Acculturation stress and drinking problems among urban heavy drinking Latinos in the Northeast.

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Acculturation Stress and Drinking Problems Among Urban Heavy Drinking Latinos in the Northeast a

b

b

Christina S. Lee , Suzanne M. Colby , Damaris J. Rohsenow , c

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Steven R. López , Lynn Hernández & Raul Caetano

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Bouvé College of Health Sciences, Northeastern University , Boston , Massachusetts b

Brown University , Providence , Rhode Island

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University of Southern California , Los Angeles , California

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University of Texas School of Public Health , Dallas , Texas Published online: 12 Nov 2013.

To cite this article: Christina S. Lee , Suzanne M. Colby , Damaris J. Rohsenow , Steven R. López , Lynn Hernández & Raul Caetano (2013) Acculturation Stress and Drinking Problems Among Urban Heavy Drinking Latinos in the Northeast, Journal of Ethnicity in Substance Abuse, 12:4, 308-320, DOI: 10.1080/15332640.2013.830942 To link to this article: http://dx.doi.org/10.1080/15332640.2013.830942

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Journal of Ethnicity in Substance Abuse, 12:308–320, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1533-2640 print/1533-2659 online DOI: 10.1080/15332640.2013.830942

Acculturation Stress and Drinking Problems Among Urban Heavy Drinking Latinos in the Northeast CHRISTINA S. LEE Downloaded by [Michigan State University] at 10:35 25 February 2015

Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts

SUZANNE M. COLBY and DAMARIS J. ROHSENOW Brown University, Providence, Rhode Island

STEVEN R. LÓPEZ University of Southern California, Los Angeles, California

LYNN HERNÁNDEZ Brown University, Providence, Rhode Island

RAUL CAETANO University of Texas School of Public Health, Dallas, Texas

This study investigates the relationship between the level of acculturation and acculturation stress and the extent to which each predicts problems related to drinking. Hispanics who met criteria for hazardous drinking completed measures of acculturation, acculturation stress, and drinking problems. Sequential multiple regression was used to determine whether the levels of self-reported acculturation stress predicted concurrent alcohol problems after controlling for the predictive value of the acculturation level. Acculturation stress accounted for a significant variance in drinking problems, while adjusting for acculturation, income, and education. Choosing to drink in response to acculturation stress should be an intervention target with Hispanic heavy drinkers. KEYWORDS

acculturation stress, alcohol, Latinos

Funding was provided by the National Institute on Alcohol Abuse and Alcoholism, K23AA14905, PI: C. Lee, and a Senior Research Career Scientist Award from the Department of Veterans Affairs, awarded to the third author. Address correspondence to Christina S. Lee, PhD, Northeastern University, 431 International Village, Boston, MA 02116. E-mail: [email protected]. 308


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Hispanic Americans will constitute approximately 29% of the U.S. population by 2050 (U.S. Census Bureau, 2003). The burden of illness and the negative social consequences related to hazardous alcohol use is disproportionately greater for Hispanics compared with other racial/ethnic groups in the United States (Caetano et al., 1998; Caetano, Ramisetty-Mikler, & Rodriguez, 2008a; Grant et al., 2004; Mulia, Ye, Greenfield, & Zemore, 2009; Sutocky, Shultz, & Kizer, 1993). Therefore, it is important to identify modifiable risk factors for hazardous drinking among Hispanics in an effort to address alcohol-related health disparities in this population. Acculturation refers to the affective, cognitive, or behavioral changes that result from sustained contact with another culture as people adjust to differences in their new social environment (Berry et al., 1987). Although the relationship between acculturation and drinking behaviors has been widely examined, findings have not been uniform across gender or Hispanic national groups. First, greater acculturation is more consistently associated with increased drinking for women than for men, possibly because drinking tends to be less normative in Latin countries and is more normative in the United States. Thus, the observed increases in drinking among women may be part of adjustment to a new social environment (Caetano, 1987; Gilbert, 1987; Markides, Ray, Stroup-Benham, & Trevino, 1990; Pearson, Dube, Nelson, & Caetano, 2009; Saitz, Lepore, Sullivan, Amaro, & Samet, 1999; Zemore, 2005, 2007). Second, the relationship between acculturation and drinking in the United States also varies across Hispanic national groups. Length of U.S. residency is often used as a proxy for the level of acculturation. Although the range of acculturation within groups varies, Puerto Ricans and Cuban Americans are arguably, on average, among the more acculturated Hispanic national groups given their greater exposure to the United States relative to other Hispanic national groups. (Puerto Ricans have been U.S. citizens since 1917 and many Cuban Americans immigrated to the United States as political refugees in the 1960s.) Of note, Puerto Ricans reported a higher volume of alcohol consumption and greater problems related to drinking, including higher rates of alcohol dependence, than Cuban Americans (Alegría et al., 2008; Caetano et al., 2008a; Caetano, Ramisetty-Mikler et al., 2009). The variability of findings among Hispanic national groups suggests that drinking behavior among Hispanics cannot be understood solely by examining acculturation level. For example, the contexts of migration may be more stable for Cubans compared with other Hispanic national groups, such as Puerto Ricans. Cubans living in Miami, Florida have long-established ethnic enclaves characterized by large social networks (Gil & Vega, 1996) that provide important emotional and economic resources, enforce protective norms against substance use (Portes & Zhou, 1993), and act as a buffer against discrimination. In contrast, despite years of U.S. residency, Puerto Ricans reside in ethnically mixed, impoverished neighborhoods


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(e.g, New York, New York, and Boston, Massachusetts) (Treschan, 2010). The context of migration and country of origin are factors that may influence the acculturative process and whether it is experienced as stressful (Gil & Vega, 1996; Goldston et al., 2008). Social stressors that occur in the context of acculturation should be an increasingly important focus. Acculturation stress theory, based on the Lazarus Stress and Coping model (Lazarus & Folkman, 1984), hypothesizes that stress results when events are appraised to overwhelm one’s ability to cope (Berry, 2003; Berry & Kim, 1988; Collazos, Qureshi, Antonin, & Tomas-Sabado, 2008; Deren, Shedlin, Kang, & Cortes, 2011; Ehlers, Gilder, Criado, & Caetano, 2009; Joiner & Walker, 2002). Furthermore, avoidant coping strategies, such as drinking and drug use (e.g., emotional disengagement from the stressor), are preferred when stressors are perceived to be insurmountable or not under one’s control (Carver, Scheier, & Weintraub, 1989; Crockett et al., 2007). Therefore, an important extension of acculturation stress theory to alcohol use among Hispanic groups is that alcohol misuse is an ineffective coping mechanism in response to acculturation stressors that are perceived to be chronic and insurmountable. Changes in the social context, such as the increasingly antiimmigrant attitudes and policy changes of the past two decades (e.g., the Immigration Reform Act of 1996), have been associated with reported increases in acculturation stress (Arbona et al., 2010; Cervantes, Goldbach, & Padilla, 2012; Cervantes, Padilla, & Salgado, 1991) . Consistent with predictions, the chronic, invisible, and damaging effects of perceived discrimination and social isolation, the loss of valued social networks, unfair treatment in the United States, and family conflict related to acculturation changes within families have been associated with increased alcohol and substance use (Blume, Resor, Villanueva, & Braddy, 2009; Caetano, Ramisetty-Mikler, & Vaeth, 2007; Conway, Swendsen, Dierker, & Canino, 2007; Ehlers et al., 2009; Ortega, Rosenheck, Alegría, & Desai, 2000; Paradies, 2006; Williams, Neighbors, & Jackson, 2003; Williams, Yu, Jackson, & Anderson, 1997; Zemore, Karriker-Jaffe, Keithly, & Mulia, 2011) and problems related to use (Zemore et al., 2011). Interestingly, gender differences in coping (Carver, Scheier, & Weintraub, 1989; Folkman & Lazarus, 1980; Scheier, Weintraub, & Carver, 1986) were replicated in a 2006 analysis of the Hispanic Americans Baseline Alcohol Survey data, wherein only men reported drinking to cope with acculturation stress (Vaeth, Caetano, & Rodriguez, 2012). Last, emerging evidence suggests that acculturation stress affects individuals of all acculturation levels, although perhaps through different pathways. For example, less acculturated individuals report stress due to language barriers, feeling socially isolated, working in dangerous jobs, lacking citizenship documentation, or being separated from their families (Finch, Catalano, Novaco, & Vega, 2003; Hovey, 2000). In contrast, more highly acculturated individuals, such as Hispanic college students, report greater


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stress due to their increasing awareness of feeling stigmatized or discriminated against in work or college settings, where they have greater exposure to the mainstream and social messages that stereotyped them, which leds to feelings of marginalization and disempowerment (Grove & Ziwi, 2006). To summarize, it is plausible that stressors related to acculturation are more strongly predictive of hazardous alcohol use and related problems than acculturation. Evidence suggests that acculturation stress can affect individuals across varying acculturation levels. In line with these findings, we hypothesized that acculturation stress would be predictive of concurrent drinking problems and that acculturation stress would predict drinking problems even after controlling for acculturation level, education, and income level.

METHOD Participants and Procedures Participants who were Hispanic, bilingual (speaking Spanish and English), and met criteria for heavy drinking (≥5 drinks per episode or >14 drinks per week for men and ≥4 drinks per episode or >7 drinks per week for women) (Wechsler & Nelson, 2001) were recruited from a New England state using community-based approaches. The study was advertised in Spanish newspapers, on a Spanish radio talk show, and by research assistants who approached potential volunteers in community settings (i.e., community-based organizations). Nontreatment seeking participants were proactively recruited from the community for a brief alcohol intervention trial (Lee et al., 2011). After screening and informed consent, participants completed baseline measures of demographics, acculturation, acculturation stress, and drinking problems and were compensated $60 in gift cards for their time. Only baseline data are used for the current analyses, so the rest of the clinical trial will not be described. A trained, bilingual research assistant administered all assessments to participants after obtaining informed consent. All assessments were selfreported pencil-and-paper questionnaires. Research assessments occurred in a private research office, and participants were assured of the confidentiality of their self-report. The Institutional Review Board approved all procedures.

Measures DEMOGRAPHICS Questions asked participants about their nationality, age, gender, marital status, total household income (continuously scored between $10,000– $70,000+ for yearly income), and education level (continuously scored from Grade 9 to post graduate).

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THE SHORT ACCULTURATION SCALE FOR HISPANICS (SASH) The SASH is a 12-item scale in which higher scores reflect greater levels of acculturation (Marin, Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987). The scale assesses English- or Spanish-speaking preference, as well as behavioral dimensions (media preference, social relations), with good to excellent reliability and good criterion validity (Marin et al., 1987). The mean score ranges from 1 (less acculturated) to 5 (highly acculturated). Internal consistency in this sample was Cronbach’s α = .88.


SCALE OF ACCULTURATION STRESS (SAS) The SAS (Caetano et al., 2007) measures acculturation stress using 11 items rated on Likert-type scales (1 = extremely stressful, 5 = not at all stressful) and covers topics such as negative reactions from friends and family, changing values, and difficulty with language barriers. It has demonstrated construct validity (Caetano et al., 2007; Caetano, Vaeth, et al., 2009) and excellent reliability (Ehlers et al., 2009). It includes items from the Social, Attitudinal, Familial, and Environmental Acculturative Stress Scale (Mena, Padilla, & Maldonaldo, 1987; Padilla, Wagatsuma, & Lindholm, 1985) and items that include perceived discrimination, an acculturation stressor (Vega, Gil, Warheit, Zimmerman, & Apospori, 1993). Sample items include the following statements: “Close family members and I have conflicting expectations about my future” and “Because of my ethnic background, I feel that others often exclude me from participating in their activities.” Internal consistency in this sample was Cronbach’s α = .82. ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT) The AUDIT is a widely used 10-item screening questionnaire asking about the quantity and frequency of alcohol use, alcohol-related negative consequences, and a few indices of dependence (Saunders, Aasland, Babor, DelaFuente, & Grant, 1993). AUDIT scores >8 for men and >6 for women reflect probably hazardous drinking. This measure was used to describe participants’ alcohol severity at baseline. Internal consistency in this sample was Cronbach’s α = .82. DRINKER INVENTORY OF CONSEQUENCES (DrInC) The DrInC is a 45-item self-report measure of drinking problems that asks about adverse consequences of alcohol use in five areas—interpersonal, physical, social responsibility, impulse control, and intrapersonal—with well-established psychometric properties (Miller, Tonigan, & Longabaugh, 1995). Higher total scores indicate a greater number of adverse consequences experienced. Internal consistency in this sample was Cronbach’s α = .95.


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Data Analysis Analysis was performed using SPSS REGRESSION (version 17.0, IBM, New York, NY) for evaluation of assumptions. Frequency distributions were evaluated for normality and outliers were adjusted (Tabachnick & Fidell, 2001). Tests of multicollinearity indicated that it was not an issue (tolerance = .91, .93, .88, and .91 for acculturation, level of education, level of income, and acculturation stress, respectively). The total DrInC score was log-transformed to correct for positive skew. Bivariate correlations were calculated among the SASH, SAS, education, income, gender, and DrInC. Next, we used multivariate regression analysis, with SASH, gender, education, and income level entered in the first step as covariates and SAS entered in the second step as predictors of DrInC. After finding that both income and SAS were significant predictors, we conducted an additional analysis to test for possible interaction effects between these two variables by repeating the regression while adding a third step containing a term for the interaction of income with SAS.

RESULTS Participants Of the 145 individuals screened for the study, 91 (62.8%) qualified for participation. Of those, 61 (67%) completed baseline assessments. Of the 57 total participants (n = 4 missing), 29 (54.7%) participants were men. 28 (52.8%) were single, and the average age was 35 years (standard deviation [SD] = 12.35 years). Educational attainment ranged from high school (grade 9) to postgraduate work. The average level of educational attainment was high school graduation or its equivalent (e.g., GED). 47 (94.0%) were employed but were working at lower wage jobs, such as domestic care, janitorial services, and teacher aides. 26 (49.1%) participants reported an annual income of less than $20,000 per year. Consistent with demographic data for the Northeast, 29 (54.8%) participants were from the Caribbean and the remaining 24 (45.2%) were from Colombia, Mexico, Guatamala, Venezuela, Peru, Ecuador, or Brazil. According to the SASH, participants represented the full range of acculturation levels, whereas average scores were at the moderate to high level (mean [M] = 3.12, SD = .78, range = 1.33–5.00). 48 (87.3%) participants met AUDIT criteria for possible alcohol use disorder.

Correlations Between Acculturation, Acculturation Stress, and Drinking Problems at Baseline Table 1 presents the means, SDs, and correlations for the predictor and dependent variables. Bivariate correlations (n = 57, data was missing for 4 participants)

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TABLE 1 Intercorrelations of Acculturation, Acculturation-Related Variables, Acculturation Stress, and the DrInC at Baseline (N = 57) Measure


1. SASH 2. Education level 3. Income 4. SAS 5. DrInC 6. Gender

1

2

3

4

5

6

– –.03 –.19 .21 .03 .00

– .25 .20 –.28* .03

– .14 –.33* –.05

– –.45**,a –.07

– –.13

–

*p ≤ .05, **p ≤ .01. SASH = Short Acculturation Scale for Hispanics; SAS = Scale of Acculturation Stress; DrInC = Drinker Inventory of Consequences. a The SAS is reverse scored (1 = extremely stressful, 5 = not at all stressful), e.g., negative correlation means higher stress and higher DrInc score.

revealed that acculturation (as measured by the SASH) was not significantly correlated with level of education or income or the DrInC. Acculturation stress (as measured by the SAS) did not correlate significantly with SASH, education, or income level but was positively correlated with DrInC (r = .49, p < .001), indicating a positive association between acculturation stress and alcohol problems at baseline (Table 1).

Acculturation Stress as a Predictor of Drinking Problems Sequential multiple regression was used to determine whether SAS scores improved the prediction of DrInC after controlling for variance accounted for by SASH, income, and education. Step 1, with SASH, level of education, and income in the equation, was significant, F(4,51) = –2.25, p < .05, with only income level a significant predictor of DrInC. Step 2, entering SAS, resulted TABLE 2 Multiple Regression Analysis Predicting DrInC With Acculturation Variables and Acculturation Stress (SAS) Model Model 1 SASH Income Education Gender Model 2 SASH Income Education Gender SAS

R2 Change

Beta

.157 –.017 –.315* –.166 –.105 .189**

*p ≤ .05, **p ≤ .01. SASH = Short Acculturation Scale for Hispanics; SAS = Scale of Acculturation Stress. a The SAS is reverse scored (1 = extremely stressful, 5 = not at all stressful).

.099 –.264* –.084 –.127 –.460**,a


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in a significant change, R2 = 0.19, F(1,46) = 13.27, p < .01 (Table 2). Income remained a significant predictor of DrInC when all variables were in the model, with a negative beta weight, suggesting that higher income predicted fewer alcohol problems. The significant change in R2 attributed to the SAS in Step 2 indicates that acculturation stress predicts unique variance in alcohol problems above that contributed by income alone. The additional regression testing the interaction of acculturation stress and income was not significant (change in R2 = 0.015, F[1,45] = 1.031, n.s.).


DISCUSSION Consistent with our first hypothesis, we did not find a significant relationship between acculturation and either acculturation stress or alcohol problems. This finding suggests that acculturation and acculturation stress are conceptually different and documents the importance of distinguishing between the two. It also supports the idea that acculturation level does not necessarily determine the level of acculturation stress experienced. People of all levels of acculturation may experience acculturation stress. Furthermore, acculturation stress was related to alcohol problems, whereas acculturation alone was not. We also found support for our second hypothesis—that even after controlling for acculturation level, income, and educational attainment, greater acculturation stress was found to predict more alcohol problems. Our results suggest that acculturation stress may have more use as an indicator of a potential for drinking problems among Hispanics. Of note, although a higher income was found to predict fewer alcohol problems, acculturation stress predicted drinking problems over and above the effects contributed by income, suggesting that acculturation stress’s effects on alcohol problems are independent of income level. The lack of significant interaction for acculturation stress and income further supports the idea that acculturation stress predicts alcohol problems across different levels of income. These interrelationships were explored among heavy drinkers enrolled in a randomized clinical trial to receive a brief intervention to reduce their hazardous use. The strong linkage between acculturation stress and alcohol problems highlights the need to focus on acculturation stress in alcohol treatment studies. Our findings suggest that those who experience acculturation stress are at risk for drinking problems. The results lend credence to the observation that tailored behavioral interventions and research models need to address multiple sources of risk, including poverty and discrimination, to enhance their relevance and efficacy (Mulia, Ye, Zemore, & Greenfield, 2008). In tailoring treatment, illustrating the stressors that might trigger alcohol use (an avoidant coping strategy) would be helpful. Interventions can include more effective proactive coping strategies to address identified stressors in ways that do not involve alcohol consumption. For example,


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Burrow-Sanchez, Martinez, Hopes, and Wrona (2011) developed a module on Ethnic Identity and Adjustment to assist Latino adolescents at risk for substance use. This model bolstered coping skills when confronting racism or discrimination, such as helping to recognize personal strengths and ways to challenge and to minimize negative stereotypic messages. Finally, documenting that more highly acculturated Hispanics are susceptible to acculturation stress supports the need to tailor treatments for individuals at all levels of acculturation. Addressing how social disadvantage and economic hardship influence alcohol use and problems (Mulia et al., 2008) will also help understand how alcohol-related health disparities are experienced and distributed among Hispanics of varying acculturation levels (Zemore et al., 2011). Our study contributes to the growing need for alcohol research focused on Hispanic nationalities such as Puerto Ricans, who have a higher prevalence of alcohol misuse and related problems relative to other Latin groups (Alegría et al., 2008; Caetano, 1988; Caetano et al., 2008a, 2008b; Caetano, Vaeth et al., 2009; Dawson, 1998; Guarnaccia et al., 2007). Puerto Ricans, although U.S. citizens and not technically immigrants, may experience acculturation stress as a result of ethnic minority status, attenuated aspirations, or an increased feeling of marginalization in the United States (Deren, Shedlin, Kang, & Cortes, 2011; Treschan, 2010). It has been noted that Puerto Ricans, by virtue of their U.S. citizenship, may migrate to the United States with higher hopes, and thus experience greater disappointment with reality than someone who lacks citizenship (Alegría et al., 2007). Limitations include the study’s small size and that participants were recruited for a randomized clinical study in a single urban area, rather than being representative of all U.S. Latino heavy drinkers. However, the data set did provide an opportunity to get a preliminary look at the interrelationships between acculturation, acculturation stress, and drinking problems. Our study extends the literature by examining the effects of acculturation stress on heavy drinking Hispanics who are more highly acculturated and who reside in the Northeast. Athough the results are by no means definitive, they make a contribution by suggesting the need to target acculturation stress as a proximal risk factor for drinking behavior and perhaps a necessary focus in treatment studies designed for Hispanic national groups.

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