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Acculturation and HIV-related sexual behaviours among international migrants: a systematic review and meta-analysis a

Hongfei Du & Xiaoming Li

a

a

Pediatric Prevention Research Center, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA Published online: 10 Oct 2013.

Click for updates To cite this article: Hongfei Du & Xiaoming Li (2015) Acculturation and HIV-related sexual behaviours among international migrants: a systematic review and meta-analysis, Health Psychology Review, 9:1, 103-122, DOI: 10.1080/17437199.2013.840952 To link to this article: http://dx.doi.org/10.1080/17437199.2013.840952

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Health Psychology Review, 2015 Vol. 9, No. 1, 103–122, http://dx.doi.org/10.1080/17437199.2013.840952

Acculturation and HIV-related sexual behaviours among international migrants: a systematic review and meta-analysis Hongfei Du* and Xiaoming Li

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Pediatric Prevention Research Center, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA (Received 19 February 2013; accepted 1 September 2013) This review examines the global literature regarding the relationship between acculturation and HIV-related sexual behaviours among international migrants. Seventy-nine articles published in English-language journals prior to July 2012 met the criteria for inclusion. We conducted a systematic review and subset meta-analysis of correlations between acculturation and five types of sexual behaviours including condom use, multiple partnerships, early sexual initiation, sexually transmitted diseases (STDs) and other unsafe sexual practices. Immigrants high in mainstream acculturation were more likely to have multiple partnerships, early sexual initiation, STDs and unsafe sex (rs ranged from 0.10 to 0.16), but acculturation was not associated with condom use (r = 0.02). Gender moderated the relationships between acculturation and multiple partnerships, STDs and unsafe sex. The relationship between acculturation and unsafe sex also varied across ethnicity. These findings suggest that acculturation may serve as a risk factor towards immigrants’ HIV-related sexual health. We offered a theoretical framework and suggested applying cross-cultural and longitudinal designs in future research on acculturation and health behaviours. Keywords: acculturation; sexual behaviours; HIV/AIDS; international migrants

Introduction According to the United Nations (2009), the estimated number of international migrants has increased by 37% from 156 million in 1990 to 214 million in 2010. Immigration poses numerous challenges to public health because immigrants may suffer from separation from families and original societies and face language barriers, substandard living conditions and discrimination (Abraído-Lanza, Armbrister, Flórez, & Aguirre, 2006; Magaña & Hovey, 2003). Low levels of mainstream acculturation were associated with low chances of learning knowledge on health, negative attitudes towards health maintenance and high barriers to health care (Bradford, Allen, Casey, & Emmers-Sommer, 2002; Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2005; Rogler, Cortes, & Malgady, 1991). This paper reports a systematic review and meta-analysis of empirical studies concerning the influence of acculturation on HIV-related sexual behaviours.

*Corresponding author. Email: [email protected] © 2013 Taylor & Francis

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Theories and assessment of acculturation Acculturation is the process whereby immigrants adopt the values, beliefs, attitudes and behaviours of the receiving culture (LaFromboise, Coleman, & Gerton, 1993; Rogler et al., 1991). Both adoption of receiving culture and maintenance of heritage culture have impacts on acculturation. Moreover, individual level factors (e.g., gender, motivation, coping skills) interact with sociocultural influences to facilitate or resist the adaptation (Berry, 1997). Researchers have proposed two conceptual models to interpret immigrants’ adherence or adaptation to heritage and receiving cultures: unidimensional and bidimensional models. The unidimensional model considers the acculturation process as a one-dimensional continuum, with the orientation from one’s heritage culture to the receiving culture. In contrast, the bidimensional model states that acculturation includes two independent dimensions: maintenance of the heritage culture and adaptation to the receiving culture, and immigrants can retain their ethnic minority culture along with acculturation to the receiving culture (Berry, 1997; Cuellar, Arnold, & Maldonado, 1995). Researchers have used diverse measures to assess acculturation. Country of birth and years in the receiving culture are the two commonly used markers of acculturation (Schwartz, Pantin, Sullivan, Prado, & Szapocznik, 2006). The use of language such as language preference and language proficiency is also a frequently assessed domain among acculturation measures (Zane & Mak, 2003). Moreover, many acculturation scales are multi-faceted and assess more than one domain relevant to cultural change (e.g., cultural knowledge, language use, social affiliations). Ethnic identity, the extent to which a person identifies with a particular culture, is another domain which has been employed to indicate acculturation (Shehadeh et al., 2012). Some established acculturation measures include identification of ethnicity as a dimension (e.g., Cuellar et al., 1995; Suinn, Rickard-Figueroa, Lew, & Vigil, 1987), although recent research suggests that ethnic identity and acculturation may represent different aspects of cultural identity (Schwartz, Zamboanga, & Jarvis, 2007). Acculturation and health In recent years, a considerable number of studies have documented a relation between acculturation and health (Lara et al., 2005; Rogler et al., 1991). Researchers have found an immigrant paradox regarding the effect of acculturation on health: More acculturated immigrants have greater access to health care but have worse behavioural outcomes (Lara et al., 2005). The reasons for the immigrant paradox may be complex, such as the deterioration of cultural, social and familial norms as well as the increased exposure to risky situations in receiving cultures (Prado et al., 2009). Two theoretical approaches may explain the influence of acculturation on health-related behaviours. Cultural norms theory posits that immigrants adopt the norms and values in the receiving culture and thereby learn and display corresponding behaviours (Meston & Ahrold, 2010), which emphasises the roles of norms in mainstream cultures. Acculturation stress theory postulates that immigrants have to face stressful situations in the process of adapting to the receiving culture. Stressors (e.g., discrimination, language barriers) make them highly vulnerable to maladaptive behaviours (Guilamo-Ramos, Jaccard, Pena, & Goldberg, 2005; Vega, Zimmerman, Gil, Warheit, & Apospori, 1993). The focal point of the acculturation stress theory is that the process of adapting to a new environment leads to adjustment strain which triggers acceptance of maladaptive behaviours. The two theories present different perspectives on the influence of acculturation on behaviour.

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Berry (1997) proposed an integrative model of acculturation addressing the influence of both cultural norms and stress which is useful in understanding the relationship between acculturation and health-related behaviours. According to the model, acculturation exerts an impact on long-term outcomes through life events and stressors. The impact varies by individual level (e.g., gender, age) and group level factors (e.g., ethnicity, social support, attitudes of the receiving culture). The current review attempted to employ this model to summarise the studies on acculturation and HIV-related sexual behaviours.

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Acculturation and HIV-related sexual behaviours Empirical studies have emerged to investigate whether acculturation is associated with behaviours related to HIV infection or HIV risk reduction (Wei et al., 2011). Some previous reviews have examined immigrants’ HIV-related behaviours but have not focused on the impact of acculturation on sexual behaviours (Organista & Organista, 1997; Tosh & Simmons, 2007; Wei et al., 2011). Two exceptions are the reviews conducted by Bradford et al. (2002) and Afable-Munsuz and Brindis (2006). Through a meta-analysis of 11 studies undertaken between 1990 and 1998, Bradford et al. (2002) found that acculturation among Latinos in the USA was positively associated with condom use; however, acculturation was also positively associated with risk behaviours in terms of risky sex practices and needle sharing. Afable-Munsuz and Brindis (2006) examined 17 studies from 1985 to 2005 and revealed positive associations of acculturation with early sexual initiation and condom use in most of the studies. The two reviews are informative in synthesising existing research on acculturation and sexual health. However, these reviews only included Latino-focused studies in the USA. Given that both heritage and receiving cultures exert influences on acculturation (Berry, 1997), immigrants from different cultural backgrounds may have different experiences of acculturation that result in ethnic differences in sexual behaviours. The current review will expand on previous reviews by examining findings on the impact of acculturation on HIV-related sexual behaviours among various ethnic groups. Moreover, this review will expand on the current literature by examining the potential moderators in the relationships between acculturation and sexual behaviours. Gender and ethnicity have emerged as the moderators in previous literature (Ahrold & Meston, 2010; Marin, Tschann, Gomez, & Kegeles, 1993). Conceptualisations and measures of acculturation have also been identified as a factor contributing to inconsistent findings (Cabassa, 2003). Therefore, the current review will test the moderating effects of gender, ethnicity and measures of acculturation in associations between acculturation and sexual behaviours. To achieve these aims, we synthesise studies examining associations between acculturation and HIV-related sexual behaviours including condom use, multiple partnerships, unsafe sex, early sexual initiation and sexually transmitted diseases (STDs). Unsafe sex in the current review refers to commercial sex, sexual behaviours assessed by composite sexual risk indices and other sexual acts (vaginal, oral and anal sex) that place individuals at risk of STDs/HIV. Moreover, this review mainly focuses on the influence of mainstream acculturation. The term ‘acculturation’ in the current review refers to mainstream acculturation. We also report the findings of heritage acculturation, but we do not include this in meta-analysis because relatively few studies examined the impact of the maintenance of heritage culture. Regarding each type of sexual behaviour, we examined whether its association with acculturation is consistent across gender, ethnicity of immigrants and measures of acculturation. To examine potential influences of

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various measures of acculturation, we categorised the measures of acculturation into three groups including length of stay in a receiving culture and residency, language use and preference, and multi-faceted scales (Zane & Mak, 2003).

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Methods Inclusion criterion We conducted a systematic literature search to identify studies that: (1) were peerreviewed and published in English-language journals prior to July 2012; (2) included measures of acculturation and measures of HIV-related sexual behaviours and (3) provided quantitative data regarding the associations between acculturation and HIVrelated sexual behaviours. Data source We conducted the literature search in PubMed, PsycINFO, Sociological Abstracts and Web of Science using the following terms: acculturation AND HIV OR AIDS, acculturation AND condom use, acculturation AND multiple partners, acculturation AND commercial sex, and acculturation AND sexual risk. We also hand-searched reference lists from previous literature reviews (Afable-Munsuz & Brindis, 2006; Bradford et al., 2002; Hunt, Schneider, & Comer, 2004; Roncancio, Ward, & Berenson, 2012; Schwartz, Unger, Zamboanga, & Szapocznik, 2010; Wei et al., 2011). Seventy-nine studies met all the aforementioned inclusion criteria. Supplemental data Figure 1 provides a flow chart of the process in which the records were screened, assessed for eligibility and included in the review. Of these 79 studies, 15 studies were excluded from meta-analysis because these studies (1) did not present information that allows for an exact estimate of effect size (i.e., means, standard deviations, exact probability levels and population proportions), (2) did not separately report results of immigrant and native populations and (3) did not examine the relationship between sexual behaviours and mainstream acculturation (e.g., examined heritage acculturation), leaving 64 studies for meta-analysis (see supplemental data Table 1). Data abstraction Data abstraction forms were used to retrieve information on the study characteristics, the measures of acculturation and the associations between acculturation and HIV-related sexual behaviours. The study characteristics included study location and sample characteristics (e.g., ethnicity, sample size). Meta-analytic procedure We used Pearson product moment correlations as the index of effect size. When no correlations were given, we computed r from other information available (Lipsey & Wilson, 2001). Many studies reported more than one association between acculturation and each sexual behaviour since these studies used more than one measure of acculturation and more than one ethnic sample. To assure independence of the correlations, we averaged multiple correlations within each study so that effect sizes in meta-analysis were derived from different samples (Lipsey & Wilson, 2001). Gender groups within each study were retained given that gender was a potential moderator in the relationships between acculturation and sexual behaviours (Marin et al., 1993).

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Meta-analyses were conducted with random effects models because such an approach is a conservative solution to deal with heterogeneity (Kisamore & Brannick, 2008). Following recommendations by Lipsey and Wilson (2001), we transformed correlation coefficients to Fisher’s zs, combined these statistics using meta-analysis, and transformed the pooled z statistic to pooled r. A mean effect size of each type of sexual behaviour was calculated. To test whether effect sizes differed for moderator variables, we partitioned between study variance using an ANOVA analogue procedure that yields a Qb test for moderators and a Qw test for remaining unexplained variance (Lipsey & Wilson, 2001). We evaluated publication bias using funnel plots and rank correlation tests between sample size and effect size.

Results Study characteristics Of the 79 studies in this review, 73 studies were conducted in the USA, one study in both the USA and Mexico, two studies in Canada, one study each in Australia, Spain and England. Supplemental data Table 1 presents a summary of all studies including information about research design, study location, sample size, ethnicity, age distribution and basic findings. Most of the studies investigated the associations between acculturation and sexual behaviours among Hispanic or Latino samples (53 studies). Eight studies have focused on Asian and Pacific Islanders. Two studies have exclusively focused on other minorities (one among Russians, one among Middle Easterners). Other studies used samples from diverse ethnic groups. Twenty studies exclusively sampled female immigrants, whereas 10 studies only sampled male immigrants. Other studies include both female and male samples. Measures of acculturation Measures of acculturation in these studies were very diverse and included both proxy indicators (e.g., length of residency, country of birth and language preference) and established scales. Supplemental data Table 2 listed the established measurement instruments. We categorised the measures of acculturation into three groups: length of time living in the receiving culture and residency, language use and preference, and multifaceted measures. Given that some multi-faceted measures include ethnic identity as a domain of acculturation, we categorised the two studies using the ethnic identity measure (Raffaelli, Zamboanga, & Carlo, 2005; Shehadeh et al., 2012) into the group of multifaceted measures. In the first group, length of residency (10 studies) and country of birth (14 studies) were mostly used. There is a debate on whether people who are born in the receiving country but raised by foreign-born parents are migrants. We included this population since being born in the receiving country does not mean that this population is only exposed to the receiving culture. Second- or even third-generation individuals can be influenced by both the receiving and heritage cultures. For example, parents may direct children to selectively acculturate while maintaining their original cultural traditions (Rothe, Pumariega, & Sabagh, 2011). Other proxy indicators included nationality, percentage of life living in the receiving country, country of birth of parents and generation status. Language use and preference was assessed through either participants’

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preference for the language of interview (e.g., in Spanish vs. English) or established scales. Other studies used multi-faceted established scales or composite measures including more than one proxy indicator. Overall analyses

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The current meta-analysis included 38 studies on condom use, 37 studies on multiple partnerships, 16 studies on unsafe sex, 18 studies on early sexual initiation and 15 studies on STDs. Effect sizes for individual studies appear in supplemental data Table 1, and pooled effect sizes appear in supplemental data Table 3. The Q statistics, the number of independent correlation coefficient (K), sample size (N), combined effect size (r) and corresponding 95% confidence intervals (CIs) are also shown in supplemental data Table 3. Condom use Acculturation was not associated with condom use (r = 0.01, 95% CI: −0.03 to 0.06). While the pooled effect size was heterogeneous (p < 0.001), the association did not differ by gender, (Qb(2) = 5.67, p = 0.06), ethnicity, (Qb(2) = 1.36, p = 0.51) or measures of acculturation (Qb(3) = 1.86, p = 0.60). Two studies, not included in the meta-analysis, examined the impact of maintenance of original culture on condom use (Dixon, Saul, & Peters, 2010; Nakamura & Zea, 2010). Dixon et al. (2010) found that lower attachment to the heritage culture was associated with more condom use among Puerto Rican women in the USA. Nakamura and Zea (2010) conducted a study among Latino gay and bisexual men and found that attachment to the original culture was negatively associated with both condom use during receptive anal intercourse and condom use during sex under the influence of drug, while it was positively associated with condom use during insertive anal intercourse. These findings show conflicting associations of maintenance of heritage culture and condom use. Multiple partnerships Acculturation was positively associated with multiple partnerships (r = 0.15, 95% CI: 0.09–0.20). The pooled effect size was heterogeneous (p < 0.001). The association differed by gender (Qb(2) = 11.22, p < 0.01), such that the mean effect size was significantly positive in the studies including females only (r = 0.21, p < 0.001) and in the studies employing mixed gender (r = 0.15, p < 0.001), whereas it was not significant in the studies including males only (r = 0.01, p = 0.83). The findings suggest that acculturation may lead to multiple sexual partners among women more than men. However, the association did not differ by ethnicity (Qb(1) = 0.001, p = 0.98) or measures of acculturation (Qb(2) = 0.55, p = 0.76). Recent research has also revealed the impact of heritage acculturation on multiple partnerships. Deardorff, Tschann, Flores, and Ozer (2010) found that a preference for speaking Spanish was associated with declines in multiple partnerships among female adolescents but not among male adolescents. Meston and Ahrold (2010) revealed that heritage and mainstream acculturation interacted to affect multiple partnerships. They found that mainstream acculturation was positively associated with multiple partnerships among Asian women but not among men. Moreover, this effect was stronger among Asian women who were less involved in their original cultures. Among Hispanic men (but not women), mainstream acculturation was positively associated with multiple partnerships among those who had low attachment to the heritage culture, but it was

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negatively associated with multiple partnerships among those who had high attachment to the heritage culture. Heritage acculturation had some association with multiple partnerships, but no single pattern emerged.

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Unsafe sex Acculturation was positively associated with unsafe sex (r = 0.16, 95% CI: 0.08–0.23). The pooled effect size was heterogeneous (p < 0.001). The association differed by gender (Qb(2) = 9.79, p < 0.01), such that the mean effect size was significantly positive in the studies including females only (r = 0.27, p < 0.001) and in the studies employing mixed gender (r = 0.11, p < 0.05), whereas it was not significant in the studies including males only (r = −0.13, p = 0.35). The findings indicate that acculturation was associated with a tendency to have unsafe sex among female immigrants but not among male immigrants. The association also differed by ethnicity (Qb(2) = 18.76, p < 0.001), such that there was a small effect size among Hispanic immigrants (r = 0.10, p < 0.05), a medium effect size among Asian immigrants (r = 0.25, p < 0.001), but a large effect size among other ethnicities (i.e., Russians, White and Black immigrants) (r = 0.63, p < 0.001). Closer scrutiny revealed that the large effect size among other ethnicities was mainly attributable to a strong correlation between acculturation and unsafe sex among Russian immigrants (r = 0.63). However, the relationship between acculturation and unsafe sex did not differ by measures of acculturation (Qb(2) = 0.08, p = 0.96). Two studies examined the effect of heritage acculturation on unsafe sex. Raffaelli et al. (2005) found that the maintenance of original culture (i.e., the identification with ethnic culture) was positively associated with unsafe sex among Cuban women in the USA. Schwartz et al. (2011) revealed a negative association between Hispanic cultural orientation and unsafe sex among Hispanic immigrants. Additional evidence is needed to clarify the influence of heritage acculturation on unsafe sex. Early sexual initiation Acculturation was positively associated with early sexual initiation (r = 0.13, 95% CI: 0.05–0.21). While the pooled effect size was heterogeneous (p < 0.001), the association did not differ by gender (Qb(2) = 3.24, p = 0.20), by ethnicity (Qb(1) = 0.11, p = 0.74) or by measures of acculturation (Qb(2) = 1.28, p = 0.53). There was a tendency towards a gender difference such that the mean effect size was significant in the studies including females only (r = 0.18, p < 0.01) and in the studies employing mixed gender (r = 0.14, p < 0.01) but not in the studies including males only (r = −0.02, p = 0.82). STDs Acculturation was positively associated with STDs (r = 0.10, 95% CI: 0.04–0.17). The pooled effect size was heterogeneous (p < 0.001). The association differed by gender (Qb(2) = 10.75, p < 0.01), such that the mean effect size was significantly positive in the studies including females only (r = 0.14, p < 0.001) and in the studies employing mixed gender (r = 0.16, p < 0.001), whereas it was not significant in the studies including males only (r = −0.07, p = 0.25). The association did not differ by ethnicity (Qb(1) = 0.14, p = 0.71) or by measures of acculturation (Qb(2) = 1.23, p = 0.54).

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Publication bias To assess the possibility of publication bias, we generated a funnel plot (Light & Pillemer, 1984) with the studies’ sample size by effect size for each type of sexual behaviour. The observations in the plots appeared to be symmetrically distributed around the grand mean. The rank correlations between acculturation and sexual behaviours were r = 0.13 (p = 0.42) in the studies on condom use, r = −0.03 (p = 0.88) in the studies on multiple partnerships, r = −0.34 (p = 0.20) in the studies on unsafe sex, r = 0.03 (p = 0.91) in the studies on early sexual initiation and r = 0.10 (p = 0.71) in the studies on STDs. These findings did not indicate publication bias.

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Discussion The present review examines the literature on the impact of acculturation on HIV-related sexual behaviours. Researchers have proposed acculturation as an important factor influencing immigrants’ health and behaviour (Frisbie, Cho, & Hummer, 2001; Kaplan, Chang, Newsom, & McFarland, 2002). The present review brought sexual behaviours into the focus due to its considerable impact on health among immigrants. Through examining recent findings, we summarised the evidence of the impact of acculturation on sexual behaviours and recognised confounding variables such as gender and ethnicity. The impact of acculturation on sexual behaviours varied across types of sexual behaviours. Acculturation was positively associated with four types of risky sexual behaviours including multiple partnership, unsafe sex, early sexual initiation and STDs, which is consistent with previous findings (Afable-Munsuz & Brindis, 2006; Bradford et al., 2002). Gender moderated the relationships between acculturation and multiple partnerships, unsafe sex and STDs. The associations between acculturation and risky sexual behaviours were stronger among female immigrants than male immigrants. In addition, ethnicity moderated the relationship between acculturation and unsafe sex. On the other hand, there was no reliable relationship between acculturation and condom use. This finding is inconsistent with the finding of Bradford et al. (2002). Ethnicity Ethnicity served as a moderator between acculturation and unsafe sex but not between acculturation and other types of sexual behaviours. Caution should be taken in interpreting these findings. In the current review, most of the studies included Hispanic samples. Only a small number of the studies involved samples of other ethnic immigrants (e.g., Asians, Russians). The disproportionate samples may lead to bias of the findings. Future research focusing on ethnicity differences is definitely needed. Many factors may contribute to the ethnic difference in the relationship between acculturation and unsafe sex. According to the acculturation stress theory, immigrants may suffer from stress due to cultural barriers (e.g., language) and discrimination in the receiving culture, which may induce immigrants to engage in risky behaviours in order to cope with aversive moods and seek pleasure. People with different ethnic backgrounds may experience different levels of barriers and experience and display varied levels of maladaptive behaviours. Discarding one’s original culture during the adaptation to a new culture is another risk factor towards health-related behaviours (Abraído-Lanza et al., 2006). Moreover, the influence of losing original cultures on unsafe sex varies across ethnicity (Schwartz et al.,

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2011). Traditional cultural norms, sexual values and religious proscriptions may play a role in the effect of heritage acculturation (Edwards, Fehring, Jarrett, & Haglund, 2008). For example, Asian cultures attach crucial importance to family unity so that family members tend to conform to family values and norms (Du et al., 2013; Du, King, & Chi, 2012). The pressure from family members may hinder Asians from engaging in sex (Hahm et al., 2008; Schuster, Bell, Nakajima, & Kanouse, 1998). Researchers have also assumed that sexually conservative beliefs in Asian cultures may protect Asian immigrants against risky sexual behaviours during the acculturation process (Hahm et al., 2008; O’Connor, Shaw, Wen, & Quine, 2009). However, if Asians discard the traditional values and beliefs in the process of acculturation, they may become more vulnerable to risky sexual behaviours than other ethnic groups. Gender Gender is a notable moderator of the relation between acculturation and sexual behaviours. Gender differences in sexual behaviours may be related to immigrants’ cultural values (Deardorff et al., 2010). For example, traditional Latino cultures advocate sexual abstinence and discourage sexual activity among adolescent girls (Pavich, 1986). During the acculturation process, Latino women may discard the traditional values on sexual abstinence and engage in risky sexual behaviours (Jimenez, Potts, & Jimenez, 2002; Schwartz et al., 2011). In contrast, Latino men who are not restricted by the norm of sexual abstinence may experience a small change in sexual behaviours. In addition, acculturation may lead to less family support so that more acculturated women are more likely to seek attachment in partner relationships and thereby get involved in risky sexual activity (Hahm, Lahiff, & Barreto, 2006). Future research may consider cultural meanings of gender in addition to biological sex. For example, in a society in which women are perceived inferior to men, women may not have much sexual decision-making power so they might need to comply with men’s requests and get involved in risky sexual behaviours (Gómez & Marin, 1996). Measurement of acculturation The relationships between acculturation and sexual behaviours were not different across the variety of acculturation measures. Caution should be exercised in interpreting this result. Although we attempted to differentiate the measurements, it should be recognised that the three groups (i.e., length of stay in receiving culture and residency, language use and preference, and multi-faceted scales) were not completely distinct. For example, many multi-faceted instruments involve language use as an indicator of acculturation, which leads to an overlap between the group of language use and the group of multifaceted scales. Moreover, a large variety of measures exist within each group. The first group includes several proxy indicators such as country of birth, length of living in the receiving culture and generation status. Also, some multi-faceted scales assessed both ethnic identification and behavioural acculturation, which represent different aspects of acculturation and contribute to the ambiguity of the findings (Lopez-Class, Castro, & Ramirez, 2011; Schwartz et al., 2010). Therefore, based on available data, we cannot rule out the possibility that inconsistent findings in literature were partly due to the mixed use of acculturation measures. The studies using more than one measure of acculturation could be informative in detecting the distinction between different domains of acculturation. For example,

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Shehadeh et al. (2012) reported that length of residency, country of birth and ethnic identity positively predicted condom use, whereas language preference was not associated with condom use. This finding suggests that different domains of acculturation may have differential associations with sexual behaviours. In the current meta-analysis, although measures of acculturation did not emerge as a significant moderator between acculturation and sexual behaviours, we did observe different tendencies across measures. For example, regarding the association between acculturation and early sexual initiation, the studies using length of time and residency as indicators showed a small effect size (r = 0.06, p = 0.59), whereas the studies assessing acculturation through language use (r = 0.14, p = 0.07) and the studies assessing acculturation with multi-faceted scales (r = 0.19, p < 0.01) demonstrated relatively stronger associations. The findings indicate that relative to simplistic proxy measures (e.g., country of birth), multi-domain conceptualisations of acculturation including behaviours, attitudes, values and identifications may more accurately represent the acculturation. Another issue contributing to inconsistent findings is that the measures of acculturation may assess not only the domains relevant to sexual behaviours but also the domains that are not closely associated with sexual behaviours. The advantage of multi-faceted scales is the ability to assess acculturation from a broader perspective such as language use, media use, food use and cultural practices. However, it is unclear if all the domains of acculturation included in the instruments are related to the outcomes of interest such as sexual behaviours. For example, language and media can strongly influence immigrants’ social interaction with the receiving society so that these two indicators can be related to immigrants’ sexual lifestyle. In contrast, food use is less relevant to the immigrants’ sexual activity (So, Wong, & DeLeon, 2005). The inclusion of an indicator of acculturation that is not closely associated with sexual behaviours (e.g., food use) may contribute to non-significant findings. In addition, acculturation in the public domain (e.g., language, news and social contacts) and acculturation in the private domain (e.g., cultural habits, celebrations) may have different influences on sexual behaviours. One may adhere to sexual conservatism of their culture of origin at home (i.e., private domain) but engage in unsafe sex with casual sexual partners outside the home (i.e., public domain). In this case, acculturation in the public domain may predict sexual behaviours better than acculturation in the private domain. Therefore, choosing an appropriate acculturation instrument may improve the validity of studies. Most of the studies in the current review examined acculturation as a unidimensional construct. However, the bidimensional model of acculturation (Berry, 1997) posits that both adaptation to the receiving culture and maintenance of the original culture exert influences on acculturation. Several studies included in the current review confirmed this assumption by showing a difference in the influence of heritage culture and mainstream culture on sexual behaviours (e.g., Meston & Ahrold, 2010; Schwartz et al., 2011). Future research should strive to use the bidimensional model of acculturation which holds promise in advancing our understanding of the relation between acculturation and sexual behaviours. Suggestions for future research Theoretical frameworks are strongly needed for advancing the research on acculturation and HIV-related behaviours (Abraído-Lanza et al., 2006; Cabassa, 2003; Hunt et al., 2004). Many studies in the current review did not include a theoretical model and did not

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examine the mechanism through which acculturation can influence sexual behaviours. Based on previous literature (Berry, 1997; Cabassa, 2003), we proposed a three-level conceptual model. The first level focuses on the influence of heritage and receiving cultures. Acculturation is a process happening in cultural contact and cultural changes between two cultural worldviews. It is crucial to understand where immigrants come from and go to and what knowledge and behaviour immigrants carry with them and will learn in the process. Cultural background could be a reliable predictor of health-related behaviour. Cultural factors may include cultural sexual norms, gender sexual norms, religious proscriptions and HIV beliefs in both heritage and mainstream societies (Gómez & Marin, 1996). For example, Asian immigrants hold traditional values associated with sexual conservatism and Latino female immigrants hold traditional values on sexual abstinence. The extent of Asians and Latinos adhering to their sexual beliefs in the receiving culture can partly determine the impact of acculturation on sexual behaviours. The second level focuses on social factors including the relationships with family, peers and community. Social support from family is beneficial for immigrants to cope with acculturation stress. Moreover, in some cultures, such as the Asian, people can perceive pressure from family members, which prevents them from engaging in risky sexual behaviours (Hahm et al., 2008). In contrast, separation from family and spouse makes migrants vulnerable to HIV risk behaviours (Wang et al., 2007). In addition, peers and community can exert impacts on sexual behaviours in the acculturation process because immigrants can adopt peers’ and community residents’ sexual attitudes and learn their sexual behaviours (Campbell, Williams, & Gilgen, 2002; Le & Kato, 2006). The third level focuses on individual factors such as coping strategy, personality, expectation, economic status and demographic factors. Although acculturative stress is common in the adaptation process (Berry, Kim, Minde, & Mok, 1987), immigrants can use their coping strategies to attenuate negative effects of stressors. People who have positive attitudes, seek social support, perceive a higher degree of control over sexual acts and engage in spiritual activities are more likely to have safe sex (Folkman, Chesney, Pollack, & Phillips, 1992; Loue, Cooper, Traore, & Fiedler, 2004; Taylor et al., 1992). These individual factors may moderate or mediate the impact of acculturation on sexual behaviours. Cultural, social and individual factors, separately or interactively, enhance or mitigate the influence of acculturation on sexual behaviours. Examination of this model requires cross-cultural and longitudinal designs and sensitive measures of acculturation. A crosscultural perspective may be useful in understanding the differences in sexual norms and behaviour between heritage and receiving cultures and predicting possible sexual behavioural changes among immigrants. Recognising sexual beliefs in the two cultures also facilitates interpreting the relationship between acculturation and sexual behaviours. Longitudinal research is needed to track sexual activities and observe changes in sexual behaviours of immigrants since their arrival in the receiving society. Moreover, longitudinal studies should include social and individual factors, which may explain variations of sexual behaviours within ethnic groups. Limitations of the current review This review is subject to some limitations. First, we examined the studies focusing on international migrants. The literature on internal migrants, which was excluded in the current review, may provide additional evidence on the relationship between acculturation

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and risky sexual behaviours. Second, for practical reasons (e.g., full-text of the study was not available), we did not consider non-English publications, which may lead to selection bias. Third, regarding the categorisation of measures of acculturation, caution should be taken in interpreting the findings because the group of multi-faceted scales was not totally distinct from the group of length of stay in a receiving culture and residency, and the group of language use. Finally, we categorised composite measures of risky sexual behaviours as unsafe sex, which partly overlapped with other types of sexual behaviours. Hence, caution is needed with regard to interpreting the findings on unsafe sex.

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Conclusion Adaptation to a new culture brings new challenges to immigrants’ sexual health. This article reviews the empirical literature on acculturation and sexual behaviours. The results showed that immigrants high in mainstream acculturation were more likely to have multiple partners, early sexual initiation, STDs and unsafe sex. Moreover, the associations between mainstream acculturation and multiple partnerships, early sexual initiation, STDs and unsafe sex were stronger among female immigrants than among male immigrants. Acculturation seems to have limited impact on condom use. The current review calls for more attention to the role of context given that the association between acculturation and sexual behaviours may be context-dependent. To depict the complex relationship between acculturation and sexual behaviours, we proposed a three-level conceptual model which illustrates the roles of cultural, social and individual factors in the relationship. Crosscultural and longitudinal research has the potential to clarify the impact of acculturation on sexual behaviours as well as elucidate the roles of potential mediators and moderators. Measures of acculturation need to include both adaptation to a new culture and maintenance of the original culture. Improved instruments to measure acculturation may be needed. A greater understanding of the relationship between acculturation and HIV-related behaviours would help in developing culturally based prevention and intervention programmes among the growing immigrant population. Acknowledgements This research was supported by NIH Research Grant R01NR010498 by the National Institute of Nursing Research and National Institute of Mental Health.

Supplemental data Supplemental data for this article can be accessed here: http://dx.doi.org/10.1080/17437199. 2013.840952

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