Host society acculturation and health practices and outcomes in the United States: public health policy and research implications worldwide.

Original Article

Host society acculturation and health practices and outcomes in the United States: Public health policy and research implications worldwide Valentina A. Andreevaa,b,* and Jennifer B. Ungera a Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA. b Nutritional Epidemiology Research Group, University of Paris XIII, Bobigny, France.

*Corresponding author.

Abstract

The unprecedented ethnocultural diversity in the United States and other Western countries likely changes the social norms for various health practices in the host populations, thus impacting prevalence of such practices and leading to the need for modification of public health policies. However, application of host acculturation (HA) principles in the public health domain remains underdeveloped. We conducted a narrative review of theoretical and empirical information about the association between HA and health practices or outcomes, drawing on evidence from health-care services, complementary and alternative medicine, diet, smoking, alcohol use, and psychological well-being. Given the experience of different countries with large immigrant populations, future multidisciplinary studies are needed both to supply additional empirical evidence and to identify ubiquitous HA processes, and thus inform public health promotion initiatives in the United States and worldwide. Journal of Public Health Policy (2014) 35, 278–291. doi:10.1057/jphp.2014.9; published online 3 April 2014 Keywords: public health; acculturation; health behavior; social environment; immigration; policy

Introduction Migration is a driving force of the globalization movement leading to international integration with cultural and economic interdependence.1 From 2000 to 2010, the greatest increase in migrant settlement worldwide occurred in North America, with the United States (US) hosting the largest share of the migrant population.2 In the US, where 13 per cent of the population is foreign-born and 11 per cent is second generation

© 2014 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 35, 3, 278–291 www.palgrave-journals.com/jphp/

Host acculturation and health

(with one or two foreign-born parents), ethnocultural diversity is unprecedented.3 First-generation immigrants often report more favorable health practices (less smoking, better diet) than do longer-term immigrants or the native-born.4–6 This observation relates to the ‘healthy immigrant effect’ – that health indicators among foreign-born or recently arrived individuals surpass those of the native-born for chronic conditions and all-cause mortality.7 As the proportion of new immigrants grows, it changes social norms and prevalence of various health practices. In 2005, 28 per cent of the difference between smoking prevalence in California (15 per cent) and that nationwide (21 per cent) was explained by California’s larger proportion of Latino- and Asian-origin individuals and first-generation immigrants.8 Understanding of the role of ‘host acculturation’ (HA – the role of immigrants in shaping practices of populations in host countries) is insufficient to inform public health strategies. We targeted this gap with a narrative review of theoretical and empirical information about the association between HA and health practices and aimed to provide impetus for further study of host populations’ health practices or outcomes in multicultural settings. We begin by outlining theoretical aspects and distinguishing immigrant acculturation (IA) from HA. Next, we present evidence in support of the HA role in public health. We conclude with an outline of research areas in the HA – health domain that merit particular attention. Theoretical background Interest in acculturation, from the early twentieth century, stems from anthropology.9 Then, acculturation outcomes included acceptance (loss of native culture), adaptation (combining native and host cultures), and reaction.9 Contemporary models often rely on an ‘attitude-centered’ framework guided by retention of heritage culture and acquisition of receiving culture, and acculturation includes strategies for immigrants (integration, assimilation, separation, marginalization) and for hosts (multiculturalism, melting pot, segregation, exclusion).10 Many disciplines have advanced acculturation theories with notions of multidimensionality, reciprocity of changes in all cultures following sustained contact, and the impact of each culture on the overall context,10,11 which permit comparisons across the differing conceptualizations.

© 2014 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 35, 3, 278–291

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Some pertinent knowledge about HA has been gathered in community psychology12–14 and intergroup relations studies.15,16 Unlike IA, HA does not entail identity change.17 However, globalization and the decreasing importance of national boundaries may lead both immigrants and host members to combine heritage, host, and global cultures, thus forming multicultural or hybrid identities.1,17 Here, we define HA as a context-specific, multifactorial process driven by the cultural and behavioral impact of immigrant groups on the host society, which leads to adoption of a bicultural or multicultural perspective – and ultimately to changes in certain health practices or outcomes. Consistent with US-based acculturation research where the reference group is often the third or later generation,4,18 we consider individuals belonging to the third or later generation, regardless of the ethnoracial background, to be part of the host society. Due to the inherent heterogeneity of the host population – including many individuals with multiple cultural roots,19 as well as native Latinos and Native Americans in the US southwest – any classification is liable to be imperfect.

Methods We began with a broad MEDLINE medical subject headings search for ‘acculturation’ and ‘health behavior’ without any country, language, or age restrictions. We then added keywords: HA, reverse acculturation, and acculturation-in-reverse. We repeated this search in the EMBASE database, then conducted a manual search of the bibliographies of all relevant articles. The inclusion criteria were: observational or review studies published through January 2014, dealing with at least one health behavior or health outcome in a host population. We excluded studies dealing with sociological or demographic aspects of HA. Given our objectives, the number of health behavior domains identified was of greater import than the number of studies retrieved. Our results emphasize several examples of shifts in health practices or outcomes experienced by the host society as a result of prolonged contact with immigrants. We draw evidence from the fields of health-care services, complementary and alternative medicine (CAM), psychological wellbeing, diet, smoking, and alcohol use. We also discuss the ‘Latino paradox’ and health practices of later-generation Latinos. The principal elements of this overview appear in Table 1. Most articles retrieved came from the US; we include also pertinent findings from other countries.

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Table 1: The role of host society acculturation in public health Health domain

Support

Examples

I. Health-care services

●

Awareness about ethnocultural issues Substantial health services research CLAS standards

●

●

●

Established National Center for Complementary and Alternative Health Government funding Substantial CAM research

III. Psychological well-being

●

Biculturalism

●

Latinization (acculturation-in-reverse)

IV. Diet

●

Changes in food supply and preferences

●

Consumption of ethnic foods Mexican food as dietary staple Fruit and vegetable consumption in immigrant-dense neighborhoods, regardless of immigrant status

● ●

II. CAM

●

●

● ●

● ●

● ●

V. Smoking

● ●

VI. Alcohol use

●

Cross-cultural medical education Ethnicity-specific mental health care Language assistance services Licensing/coverage of acupuncture CAM courses in medical schools Cross-ethnic patterns of CAM use

Lower smoking prevalence among immigrants Support for smoking bans among immigrants

●

Comparatively low smoking prevalence in states with large immigrant populations, independent of anti-tobacco efforts

Expansion of immigrant communities with low levels of alcohol consumption

●

Presence of Muslim immigrants in peer/social networks associated with reduced alcohol use among host individuals

Results Health-care services McGill University in Canada is a pioneer in the field of cultural psychiatry, having established its program in 1955 to address cultural influences on major psychiatric disorders.19 In 2000, the Office of Minority Health at the US Department of Health and Human Services proposed 14 organization- and provider-level standards for culturally and linguistically appropriate services in health care (CLAS standards).20 Cultural competence guidelines stress the importance of recruiting minority health professionals, provision of interpreter services and


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language-appropriate education materials, integration of ethnocultural health-care resources, and cross-cultural provider training.21 Gradually, medical education incorporated cross-cultural curricula.22 Organizational changes represent HA at the institutional level.23 Qualitative findings of change include adaptation in procedures, staffing, and use of resources in health-care services resulting from growing foreign-born populations in communities.14 Complementary and alternative medicine (CAM) CAM represents a group of therapeutic and diagnostic strategies applied in conjunction with, or in place of, conventional treatment.24 Types of CAM include Chinese or Korean acupuncture, Latino herbal medicine, Indian Ayurveda-type medicine, Japanese reiki, massage, chiropractic, yoga, spiritual healing, homeopathy, and consumption of green tea and soy products.24 In 1976, California became the first US state to license acupuncture as an independent health-care profession.25 Exposure of the host population to the large and growing number of Chinese and Korean immigrants in California suggests that licensure may, in part, have been encouraged by HA processes. Across the US (1997–2007), visits to acupuncturists increased three times, reflecting licensing, coverage for services, and awareness among the population.24 Interest in CAM is growing rapidly, as evidenced by the increasing number of practitioners, CAM courses in medical schools, and government funding.24,26 In 1992, the US Congress established at the US National Institutes of Health the Office of Alternative Medicine, now the National Center for Complementary and Alternative Health.27 CAM is particularly popular among those with chronic conditions (cancer, diabetes, pain), whites, females, and those of high socioeconomic status (SES).24 Findings from the 2001 California Health Interview Survey revealed that about 51 per cent of blacks, 49 per cent of whites, 40 per cent of Latinos, and 69 per cent of Asians used Asian CAM (acupuncture, traditional Chinese medicine, green tea, soy products), and that whites used Asian-specific CAM more than white-specific CAM (massage, osteopathy).28 Psychological well-being Researchers have long observed acculturation of white Americans to the Latino culture (Latinization) in states with large Latino populations.29

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Learning Spanish is an example of ‘acculturation-in-reverse’ among native whites and blacks in Florida.16 Multiple definitions of ‘biculturalism’ have been advanced; they commonly share notions of comfort and proficiency with both one’s heritage and host cultures.30 Studies with Chinese Americans in California revealed that bicultural orientation predicted the highest psychological well-being.31 Research with Latino adolescents in Miami showed that bicultural youth evinced the most adaptive functioning across multiple sociocultural domains, and an association between engagement in both Latino and American cultural practices and the most favorable of psychosocial outcomes.32 Findings about university students demonstrated that self-esteem, purpose in life, internal locus of control, and resilience depended on attachment to both the US and heritage values and practices.17 Another study showed that such an integrated identity proved an important antecedent of beneficial psychological outcomes; identification solely with one’s ethnic culture (Hong Kong or mainland China) predicted adjustment negatively.33 Diet Multiculturalism and globalization also impact dietary practices.34 Food choices and eating habits undergo important modifications in succeeding generations of immigrants, showing distinct dietary patterns by birthplace and dominant language.35,36 US-born Mexican American adults, for example, consume significantly differently from their Mexico-born counterparts, with intakes higher in calories, lower in fruit and vegetables, and higher in non-Mexican fast food.36 Dietary acculturation commonly describes adoption by immigrant groups of eating patterns and food choices typical of the host population.37 However, the host culture appears to have adopted different Latino tastes and food preferences throughout the US.38 Nationally representative 1977–1998 data in the US showed widespread consumption of Mexican food.39 Expanding Latino population in the US portends growing per capita consumption of fruits, nuts, fish and declining consumption of dairy products.40 Researchers attribute popularity of ethnic supermarkets and restaurants throughout the US37 and introduction of new foods to the American culture to growing ethnoracial diversity.41A qualitative study from New York noted that local supermarkets adapted quickly to the presence of refugee groups,


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expanding offerings of ethnic foods.14 Research from the United Kingdom identified a trend of increasing consumption of Chinese and Indian food, with higher SES predicting higher consumption.42 Factors driving changes in food supply and preferences include area of residence, degree of exposure to, and size of the ethnic community.37,41 Because less acculturated Latinos likely consume more servings of fruits and vegetables, more fiber, and less fat compared with their more acculturated counterparts,6 having sustained contact with Latinos in family, leisure, or worksite contexts could be beneficial for the dietary behaviors of host members. Intakes of dietary fat, fruit, and vegetables have been associated with social networks, social norms, and neighborhood ethnoracial characteristics.35,43 For example, for each 10 percentage points increase in the Census tract foreign-born population, there was a significant 1/3 increase in the daily servings of fruit and vegetables.35 Women living in immigrant neighborhoods had higher fruit and vegetable intake regardless of their immigrant status.35 Living in a Census tract with a higher proportion of immigrants was associated with lower consumption of high-fat foods among Latino and Chinese Americans, independent of SES.43 Authors speculate that the benefits of social capital in immigrant neighborhoods extend beyond the immigrants with regard to positive health behavior change.35 Smoking The social context is also an important determinant of smoking behavior.44 California launched a Tobacco Control Program in the late 1980s to discourage smoking through changes in social norms.44 Research found that if the US had the same demographic profile as California (with a higher proportion of Latino- and Asian-origin individuals) then adult smoking prevalence in 2005 would have been 1.6 percentage points lower than observed.8 In parallel to an increasing trend across ethnic groups for supporting non-smoking in public venues,44 adult smoking prevalence declined from 30 per cent to 19 per cent in the US during 1985–2003.45 Smoking prevalence among immigrants is consistently lower than that of native-born individuals.4,46 A greater proportion of foreign-born compared with US-born Asians and Latinos are ‘never smokers.’47 Research with black immigrants from Africa and the Caribbean to the US demonstrated that almost 40 per cent of the non-smokers were foreign-born, compared with 11 per cent who

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were US-born.46 Nationally representative findings in the US (1995– 2002) further indicated that immigrants, regardless of region of origin, displayed stronger support for smoking bans in public places than did their native-born counterparts.18 Whereas such support grew over time, foreign-born respondents remained 67 per cent more likely than thirdgeneration US citizens to support smoking bans in at least four out of six public venues, independent of SES and smoking status.18 Content analyses of tobacco industry documents revealed the industry’s awareness of Asian and Latino immigrants’ low smoking rates and the protective effect of culture.48 Overall, the ongoing proportional increase in foreign-born blacks, Asians, and Latinos in the US could favorably change both the sociocultural norms and the respective regulations for cigarette smoking. Alcohol use Similar to smoking, drinking behaviors are also strongly influenced by social networks.49,50 Evidence about the link between HA and alcohol use is presently derived from research outside of the US. Findings from youth and adult samples in Norway, Sweden, and the Netherlands revealed beneficial influence of immigrants’ lower current drinking on the respective behaviors in the host populations.49–52 For example, Norwegian students who reported drinking did so less frequently where there were larger proportions of Muslim students in their school.51 The authors highlighted that in Western multicultural societies the presence and expansion of immigrant communities with low alcohol consumption is contributing to reduced alcohol consumption among the nativeborn, suggesting lower rates of alcohol-related disorders at the population level.49,50 The ‘Latino paradox’ A concept related to the ‘healthy immigrant effect’ is that of the ‘Latino paradox,’ suggesting that Latinos might have lower mortality than nonLatino whites despite their less favorable SES profiles, owing to retention of the heritage culture.53,54 Research on perinatal substance use in California found that a 1 per cent increase in community acculturation increased the relative odds of testing positive for tobacco use by 2 per cent, by 9 per cent for marijuana use, and by 15 per cent for


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amphetamine use.5 Further, using US nationwide data, researchers showed that breast, colorectal, and lung cancer incidence among Latinos was inversely associated with the percentage of Latino residents in the Census tract.54 Latinos living in high-density Latino neighborhoods had 30 per cent lower lung cancer rates across Census tract income levels.54 Researchers have identified health-promoting potential of immigrant neighborhoods in reducing social isolation and availability of ethnic food stores relevant for a healthy diet.55 Also, the negative impact of neighborhood poverty could be counterbalanced by the positive morbidity and mortality consequences of living among co-ethnics.56 Collective efficacy (a type of social capital pertaining to a neighborhood’s social cohesion and informal social action capabilities) was associated with self-rated physical health when demographic and health factors were controlled.57 The growing number of Latino immigrants in the US could contribute to favorable changes not only in the sociocultural norms for substance use but also to the overall health status of Latinos. Benefits of living among co-ethnics or immigrants might be offset by reduced income and access to care, and insufficient engagement in prevention.55

Discussion and Future Directions Our review indicates HA has driven structural and policy developments across several public health domains, including health-care services, diet, smoking, drinking, CAM use, and psychological well-being. Health-care providers, for example, should not assume that use of treatments or dietary supplements will match ethnic stereotypes. Also, dietary recommendations (individual or population) should include foods from the represented immigrant cultures. Most of the evidence points to a favorable HA role, but not all.58 Critics of cultural integration in health care have indicated that such models are inconsistent with mental health policies’ emphasis on ‘integration’ and might in fact promote divisions along ethnoracial lines.58 Some investigators have suggested that biculturalism might in fact be maladaptive in monocultural contexts.59 Next, despite lower cigarette smoking prevalence, other related and dangerous behaviors (that is, hookah smoking of flavored tobacco) might be more prevalent among immigrants than among host members.60 Finally, it is possible that other societal-level factors that we have not explored here (for example, differential effect of marketing of foods, alcohol, tobacco,

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medicines and so on on immigrant and host populations) might explain some of the observed HA effects. IA and HA share some elements (context, contact and degree of exposure, social network features10,11,13,61) yet might be fundamentally different constructs. One of the main premises of IA is the degree of heritage culture preservation and this is precisely the aspect that, if robust, could promote HA. Another principal aspect – mastery of a second language – is a valued asset regardless of one’s cultural belonging; yet it has greater utility for immigrants than for host individuals. Whereas IA is linked mainly to opportunities to function and thrive in the receiving society, for the host community HA entails the development of a bicultural or multicultural perspective that could impact cognitions and behaviors. Currently understudied areas include: ●

●

HA assessment and comparison of its effects on health across multiethnic countries: We found only one scale for the assessment of HA about development of a bicultural perspective. The Exposure to Asians Scale61 assesses social context and bicultural experiences and this scale’s adaptation to other ethnocultural groups and to the health domain should be part of future research. Multidisciplinary research for empirical evidence and better understanding of uniquely American versus ubiquitous HA processes to inform public health strategies: New studies could build on those indicating similarities across host populations worldwide about CAM practices, dietary shifts, and cultural competence in health care. Social psychologists created the Host Community Acculturation Scale tool more than a decade ago,15 but its focus on ideological orientations limits its utility for public health.

This review provides a basis for further study of health behavior for shaping more effective intervention and regulation strategies to improve population health.

Acknowledgements This work was supported in part by a doctoral dissertation fellowship from the Department of Preventive Medicine, Keck School of Medicine, University of Southern California (Dr Andreeva).


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About the Authors Valentina A. Andreeva, PhD, is Associate Professor of Epidemiology at the University of Paris XIII. Jennifer B. Unger, PhD, is Professor of Preventive Medicine at the Keck School of Medicine, University of Southern California.

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Editor’s Note: The effect of migration, the movement of populations into a society, is an important question for public health and we are pleased to publish this groundbreaking piece. We are not experts in this field, but JPHP has published extensively on the marketing of food, alcohol, and tobacco. We hope that researchers studying the effect of in-migration on the behaviors of the ‘receiving population’ will consider the role of commerce in future studies. Billions of dollars are spent each year to sell food, alcohol, and tobacco, much of it directed at particular segments of the population. Isn’t it possible that this commercial activity affects the behavior of both receiving and immigrant populations?


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Public Health and Epidemiology Informatics: Recent Research and Trends in the United States.

Public Health and Solitary Confinement in the United States.

Islamophobia and Public Health in the United States.

Climate change and vector-borne diseases: what are the implications for public health research and policy?

Health and surgical outcomes in Canada and the United States.

Public Health System Research in Public Health Emergency Preparedness in the United States (2009-2015): Actionable Knowledge Base.

Health Policy Considerations in Treating Mental and Behavioral Health Emergencies in the United States.

Sexual orientation data collection policy in the United States: public health malpractice.

Hunger in the United States: policy implications.

Monitoring of health care personnel employee and occupational health immunization program practices in the United States.

Australian alcohol policy 2001-2013 and implications for public health.

Health professions education and public policy: a research agenda.

Which public and why deliberate?--A scoping review of public deliberation in public health and health policy research.

Public policy and health manpower.

Public health in the United States: the next 100 years.

Improving education, policy and research in mental health worldwide: the role of the WPA Collaborating Centres.

Funding Public Health Emergency Preparedness in the United States.

A plan to strengthen public health in the United States.

Coping with a New Health Culture: Acculturation and Online Health Information Seeking Among Chinese Immigrants in the United States.

Public health research in China: some recent findings and implications.