. Nakamura, C.M., C.A. Molgaard, E.P. Stanford, K.M. Peddecord, D.J. Morton, S.A. Lockery, M. Zuniga, and L.D. Gardner 1990 A Discriminant Analysis of Severe Alcohol Consumption Among Older Persons. Alcohol and Alcoholism 25(1):75--80. Palinkas, L.A. 1989 Rhetoric and Religious Experience: The Discourse of Immigrant Chinese Churches. Fairfax, Virginia: George Mason University Press, Pasquali, E.A. 1985 The Impact of Acculturation on the Eating Habits of Elderly Immigrants: A Cuban Example. Journal of Nutrition for the Elderly 5(1):27-36. Ring, B. 1987 Gender Roles in Vietnamese Refugee Society. Unpublished Master's Thesis. San Diego State University. Rumbaut, R. and J.R. Weeks 1986 Fertility and Adaptation: Indochinese Refugees in the United States. International Migration Review 20(2):428-465. Salgado 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. Stanford, E.P., C.J. Happersett, D.J. Morton, C.A. Molgaard, and K.M. Peddecord 1991 Early Retirement and Functional Impairment from a Multi-Ethnic Perspective. Research on Aging 13(1):5-38. Suirm, R.M., K. Rickard-Figueroa, S. Lew, and P. Vigil 1987 The Suinn-Lew Asian SelfIdentity Acculturation Scale: An Initial Report. Educational and Psychological Measurement 47:401-407. Tran, Thanh V. 1988 Sex Differences in English Language Acculturation and Learning Strategies Among Vietnamese Adults Aged 40 and Over in the United States. Sex Roles 19(11/12):747-759. Weeks, J.R. and R.G. Rumbaut 1988 Infant Health and Mortality Among Indochinese Refugees in San Diego County: Final Report. San Diego State University, San Diego, CA. Wells, K.B., J.M. Golding, R.L. Hough, M.A. Burnam, and M. Karno 1989 Acculturation and the Probability of Use of Health Services by Mexican Americans. Health Services Research 24(2):237-257. Wong, P.T.P. and G.T. Reker 1985 Stress, Coping, and Well-Being in Anglo and Chinese Elderly. Canadian Journal on Aging 4(1):29-37. Yu, L.C. 1984 Acculturation and Stress Within Chinese American Families. Journal of Comparative Family Studies 15(1):77-94. Yu, L.C. and E. Harburg 1981 Filial Responsibility to Aged Parent - Stress of Chinese Americans. International Journal of Group Tensions 11 (1-4):47-58. Yu, L.C. and S.C. Wu 1985 Unemployment and Family Dynamics in Meeting the Needs of Chinese Elderly in the United States. The Gerontologist 25(5):472-476.

University Center on Aging College of Health and Human Services San Diego State University San Diego, CA 92182-0273, U.S.A.