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Sac. Sri. Med. Vol. 40, No. 12, pp. 1643-1653, 1995 Copyright 0 1995 ElsevierScience Ltd Printed in Great Britain. All rights resewed 0277-9536195 $9.50 + 0.00
ACCULTURATION AS A RISK FACTOR FOR CHRONIC DISEASE AMONG CAMBODIAN REFUGEES IN THE UNITED STATES LAWRENCE A. PALINKAS and SHEILA M. PICKWELL Division of Family Medicine, Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA 92093-0807, U.S.A. Abstract-Although the concept of acculturation originated within anthropology, in recent years it has assumed a prominent role within epidemiology as a risk factor for chronic disease. However, these studies often consider acculturation in structural terms, reflected in differences between groups assumed to lie along the same continuum, all moving in the same direction toward greater acculturation to the values and behaviors of the dominant society. This paper addresses how acculturation should be conceptualized when examining it as a potential risk factor for chronic disease and how it should be measured so that it becomes both theoretically and clinically meaningful. Four case studies of Cambodian refugees of San Diego, California are used to illustrate the following: (1) the importance of integrating an acculturation-as-process perspective with an acculturation-as-structure perspective; (2) viewing acculturation as both individual and group experience of conflict and negotiation between two systems of behavior and belief; (3) measuring it longitudinally and as narrative; and (4) understanding that rather than being an inherent health risk, it may also promote health by creating access to certain forms of health care unavailable in the country of origin and by contributing to the abandonment of risky health-related behaviors and the adoption of behaviors that promote good health. Ke.y words-acculturation,
chronic disease, migration, epidemiology, refugees
Regardless of country of origin, the experience of migrant populations in the United States has long been viewed as illustrative of the process of acculturation, defined in the mid-1930s by Redfield, Linton and Herskovits as “those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact with subsequent changes in the original culture patterns of either or both groups” [ 11.Although interest in and research on these phenomena underwent a noticeable decline within cultural anthropology during the 1960s [2], it gained prominence within the field of epidemiology, beginning with Henry and Cassel’s [3] seminal work on the association between modernization and blood pressure, and extending to Marmot and Syme’s [4] study of the association between acculturation and heart disease in Japanese-Americans. Since then, acculturation has been examined in a wide variety of health-related contexts, including cancer [5], diabetes [6], hypertension and coronary heart disease [7-91, and mental illness [lo, 111. The causal link between acculturation and these chronic diseases has been established through a number of mechanisms, including acculturative stress [12, 131, obesity [ 14, 151 and changes in health-related behaviors such as alcohol use [ 16, 171, diet [ 18, 191and cigarette smoking [20,21], and lack of access to modern health care [22-241. These studiescontribute to our understanding of the etiology and prognosis of chronic disease by enabling us to examine a complex set of environmen-
tal, social, cultural and psychological risk factors while holding genetic influences constant [25]. They also point to the need for specific forms of clinical interventions and community-based programs to prevent the occurrence of chronic disease in acculturating populations [26, 271. However, the use of social science concepts like acculturation in both epidemiologic research and clinical practice is problematic for a number of reasons. An analysis of the use of acculturation in epidemiologic research reveals two different perspectives on the acculturation-chronic disease relationship: acculturation as a process and acculturation as structure. Anthropological and psychological studies of acculturation have tended to focus on the process that occurs over the lifetime of the individual, while studies within epidemiology have focused on differences between groups defined on the basis of language, place of birth, place of residence, and generation. As Williams and Berry [28] observe, these two perspectives require the use of separate concepts and measures, in part because they are different phenomena. Nevertheless, each perspective carries with it certain strengths and limitations. For instance, the acculturation as process perspective requires a longitudinal assessment of both the type of changes and rate of change in values, attitudes and behavior. Such an assessment, while widely considered to be of greater value in determining a causal association than the cross-sectional approach linked to the accultura-
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tion as structure perspective, is often difficult and costly, involving considerable effort in following a cohort of individuals for extended periods of time. Moreover, wide individual differences in psychological acculturative outcomes and experiences make it diffficult to identify key elements of the acculturation process that can be causally related to specific forms of chronic disease morbidity or mortality. In contrast, the acculturation as structure perspective has been favored because of the convenience of its largely cross-sectional design and because it enables one to predict individual outcomes on the basis of group experience. This perspective both takes into consideration the influence of status (age, generation, language, ethnic identity, education, social class) on the acculturation experience and approximates a process perspective by comparing groups whose status is time-dependent (e.g. before and after migration, generation as an approximation of number of years one has been exposed to the dominant culture and the nature of that exposure). However, this perspective assumes that all the groups being compared share the same goals, that the process is linear rather than interactive, and that the status of an individual is an adequate measure of a particular stage in a group process. Although originally conceived as an interactive process resulting in change in both cultural systems, the concept of acculturation as structure is usually confined to the process of change experienced by members of the minority group toward the adoption of the majority group’s culture [29]. This perspective, of course, assumes that the minority group possesses an interest in adopting the culture of the majority group [30, 311, a view that has been challenged in recent years [32-341. This perspective also ignores the changes in the distribution of wealth and power and access to goods and services that often accompany phenomena such as migration, urbanization, and modernization, which in turn influences the ability of the minority or migrant group to adopt the values and behavior of the dominant society [35]. Another problem with the conceptualization of acculturation in epidemiologic research is that, in both the acculturation as structure and acculturation as process perspectives, a distinction between the acculturation process and the migration experience is rarely if ever made; the two phenomena are often conceived to be one and the same. Consequently, higher rates of chronic disease morbidity or mortality among migrants compared to nonmigrants are often assumed to be associated with the process of acculturation with very little attention to other elements of the migration experience, including migration stress (as opposed to acculturative stress), isolation, fear, and inadequate social and economic resources [5,8, 361. Acculturation is also often linked with other phenomena such as ‘modernization’, ‘westernization’, and ‘urbanization’ and is frequently viewed as a form of adaptation [28] with little attempt to distinguish between the concept of acculturation
and these other phenomena. Lack of consistency in the way that acculturation is conceptualized has also led to the proliferation of techniques used to measure level of acculturation. For instance, Marmot and Syme [4] measured acculturation by dividing their cohort of 3809 Japanese American men in California into traditional and non-traditional or ‘western’ on the basis of three separate indices: culture of upbringing, cultural assimilation, and social assimilation. Other studies of risk factors for cardiovascular disease and alcohol use have examined the effect of acculturation by comparing Japanese in Japan, Japanese Americans in Hawaii and California, and American whites [36, 371. Acculturation scales have been developed on the basis of language use, friendship patterns, media sources, occupational status, individual and parental birthplace, and values thought to be associated with a ‘traditional’ way of life [16, 38401. The proliferation of these scales has led to the undermining and invalidation of their underlying premise which is the objectification, quantification and generalization of the acculturation experience. As a result of this inconsistency in the ways that acculturation is conceptualized and measured in epidemiologic research, both the theoretical and clinical significance of the acculturation-disease association remains unclear. This paper addresses two questions: (1) how should we conceptualize acculturation when examining it as a potential risk factor for chronic disease? and (2) how do we measure acculturation in a way that it becomes both theoretically and clinically meaningful? We examine these two questions in the context of four case studies of the association between acculturation and chronic disease within the Cambodian refugee community of San Diego, California. THE CAMBODIANREFUGEE EXPERIENCE
Between 1975 and 1979, over one million Cambodians were executed or starved to death under the harsh regime of Pol Pot. Many of the survivors who fled the country experienced sickness, rape and victimization, and lack of adequate food, shelter and sanitation. Others spent periods of time ranging from months to years in refugee camps, sponsored by a number of international relief agencies, along the Thai border. According to the 1990 U.S. Census, there were 147,411 Cambodian refugees living in the United States, 68,190 of whom were living in California, and 4185 of whom were living in San Diego County. Numerous studies have shown that of all the Southeast Asian refugees who have migrated to the United States since the mid-1970s, Cambodians are making the least progress toward a satisfactory adjustment to America [41,42]. They have more illness, both physical and psychological, than the other
Acculturation and chronic disease
groups (Vietnamese, Vietnamese-Chinese, Lao, Hmong). One of the most pervasive health problems among Cambodian refugees is the psychiatric trauma resulting from the war in Southeast Asia, genocide in Cambodia, and migration experience. Survivors of this experience exhibit a number of symptoms, including: refusal to discuss the experience; frequent nightmares and a strong current of intrusive thoughts about the past; detachment and emotional numbness; memory problems; trouble concentrating; sleep disturbance; and thoughts of death [26]. Symptoms of post-traumatic stress disorder (PTSD) such as those in Cambodian concentration camp survivors were first reported by Kinzie and colleagues [43]. Subsequent studies by Kinzie and his colleagues have found a PTSD prevalence of 50% in a nonpatient community sample of Cambodian adolescents [44], and a 92% prevalence of PTSD in 110 Cambodian patients at a psychiatric clinic for Indochinese refugees [45]. Similar rates in Cambodian patients and nonpatients have been reported in other studies as well [46,47]. In addition to PTSD, symptoms of depression and anxiety have also been reported in Cambodian refugees [26,42,47]. Many of these refugees are disabled by their psychological symptoms, being unable to work and requiring extensive caretaking by family members. Cambodian refugees have also exhibited a greater than expected prevalence of other chronic medical conditions, ranging from hypertension, diabetes, heart disease, stroke and seizures to complaints generally considered to have somatic overtones such as headaches, stomach aches, dizziness, and fatigue [19, 26,471. For the most part, Cambodian refugees have little experience with Western health care practices, and they do not understand how to access the western health care system. Screening and early detection procedures like pap smears, breast examinations, immunizations, blood tests for serum lipids and mammography are unfamiliar to these refugees and their purposes misunderstood. Khmer health behavior is grounded in an Eastern-animist framework where beliefs about illness causality (natural, spiritual, and metaphysical) usually dictate the preferred course of treatment [26]. Use of folk healing methods such as cupping (applying a heated jar to the skin to suction out headache and muscle pain), coining (rubbing a coin or spoon over the skin to “rub out” respiratory illness), and herbal medications are all common among Cambodian refugees living in San Diego [26]. When western health care is utilized and medication prescribed, the refugee frequently expects instant cure and does not persevere through the full course of treatment, thus deriving poor results from his or her encounter with the health care system. Most Cambodians seen by western health care providers receive medical care (medications and diagnostic tests) from multiple providers who have little, if any, contact with one another regarding the patients medical history or health status [26]. Inappropriate use of
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medications (ranging from noncompliance to selfregulation of multiple drugs and polypharmacy) is also quite common in the Cambodian community. Also poorly understood is the concept of chronicity imposed by a diagnosis of diabetes or hypertension. Finally, utilization of health care services is severely restricted by the language barrier, which makes phoning for appointments or finding the way around a medical center in an English-speaking system an enormous challenge to Cambodian patients. Nurse practitioner faculty at the University of California, San Diego (UCSD) work with Cambodians through two Primary Care programs. One is the Cambodian Home Health Care Program and the other is the Cambodian Health Education and Health Screening Project. The first program is based in the patients’ homes and the second alternates biweekly in two Cambodian Buddhist temples in San Diego. The following case studies involve patients in both settings. Case No. 1
Hong Soon, a very traditional Cambodian woman and the widowed mother of three teenagers, attended the nutrition classes offered in the Buddhist temples by the nurse practitioners. The classes stress low fat diet information and advocate the continued practice of traditional Cambodian cooking. The traditional Cambodian diet is one of high vegetable and fruit consumption and minimal use of meat. As can be expected, the families, especially the children, are exposed to American meals in school lunch programs and in their neighborhoods, where fast food restaurants abound. Because Hong Soon is so traditional in her dress, her habits (daily attendance at the Buddhist temple and use of betel nut), and her disinterest in learning English, the nurse practitioners attempted to draw her into the discussion by asking her to name the three dishes she prepared most frequently in her home. Her reply was “macaroni and cheese, hot dogs and pizza”. When asked why she preferred to eat these foods her reply was “I don’t, but this is all my children will eat”. Like most of the Cambodian children seen in the Cambodian Home Health Care Program, Hong Soon’s children prefer to snack on chips, fried egg sandwiches and soda after school and display little enthusiasm for meals comprised of traditional foods. Hong Soon frequently cooks Cambodian meals and keeps a rice cooker going all the time, as is the custom in Cambodian households, but admits this is more for herself than her children. On the nights she cooks ‘American’, she will often eat only rice for dinner. As is often the case with her generation, her diet is based on her preference for Cambodian food. She has little concept of the dangers of ‘hidden fat and calories’ inherent in many American recipes favored by her children. When asked how she learned to prepare these dishes requested by her children, she stated that she bought a cookbook and with the help of her oldest daughter learned how to shop for the correct
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ingredients and decipher the recipes. Single mothers are particularly vulnerable to changing eating habits among the younger generation because there is only one adult in the home to counter the rejection of traditional eating patterns by children. The nurse practitioners see many overweight Cambodians in the community and in the schools. The pattern of high fat, high calorie diets among many young Cambodians, and decreased physical activity among all generations in San Diego was not observed in a visit to Cambodia in the summer of 1991. Even in Phnom Penh, where there is an increasing United Nations presence and restaurants that cater to international tastes, the Cambodians who can afford better and more varied diets maintain their slimness by retaining their traditional diets and remaining physically active. This is not the case in the United States where changes in diet and level of physical activity/exercise predispose the population to nutritionally induced pathological conditions such as hypertension, stroke, and cardiovascular disease. Case No. 2 Male/female differences in basic personal health habits are vividly apparent in gender differences in cigarette smoking and alcohol consumption. Cambodian males of all ages are high utilizers of both cigarettes and alcoholic beverages. This is true in the United States as well as Cambodia. In Cambodia, men continue to smoke at astonishing rates. Women contribute to the family income by selling cigarettes on the street, but women are rarely seen smoking. A smoking prevalence study conducted among newly arrived Cambodian (n = 112), Vietnamese (n = 274) and Laotian (n = 14) refugees in Washington state in 1989 found that the prevalence of current cigarette smoking in males (42.5%) was more than seven times greater than the prevalence in women (5.7%) [48]. Among Cambodian men, prevalence increased with age from 13% in 18-29 year olds to 45.7% in men 30 years and older. Furthermore, this high prevalence underestimates actual smoking levels because some of these new immigrants were advised by family members to deny smoking in order to escape the perceived censure of American immigration officials. As a result of high tobacco use Cambodian men have an increased risk for smoking-related diseases. Chav Sim. for instance, is an 80-year-old male forced into a nursing home because of his history of smoking cigarettes (four packs a day for 65 years is his own estimate). He has severe emphysema and requires oxygen inhalation with even the slightest exertion. Confinement to nursing homes or extended care facilities, is anathema to Southeast Asian refugees in America. Since their arrival in 1975 the various ethnic groups have expressed their concern about the American custom of placing sick or frail elderly family members in nursing homes. In their respective countries of origin, generations cared for each other, and the old and the sick maintained their position in
the family and in the family household. All of this is changing in the United States; while access to modern medical technology has enabled older adults like Chave Sim to live longer, it has also prolonged the experience of chronic disease and disability. Moreover, one of the consequences of the migration experiences of many elderly Cambodians has been the lack of available family to properly care for them. In the case of Chav Sim, there is only his 79-year old wife to care for him. She is unable to understand the complicated medical regime required for his care (oxygen, inhalers and oral medications). Chav Sim himself is notoriously noncompliant with health care measures. The last time he was discharged from the hospital, after an admission for an acute respiratory infection, the visiting nurse fol .ld him close to death because he resumed smoking and discontinued medication. Although a very intelligent man, Chav Sim declines to get involved in discussions about the probable cause of his emphysema. Whether he believes cigarettes are a causal factor is unknown, but he clearly does not believe that he should stop smoking even though this belief has produced severe consequences for his health. Efforts to promote smoking cessation among Cambodian men such as Chav Sim are complicated by diverse health beliefs about disease causation and the strong pressures to conform with long established rites of manhood. As the Cambodian community begins to age the refugee men who were in their 40s and 50s when they arrived will be experiencing the effects of many years of smoking. Behaviorally-induced chronic illnesses will proliferate and elderly women will become caretakers for their husbands, or men will increasingly be confined to nursing homes. Because these facilities are not geared to cope with the language and cultures of these refugees, and because the younger generation has not been brought up to value the caretaking of elders, new complications will arise for an already stressed population. Case No. 3
Sum Yon, Khan Sun and Neang Phin are ages 59, 71 and 73, respectively. The three women all have significant health problems that have developed since they arrived in the United States in the early 1980s. Their diagnoses are recent (all within 2 years). Two have insulin dependent diabetes mellitus and all three have hypertension. They live in a Buddhist temple where they expect to spend the rest of their lives. All three lost husbands and children during the Khmer Rouge era (1975-1979). They have suffered great trauma and have the symptoms of PTSD (nightmares, insomnia, flashbacks and psychosomatic physical complaints). Family nurse practitioner faculty from UCSD School of Medicine have been working with these women since they were diagnosed with diabetes and hypertension. These three women have learned no English since their arrival, and have no contact with
Acculturation and chronic disease
the majority culture except through the health care system. They have continued to frequent traditional healers who are prevalent in the Cambodian neighborhood where they reside. To all appearances, these women are the least acculturated of refugees. They wear only ethnic dress, shave their heads in religious symbolism, never eat American food, never watch television and leave their community only to obtain medical care at UCSD (a distance of 7 miles). And yet, they have all adjusted to their chronic illnesses. They are faithful to their medicine regimens, they have learned and understand the complications of hypertension and diabetes, and the two with diabetes are able to test their own blood sugars daily. Yet, they continue to use herbs and traditional medicines, and solicit help from the Krew Khmer (traditional shaman) when necessary. In this way, they have evolved a rather sophisticated self care system adapted to their individual needs. It was with some surprise that the three women recently initiated a discussion with us about the possibility of initiating a ‘betel nut cessation program’. Our health education program in the Buddhist temples includes classes on child rearing, nutrition, prenatal care, well child care, exercise and chronic illness. We have discussed smoking cessation but have never addressed the use of betel. Older Cambodian women never smoke cigarettes, but they do engage in the cultural practice of chewing betel leaf, betel nut, tobacco and red limestone paste. In this ritual the leaf of the betel vine (shipped from Thailand and sold here in ethnic markets) is spread with lime paste, wrapped around a slice of betel nut, and chewed for hours. At the same time, tobacco leaf is placed between the gum and the cheek. All these necessary ingredients are kept in a container designed for their storage and for sale in any Cambodian market for $18.95. A number of epidemiologic and clinical studies have demonstrated an association between betel nut consumption and oral squamous cell cancer prevalent throughout Southeast Asia [49, 501. Betel is said to have both a stimulating effect and a narcotic effect, and is therefore as addictive as tobacco [51]. Similar measures of behavior modification will be necessary to overcome the effects of long term use. Our observations over many years of community work with Cambodian refugees indicate that the practice of betel quid chewing is widespread among women over 50 years of age and not unusual among women as young as 40 years of age. The prevalence of chewing is limited to women and is part of a socialization process learned at a very young age. The symbolism extends beyond the obvious ritual of betel quid preparation and includes female bonding, especially as it relates to motherhood. Chewing betel is understood to be a rite of passage from girlhood to womanhood. However, young Cambodians consider it distasteful and young women do not appear to be adopting the practice.
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What prompted these seemingly unacculturated women to seek treatment for their addiction? It is doubtful that any within their social network in the Cambodian community have pressured them to cease this long established habit. It is likely that the information on smoking cessation presented in the health education classes provided them with a model of a cessation program that could potentially target betel nut use. But what is it about betel nut use that convinced these women that cessation was necessary and desirable? The answer to this question may lie in the specific experience with the process of acculturation shared by these women. In this particular instance, that experience has less to do with exposure to the dominant society as a whole than it does with their interaction with a particular part of the dominant society, i.e. the western health care system. This interaction is characterized by three interrelated components: the first component is their diagnosis of diabetes and hypertension; the second is their participation in a community-oriented primary care program from which they learned the hazards associated with the practice of chewing tobacco, one of the key ingredients of the betel quid favored by these women; and the third is their utilization of elements of both the traditional and western health care systems to meet their individual needs. The experience of chronic disease may be attributed to the stressors associated with their experience in Cambodia, their experience in migrating to the United States, and their experience in residing in a relatively impoverished ethnic enclave surrounded by other cultural groups. However, this experience has also brought them into contact with the western health care system and its practitioners. In addition to facilitating the adoption of certain beliefs and behaviors as they relate to their specific chronic diseases, this interaction with representatives of the western health care system may help to reduce the stress associated with the experiences referred to by placing something that is unfamiliar (i.e. the chronic disease) in a familiar context (i.e. their experiences in Cambodia and the United States). Similarly, the participation in the nurse practitioner programs in the community has exposed them to unfamiliar concepts of disease prevention and health promotion in a familiar setting (i.e. the Buddhist temple). Finally, the use of both traditional and western health care systems to meet individual needs acts to integrate western health-related beliefs and behavior that are unfamiliar with traditional beliefs and behavior that are familiar, creating a synthesis that is tailored to individual needs and experience. In summary, the chronic diseases experienced by these three elderly Cambodian women do not appear to be a consequence of the adoption of western beliefs and behavior that are associated with an increased risk of these diseases. Rather, they precipitated a process of acculturation that occurred subsequent to interaction with the western health care system. Moreover,
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instead of creating a risk for chronic disease, this process has the potential of fostering long-term health benefits. Case No. 4
Sim Sok is a 40-year-old male who lives in East San Diego with his father, wife and five children. A rice farmer in Cambodia, he was forced by circumstances to be a village guard. In 1975, Sim Sok was captured by Khmer Rouge forces, separated from his family and sent to a distant collective farm where he labored in the rice fields for four years. The family was reunited by chance in 1979 in a refugee camp on the Thailand border. After living in the camp for six years, Sim Sok and his family were sponsored for resettlement by a fundamentalist Christian church in Texas. The church group treated them well, finding them adequate housing and a job for Sim Sok. But Sim Sok began to find the Christian church oppressive, and he had no aptitude for his job as a roofer. One day while tarring a roof he lost his footing; to avoid a fall to the ground he reached for a bucket to steady himself. The hot tar poured across his right arm and hand. He was taken to an emergency room and received care from a plastic surgeon. When the surgeon suggested skin grafting and physical therapy, Sim Sok turned instead to his belief in indigenous healing, seeking out a Krew Khmer living in Texas and spending precious months undergoing spiritual treatment and utilizing folk healing practices. He developed contractures in his right hand, rendering it useless, and experienced chronic pain from neurological damage to his arm. Eventually, he did submit to skin grafting from his right thigh to his arm and now resentfully displays two scarred areas on his extremities. He blames the American doctors for his deformed hand, chronic pain and surgical scars. Sim Sok also has a scar and depression on his right thorax where a bullet is lodged from a wartime gunshot injury. For his chronic pain and profound depression he has 17 prescription drugs in his home ordered for him by 6 physicians, each unaware of the other. He receives periodic medical care from a UCSD family practice resident, two Vietnamese physicians, a Laotian physician, and two other Americans who practice medicine in East San Diego. This practice creates a potential for adverse drug interactions. Sim Sok has a history of two psychiatric admissions and has been diagnosed as having post-traumatic stress disorder. He is supposed to be receiving outpatient psychotherapy, but rarely attends his sessions as he sees no value to them. He spends many hours sleeping during the day because terrifying nightmares keep him awake at night. All night he paces the floor smoking an endless number of cigarettes. His nighttime restlessness presents a hardship for his family. Sim Sok’s father, as the esteemed elder, occupies the apartment’s only bedroom. Sim Sok, his wife, and their five children, sleep in two double beds in the living room.
Sim Sok and his extended family live on welfare payments now that their refugee resettlement allowance has expired. He recently applied for Supplemental Social Security Insurance benefits on the basis of ‘stress, depression, a bad temper, headache, chest pain, leg pain, and poor vision’. His request was refused, and he is now consulting an attorney in preparation for an appeal. His anger toward the rejection was so intense that he threatened to kill his family, his neighbor and himself. The police were called to take this angry and belligerent ex-Cambodian soldier to Community Mental Health until a bed became available on the psychiatric unit of a local hospital. He remained hospitalized for three weeks and returned home calmer but still depressed and dysfunctional. DEVELOPING
A NEW SYNTHESIS IN EPIDEMIOLOGIC STUDIES OF ACCULTURATION
As originally defined, the concept of acculturation implies a process of interaction between two different cultural systems, such that either or both groups experience change in their original cultural patterns. The four case studies illustrate such a process in the juxtaposition and potential interaction between the acculturation as a process vs acculturation as structure perspectives. The first two case studies support the notion that comparisons of health status and health-related behavior between groups implicit in the acculturationas-structure perspective can tell us something about the acculturation-chronic disease relationship. In the first case, there is a clear difference with respect to food preference and consumption between the two generations. The mother represents the less acculturated older generation who adheres to traditional beliefs and practices, while her children represent the more acculturated younger generation who favor new beliefs and practices related to the consumption of food. With increasing acculturation, there is increasing consumption of a high-fat diet associated with cardiovascular and other chronic disease risk. The second case reveals a difference in smoking behavior with respect to gender among members of the same generation. Similar gender differences in cigarette smoking prevalence have been reported in other ethnic groups [52, 531. However, while less acculturated men are more likely to smoke than less acculturated women, the difference between men and women tend to diminish with increasing acculturation. Studies of smoking prevalence among Hispanics in the United States, for instance, have found a positive association between acculturation and smoking in Hispanic women but not in Hispanic men [54, 561. With the adoption of lifestyles and behaviors of the dominant, non-Hispanic white society, the rate of cigarette smoking among Hispanic women appears to be increasing [57]. The experience of Hispanic women in the United States, therefore, would lead us to predict
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that with increasing acculturation, the prevalence of smoking and smoking-related diseases among Cambodian women will also increase. All four case studies also illustrate many of the limitations inherent in the acculturation as structure perspective. Specifically, the focus on group comparisons ignores individual experience and the context in which that experience occurs. In the first case study, a change in behavior is observed in both mother and children. The mother’s belief system regarding traditional food preference and consumption has remained relatively intact. However, her behavior (i.e. the meals she prepares for the family) has now changed to accommodate the preferences of her children. Both generations experience acculturation, but in somewhat different forms with different consequences for their health status. Similarly, in the second case study, it is the husband who experiences the chronic emphysema resulting from several years of frequent cigarette smoking. However, the chronic disease is the result of a health-related behavior adopted prior to migration and the acculturation process rather than a consequence of that process. In this instance, the acculturation process has greater relevance for the consequences than for the risk of chronic disease. Moreover, it is the wife who must now change her behavior as a caregiver because of her unfamiliarity with the western technology needed to care for her husband and her husband’s placement in a nursing home. The third and fourth case studies illustrate both the causes and the consequences of chronic disease as it relates to acculturation. In the third case study, the stress associated with the migration experience may have precipitated the hypertension and diabetes that afflict these women. However, the diseases themselves also appear to have precipitated a process of acculturation that may lead to health promotion rather than increased stress. This case study illustrates the importance of conceptualizing acculturation as experience. This experience, in turn, illustrates a process of acculturation that extends from the experience in country of origin, to migration and refugee status, to the experience of chronic disease, to contact and interaction with the western health care system, and finally, to the efforts to initiate a health promotion program targeting individual needs. However, it remains unclear whether the experience of three elderly Cambodian women can be generalized to understand the experiences of other elderly Cambodian women, Cambodians in general, or members of other ethnic groups. The fourth case study also illustrates the importance of conceptualizing acculturation as experience. Like the three women in the third case study, Sim Sok is a first generation immigrant suffering from symptoms of post-traumatic stress disorder. However, unlike the women in the third case study, Sim Sok’s accident led to a negative encounter with the western health care
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system, contributing to his disability and chronic pain. While the experience of chronic disease in the three women led to their interest in ending their practice of chewing betel nut, the chronic pain in Sim Sok led to a delay in physical therapy for his injured hand and the use of medication from numerous physicians, leading to an increased risk for adverse effects of polypharmacy abuse. In other words, the experience of chronic disease led to behavior which might be perceived as health promotion in one instance and a health risk in the other. Williams and Berry [28] note that stress is linked to acculturation in a probablistic way and the level of stress experienced will depend on a number of factors, including mode of acculturation, phase of acculturation, nature of the larger society, characteristics of acculturating group and characteristics of acculturating individual. The acculturation as structure perspective assumes that Cambodian parents and their children can be placed on a continuum defined on the basis of these factors. However, these factors may be responsible for qualitative differences between groups defined on the basis of language, ethnicity or some other status, and not merely quantitative differences. Thus, it may be more appropriate to compare the experience of individuals within groups than to compare the experience of individuals in different groups when examining the relationship between acculturation and chronic disease. Although the sociocultural systems of the two generations overlap with one another, they are not identical. Consequently, the acculturation that occurs within Cambodian-speaking parents is not the same process that occurs among English-speaking Cambodian children. Despite these limitations, all four case studies suggest that the discrepancy between health-related beliefs and behavior is an important part of the acculturation process. In the first case study, the mother consents to cook American food for her children even though she herself believes it is preferable to eat Cambodian food. This discrepancy might be interpreted as symptomatic of the conflict associated with acculturation in particular and sociocultural change in general. Other investigators have described this conflict by means of models such as the status incongruity model [3, 581, the acculturative stress models [ 12, 131, or the internal colonialism model [59]. It would seem therefore, that the degree of discrepancy between health-related beliefs and behavior might serve as a more useful measure of level of acculturation than more static measures such as native language and place of birth. The second case study reveals an inconsistency in beliefs and behavior regarding the dangers of smoking, especially when one also has a chronic smoking-related disease. However, the inconsistency in health-related beliefs and behavior may not necessarily be indicative of conflict. It is conceivable that just as many native-born Euro-Americans maintain a certain level of inconsistency in their beliefs regarding the
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hazards of smoking, unprotected sex, excessive consumption of alcohol, or diet, and their behavior, many foreign-born acculturating individuals also develop a similar level of inconsistency in the health-related beliefs and behavior associated with the traditional culture on the one hand and the western culture on the other. In essence, a compromise of one form or another is achieved that enables an individual or group of individuals to maintain this inconsistency in the absence of conflict. This compromise is reflected in the first case study in which the mother consents to cook American food for her children while continuing to eat only traditional Cambodian food herself. The third case also reveals an attempt to resolve the inconsistency between beliefs and behavior by integrating traditional and modern health care practices on the one hand and changing traditional behavior based on beliefs of the modern health care system on the other. The case study also suggests that the process of acculturation involves the integration of the unfamiliar with the familiar in a synthesis that is designed to address individual needs. However, as the fourth case study demonstrates, this integration is not always successful. Sim Sok’s decision to seek out a traditional shaman and use folk healing to treat the chronic pain resulting from his injury led to a delay in physical therapy and skin grafting, a deep distrust for western medicine, and a frenetic search for effective treatment from numerous physicians that has increased the risk of polypharmacy abuse. The persistence of his chronic pain and inability to seek compensation in the form of disability payments also appear to have contributed to his subsequent psychiatric hospitalization. What perspective, then, should we assume when relating acculturation to chronic disease risk? Our analysis of the four case studies suggests that a comparison of changes within individuals over an extended period of time is to be preferred to the comparison of groups at a single point in time, because the former comparison provides a more accurate assessment of the process of acculturation, while the latter may provide an imperfect assessment of the product of acculturation. The acculturation as process perspective is also to be preferred from a clinical standpoint where the clinician is concerned with identifying relevant information from a patient’s personal and medical history that is of use in disease diagnosis as well as treatment, disease prevention, and health promotion strategies specific to individual needs. However, by adopting the acculturation as process perspective, we do not mean to imply that the acculturation as structure perspective is to be discarded entirely. In addition to generational differences, a number of studies suggest that both gender and socioeconomic status play important roles in the acculturation-disease relationship. For instance, less acculturated women have less chronic disease morbidity and are less likely to engage in risky
health-related behavior such as cigarette smoking, relative to their more acculturated counterparts, than less acculturated men [S, 541. These differences may either be attributed to gender differences in health status prior to migration or acculturation, differences in the pace of acculturation of health-related beliefs and behavior vs other forms of acculturation, and differences in the roles and resources assigned to and available to men and women during the acculturation process [8]. Also important to understanding the role of acculturation as a risk factor for chronic disease is the moderating influence of social class or socioeconomic status. Socioeconomic status influences the acculturationchronic disease relationship in a number of ways, including the expectations of the acculturating group [SS],the resources available to this group [59], and their access to the health care system [22]. The biphasic curve proposed by Stunkard [60], for instance, assumes that socioeconomic status is the single biggest predictor of behaviors associated with the development of chronic disease, with opposite effects in Latin America and the United States [21]. Given this commitment to retaining elements of both perspectives, what should we be measuring when we evaluate the level of acculturation of an individual patient? From an epidemiologic standpoint, one possibility would be to focus on the level of inconsistency between beliefs and behavior within individuals over an extended period of time. A similar approach was utilized by Reed and associates [20] in a longitudinal study of chronic disease among men of Japanese ancestry in Hawaii. Although it may be inappropriate to place individuals along an acculturation continuum based on their memberships in a particular group defined on the basis of status, a continuum based on the discrepancy between beliefs and behavior and the synthesis of unfamiliar and familiar health-related beliefs and behavior over time could serve as a useful tool in enabling the clinician to determine the extent to which a patient is both willing and able to engage in health promotion behavior, and comply with medication prescriptions and other treatment regimens. Thus, while a traditional epidemiologic approach to acculturation may have placed the individuals in the third and fourth case studies close to one another on a continuum based on generation or number of years in the United States, a continuum based on the discrepancy or synthesis between Cambodian and western systems of health-related beliefs and behavior would have placed the three women and Sim Sok further apart from one another. While acculturation may be conceptualized as a process of conflict and negotiation between two systems of beliefs and behavior, it should also be conceptualized as an experience that extends from the shared experiences of groups to the unique experiences of individuals. As evidenced by the earlier case studies, the experience of individuals illustrate the complexity of the acculturation process, even among individuals who share a common language and cultural tradition.
Acculturation and chronic disease
The interest within medical anthropology in the experience of normal and abnormal body processes [61-63] might conceivably serve as a model for the study of the experience of acculturation. In both instances, experience provides a window, usually in the form of a narrative, on broader social and cultural processes. Although this approach is perceived by some as limiting the ability to compare the acculturation experiences of different groups, as the case studies demonstrate, ultimately each group’s experience may initially dictate that it be evaluated in its own terms. As patterns begin to emerge from the results of studies of several different groups, generalizations can develop and advances in theory can be made. However, emphasis on context must be a major priority in acculturation research, and measurements sensitive to that context must be used. Equally important to what we should be measuring is the question of how we should measure acculturation. The Tokelau Island Migrant Study [64] serves as a useful model in this regard, highlighting the importance of a longitudinal perspective, one that is preferably prospective in design. Such a perspective is particularly important from a clinical standpoint where the patient’s social and medical history is viewed as critical to the diagnosis and treatment of chronic disease. For instance, a longitudinal perspective would enable a clinician to understand why the three women in the third case study exhibited behavior that could be perceived as promoting health while the man in the fourth case study exhibited behavior that could be perceived as creating a health risk, even though all the individuals concerned were first generation immigrants fleeing hardship and political persecution. Just as a prospective design is essential to the quantitative assessment of the acculturation-chronic disease relationship, a qualitative analysis of the experience of acculturation requires the examination of that experience as a narrative which gives meaning to both the structure and process of that experience. Stories by immigrants both represent past experiences and provide a frame for organizing experience as lived [63]. As with the prospective epidemiologic design, the narrative analysis of acculturation as experience organizes a series of events in a temporal sequence, giving it a longitudinal dimension. Such a narrative analysis can help to explain why the association between acculturation and chronic disease can differ among members of the same generation or cultural group, as in the instance of the third and fourth case studies. For instance, the narratives of Sim Sok and the three women in the third case study are both organized by a common migration experience but two very different experiences with the western health care system with two very different outcomes. Without the benefit of this narrative, the differences between Sim Sok and the three women become obscured. Finally, we need to understand that the causal relationship between acculturation and chronic SSM 40,1*--E
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disease is not fixed and immutable. As our case studies suggest, rather than acculturation inevitably preceding the occurrence of a chronic disease, the disease itself may precipitate the process of acculturation. Moreover, acculturation is not inherently a risk to health but may actually promote health by creating access to certain forms of health care unavailable in the country of origin and by contributing to the abandonment of risky health-related behaviors and the adoption of behaviors that promote good health. The extent to which this occurs, however, is again dictated by individual experience and the extent to which this experience promotes or inhibits a synthesis of traditional and western health-related beliefs and behavior. Acknowledgements-This work was supported in part by a grant from the Alliance Health Foundation. An earlier
version of this article was presented at the annual meetings of the American Anthropological Association, San Francisco, CA, 2 December, 1992.
REFERENCES 1. Redfield R., Linton R. and Herskovits M. Memorandum on the study of acculturation. Am. Anthrop. 38, 149, 1936.
2. Murphy R. Social change and acculturation. Trans. New York Acad. Sci. 26, 845, 1964.
3. Henry J. P. and Cassel J. C. Psychosocial factors in essential hypertension: recent epidemiologic and animal experimental evidence. Am. J. Epidemiol. 90, 171, 1969. 4. Marmot M. G. and Syme S. L. Acculturation and coronary heart disease in Japanese-Americans. Am. J. Epidemiol. 104,225, 1916. 5. Polednak A. P. Cancer incidence in the Puerto Rican-born population of Connecticut. Cancer 70,1172, 1992. 6. Hazuda H., Haffner S., Stern M. and Eifler C. W. Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans: the San Antonio Heart Study. Am. J. Epidemiol. 128, 1289, 1988. 7. Reed D., McGee D., Cohen J., Yano K., Syme S. L. and Feinleib M. Acculturation and coronary heart disease among Japanese men in Hawaii. Am. J. Epidemiol. 115, 894, 1982. 8. Salmond C. E., Joseph J. G., Prior I. A. M., Stanley D. G. and Wessen A. F. Longitudinal analysis of the relationship between blood pressure and migration: the Tokelau Island Migrant Study. Am. J. Epidemiol. 122, 291, 1985.
9. McGarvey S. and Baker P. The effect of modernization and migration on Samoan blood pressure. Hum. Biol. 51, 461, 1979.
10. Westermeyer J., Neider J. and Calhes A. Psychosocial adjustment of Hmong refugees during their first decade inthe United States. j. Ne&. Meat. dis. 177, 132, 1989. 11. Roaler L. H.. Cortes D. E. and Maleadv R. G. A<uration and mental health status am;& Hispanics: convergence and new directions for research. Am. Psychologist 46, 585, 1991.
12. Berry J. W. and Kim U. Acculturation and mental health. In Health and Cross-Cultural Psychology: Towards Application (Edited by Dasen P., Berry J. W. and Sartorius N.), p. 207. Sage, Beverly Hills, CA, 1988. 13. Janes C. R. Migration, changing gender roles and stress: the Samoan case. Med. Anthropol. 12, 217, 1990. 14. Hazuda H., Mitchell B., Haffner S. and Stern M. Obesity
1652
Lawrence A. Palinkas and Sheila M. Pickwell
in Mexican American subgroups: findings from the San AntonioHeart Study. Am. J. clin. Nutrit. 53,15298,1991. 15. McGarvey S. Obesity in Samoans and a perspective on its etiology in Polynesians. Am. J. clin. Nutrit. 53,1586S, 1991. 16. Graves T. D. Acculturation, access and alcohol in a triethnic community. Am. Anthropol. 69, 306, 1967. 17. Caetano R. Acculturation and drinking patterns among U.S. Hispanics. Br. J. Addict. 82, 789, 1987. 18. Wenkam N. S. and Wolff R. J. A halfcentury ofchanging food habits among Japanese in Hawaii. J. Am. Diet. Assoc. 57, 29, 1970. 19. Stavig G. R., Igra A. and Leonard A. R. Hypertension among Asians and Pacific Islanders in California. Am. J. Epidemiol. 119, 677, 1984. 20. Reed D., McGee D. and Yano K. Psychosocial processes and general susceptibility to chronic disease. Am. J. Epidemiol. 119, 356, 1984. 21. Elder J. P., Castro F. G., deMoor C., Mayer J., Candelaria J. I., Campbell N., Talavera G. and Ware L. M. Differences in cancer-risk-related behaviors in Latin0 and Anglo adults. Prevent. Med. 20, 751, 1991. 22. Wells K. B., Golding J. M., Hough R. L., Bumam A. and Kamo M. Factors affecting the probability of use of general and mental health and social/community services for Mexican Americans and non-Hispanic whites. Med. Care 26, 441, 1988. 23. Roberts R. and Lee E. S. Medical care use by Mexican Americans: evidence from the Human Population Laboratory studies. Med. Cure 18, 267, 1980. 24. Solis J. M., Marks G., Garcia M. and Shelton D. Acculturation, access to care, and use of preventive services by Hispanics: findings from HHANES 19821984. Am. J. oubl. Hlth 80 (SUDD~). 11. 1990. 25. Janes C. R. and Pawson I. G. Migration and biocultural adaptation: Samoans in California. Sot. Sci. Med. 22, 821, 1986. 26. Pickwell S. The incorporation of family primary care for southeast Asian refugees in a community-based mental health facility. Archs. psychiut. Nurs. 3, 173, 1989. 27. Perez-Stable E. J., Sabogal F., Marin G., Marin B. V. and Otero-Sabogal R. Evaluation of “Guia Para Dejar de Fumar”, a self-help guide in Spanish to quit smoking. Publ. Hlth Rep. 106, 564, 1991. 28. Williams C. L. and Berry J. W. Primary prevention of acculturative stress among refugees: application of psychological theory and practice. Am. Psychol. 46,632, 1991. 29. Mena F. J., Padilla A. M. and Maldonado M. Acculturative stress and specific coping strategies among immigrant and later generation college students. Hispanic J. behav. Sci. 9, 207, 1987. 30. Warner W. L. and Srole L. The Social Systems of American Ethnic Groups. Yale University Press, New Haven, CT, 1945. 31. Gordon M. Assimilation in American Life: The Role of Race, Religion, and National Origins. Oxford University Press, New York, 1964. 32. Greeley A. Why Can’t They be Like Us? America’s White Ethnic-Groups: Dutton, New York, 1971. 33. Bonacich E. and Model1 J. The Economic Basis of Ethnic Solidarity, Small Business in the Japanese-kmerican Community. University of California Press, Berkeley, 1980. 34. Portes A. The rise of ethnicity: determinants of ethnic perceptions among Cuban exiles in Miami. Am. Social. Rev. 49, 383, 1984. 35. Singer M. The limits of medical ecology: the concept of adaptation in the context of social stratification and social transformation. Med. Anthropol. 10, 218, 1989. 36. Kagan A., Harris B. R., Winkelstein W., Johnson K. G., Kano H., Syme S. L., Rhoads G. G., Gay M. L., Nichaman M. Z., Hamilton H. B. and Tillotson J.
37.
38.
39. 40. 41.
42.
43.
44.
45.
46. 47. 48. 49. 50.
51.
52. 53.
54.
55.
Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California: demographic, physical, dietary, and biochemical characteristics. J. Chron. Dis. 27, 345, 1974. Tsunoda T., Parrish K. M., Higuchi S., Stinson F. S., Kono H.. Okata M. and Hartford T. C. The effect of acculturation on drinking attitudes among Japanese in Japan and Japanese Americans in Hawaii and California. J. Stud. Alcohol 53, 369, 1992. Marin G., Sabogal F., Marin B. V., Otero-Sabogal R. and Perez-Stable E. J. Development of a short acculturation scale for Hispanics. Hispanic J. behao. Sci. 9, 183, 1987. Cuellar I., Harris L. and Jasso R. An acculturation scale for Mexican American normal and clinical populations. Hispanic J. behau. Sci. 2, 199, 1980. Caetano R. Acculturation and attitudes toward appropriate drinking among U.S. Hispanics. Alcohol Alcoholism 22, 427, 1987. Rumbaut, R. Mental health and the refugee experience: a comparative study of southeast Asian Refugees. In Southeast Asian Mental Health: Treatment, Services, Prevention, and Research (Edited by Owan T. and Nguyen T. D.), p. 433. U.S. Government Printing Office, Washington, DC, 1985. Gong-Guy E. The California Southeast Asian Mental Health Needs Assessment. Asian Community Mental Health Services, Oakland. CA. 1986. Kinzie J. D., Fredericksoh R. H., Ben R., Fleck J. and Karls W. Posttraumatic stress disorder among survivors of Cambodian concentration camps. Am. J. Psychiut. 141, 645, 1984. Kinzie J. D., Sack W., Angel1 R., Manson S. and Rath B. The psychiatric effects of massive trauma on Cambodian children, I: the children. J. Am. Acad. child Psychiat. 25, 370, 1986. Kinzie J. D., Boehnlein J. K., Leung P. K., Moore L. J., Riley C. and Smith D. The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asianrefugees. Am. J. Psychiot. 147,913,199< Mollica R. F.. Wvshak G. and Lavelle J. Psvchosocial impact of war trauma and torture on Southeast Asian refugees. Am. J. Psychiat. 144, 1567, 1987. Baughan D. M., White-Bat&an J., Pickwell S., Bartlome J. and Wong S. Primary care needs of Cambodian refugees. J. Pam. Pratt. 30, 565, 1990. Morbidity and Mortality Weekly Review. Cigarette smoking among Southeast Asian immigrants-washington State, 1989. MMWR 41, 854, 1992. Thomas S. J. and Maclennan R. Slaked lime and betel nut cancer in Papua New Guinea. The Lancer 340, 577, 1992. Dave B. J., Trivedi A. H. and Adhvaryu S. G. Role of areca nut consumption in the cause of oral cancers. Cancer 70, 1017, 1992. Holmstedt B. and Lindgren G. Arecoline, nicotine and related compounds: tremorgenic activity and effect upon brain catecholamines. Ann. New York Acad. Sci. 142, 146, 1967. Marcus A. C. and Crane L. A. Smoking behavior among US Latinos: an emerging challenge for public health. Am. J. publ. Hlth 75, 169, 1985. Remington P. L., Forman M. R., Gentry E. M., Marks J. S., Hogelin G. C. and Trowbridge F. L. Current smoking trends in the United States: The 1981-1983 behavioral risk factors surveys. JAMA 253, 2975, 1985. Haynes S. G., Harvey C., Montes H., Nickens H. and Cohen B. H. Patterns of cigarette smokina among Hispanics in the United States: results from HHANES 1982-84. Am. J. publ. Hlth 80 (Suppl), 47, 1990. Marin G., Perez-Stable E. J. and Marin B. V. Cigarette smoking among San Francisco Hispanics: the role of acculturationandgender. Am. J.publ. Hlth79,196,1989.
Acculturation and chronic disease 56. Coreil J., Ray L. A. and Markides K. S. Predictors findings of smoking _ among Mexican-Americans: from the Hisuanic HANES. Prevent. Med. 20., 508. 1991. * 57. Escobedo L. G. and Remington P. L. Birth cohort analysis of prevalence of cigarette smoking among Hispanics in the United States. JAMA 261,66, 1989. 58. Dressier W. W. Psychosomatic symptoms, stress and modernization: a model. Cult. Med. Psychiut. 9, 257, 1985. 59. O’Neil J. D. Colonial stress in the Canadian arctic: an ethnography of young adults changing. In Anthropology und Epidemiology (Edited by Janes C. R., Stall R. and
Gifford S.), p. 249. D. Reidel, Boston, 1986. 60. Stunkard A. J. From explanation to action
in
1653
psychosomatic medicine: the case of obesity. Psychosom. Med. 37, 195, 1975. 61. Csordas
T. J. Embodiment as a paradigm for anthropology. Ethos 18, 5, 1990. 62. Kleinman A. Social Origins of Distress and Disease: Depression,
Neurasthenia,
and Pain in Modern
China.
Yale University Press, New Haven, CT, 1986. 63. Good M. D., Good B. J., Kleinman A. and Brodwin P. E. Epilogue. In Pain as Human Experience (Edited by Good M. D., Brodwin P. E., Good B. J. and Kleinman A.), p. 198. University of California Press, Berkeley, CA, 1992. 64. Prior I. A. M., Stanhope J. M., Evans J. G. and Salmond, C. E. The Tokelau Island Migrant Study. Inr. J. Epidemiol. 3, 225, 1974.