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Acculturative stress in Korean Americans
Applied Nursing Research 38 (2017) 70–75
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Original article
Acculturative stress in Korean Americans
MARK
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Cha-Nam Shin, PhD, RN , Shannon Ruff Dirksen, PhD, RN, FAAN, Bin Suh, BSN College of Nursing and Health Innovation, Arizona State University, United States
A R T I C L E I N F O
A B S T R A C T
Keywords: Acculturative stress Immigrants Korean Americans Body mass index Blood pressure
Background: Acculturative stress is known to contribute to chronic diseases among many immigrants and yet this association in Korean Americans remains unclear. Aim: The study purpose was to examine the level of acculturative stress in Korean Americans and to determine if correlations existed with personal and physiological factors. Methods: An exploratory, cross-sectional, descriptive study was conducted in a sample of 107 Korean American adults. Data on acculturative stress and personal factors were collected using a survey questionnaire in addition to a direct measure of physiological factors (i.e., body mass index and blood pressure). Results: All 107 participants were first-generation Koreans. Most participants were women (66.4%), with a mean age of 53.9 ± 10.7, married (88.8%), and with a college education (84.2%). Acculturative stress was associated with a number of personal factors (i.e., arrival age, years of U.S education, years of U.S. residency, English proficiency), and the personal factors of gender, age, employment status, and years of U.S. residency were associated with the physiological factors. No statistically significant associations were found between acculturative stress and physiological factors. Conclusions: The mean acculturative stress score in this study was higher than findings from prior studies of Korean immigrants in the United States or Canada, with the rates of obesity and hypertension higher than prior reports of Korean Americans or Koreans residing in Korea. Future study is necessary with a larger sample from a variety of different geographic areas of the United States to examine further the impact of acculturative stress on physiological factors during the process of acculturation.
1. Introduction Acculturation is a process of cultural change and adaptation that occurs when foreign-born individuals interact with people from a new country (Lopez-Class, Castro, & Ramirez, 2011; Schwartz, Unger, Zamboanga, & Szapocznik, 2010). During the process of acculturation to a new environment, some immigrants may have a successful experience through which they modify their life to adjust to the host culture, while others may face ongoing challenges and difficulties that can result in continued stress (Al-Omari & Pallikkathayil, 2008; Berry, 2008; D'Alonzo, Johnson, & Fanfan, 2012). The stress associated with acculturation is referred as acculturative stress which can adversely affect an individuals' health, including the development of cardiovascular disease (D'Alonzo et al., 2012; DeVylder et al., 2013; Lee, Suchday, & Wylie-Rosett, 2015). An understanding of the factors that contribute to acculturative stress is crucial in helping to mitigate and lessen health problems that may be associated with this type of stress. As of 2014, more than 42.4 million foreign-born individuals (13.3% of U.S. population) reside in the United States (U.S. Census Bureau,
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2016). Immigrants are the fastest growing segment of the U.S. population with a 350% increase in number from a total of 9.6 million in 1970 to 42.4 million in 2014 (Camarota & Zeigler, 2015). Despite a relatively short history of immigration to the United States by Koreans, their numbers have rapidly grown by 39% from 1.2 million in 2000 to 1.7 million in 2010 (Pew Research Center, 2013; U.S. Census Bureau, 2014). In 2013, it was found that 1.8 million Koreans (U.S. born and foreign born) resided in the United States (U.S. Census Bureau, 2016). Among them, foreign-born (first generation) Koreans accounted for nearly four out of five Korean Americans (Pew Research Center, 2013). This first generation Korean residing in the United States is predominantly a monolingual speaker in Korean with limited English proficiency. The degree of acculturative stress that is experienced by an immigrant would seem to vary depending on the degree of similarity or dissimilarity between the heritage culture and new culture (Rudmin, 2003; Schwartz et al., 2010). For example, White, English-speaking individuals (e.g., Canadian or Australian) may experience less stress immigrating to the United States due to similarities in language spoken
Corresponding author at: 500 N. 3rd Street, College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ 85004, United States. E-mail addresses: [email protected] (C.-N. Shin), [email protected] (S.R. Dirksen).
http://dx.doi.org/10.1016/j.apnr.2017.09.010 Received 26 January 2017; Received in revised form 12 July 2017; Accepted 23 September 2017 0897-1897/ © 2017 Elsevier Inc. All rights reserved.
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2. Methods
than Asian immigrants who are not proficient in English. White, English-speaking immigrants may also adapt somewhat easier to American mainstream with less racial discrimination if the culture is closer to their own heritage culture. In contrast, Asian immigrants to the United States may experience a higher level of acculturative stress because they may have to learn a new language (i.e., English), live in a society with different cultural values and social norms (e.g., collectivism over individualism), and sometimes deal with racial discrimination (Schwartz et al., 2010). A variety of personal factors have been found to impact the degree of acculturative stress that is experienced by immigrants. For example, Korean Americans who were men, younger, had high levels of English proficiency, who arrived to the United States at a younger age, or stayed more years in the United States experienced lower levels of acculturative stress than did their counterparts who were women, older, had low levels of English proficiency, who arrived to the United States at an older age, or stayed less years in the United States (Ji & Duan, 2006; Logan, Barksdale, Carlson, Carlson, & Rowsey, 2012; Moon, 2011). In a study of immigrants from the former Soviet Union, women and older immigrants to the United States experienced higher levels of acculturative stress than did men and younger immigrants (Miller et al., 2006). In contrast, Asian Indian immigrant men in the United States experienced higher levels of acculturative stress than did women (Conrad & Pacquiao, 2005), while older Latinos residing in the United States experienced lower levels of acculturative stress than did younger Latinos (Bekteshi & van Hook, 2015). Length of residency was not associated with acculturative stress in studies of Latinos and Nigerian immigrants to the United States (Caplan, 2007; Daramola & ScisneyMatlock, 2014). Asian Americans and Latinos with low levels of English proficiency and who stayed less years in the United States experienced high levels of acculturative stress (Bekteshi & van Hook, 2015; Lueck & Wilson, 2010, 2011). First-generation Latinos with limited English proficiency were found to experience 13% more acculturative stress than second generation Latinos (Lueck & Wilson, 2011). This is because linguistic integration for immigrants in the United States is a social requirement that enforces the acquisition of English proficiency (Lueck & Wilson, 2011). Acculturative stress has been associated with physiological changes occurring within the individual, including hypertension and diabetes in Latinos and Chinese immigrants to the United States (D'Alonzo et al., 2012; Lee et al., 2015). In contrast, acculturative stress was not associated with blood pressure (BP) levels in Korean and Nigerian immigrants to the United States (Daramola & Scisney-Matlock, 2014; Logan et al., 2012). Acculturative stress has also been linked to elevated systolic BP among Latino immigrant men, but not among Latino immigrant women in the United States (McClure et al., 2010). Due to the increased numbers of individuals who are immigrating to a new culture and the observed disparities in health reported outcomes, researchers are focusing to a greater degree on acculturation, acculturative stress, and factor which may impact this process and the ensuing stress that may result. Contributing factors to acculturative stress have been explored; however, the associations between those factors and acculturative stress are inconsistent across a limited number of studies. In particular, little information is available as to whether acculturative stress is associated with physiological factors in Korean Americans. Given that the fast growing numbers of Korean Americans, it is important to understand what factors contribute to acculturative stress and if acculturative stress is associated with physiological factors for this ethnic group. Therefore, we conducted an exploratory study to describe the level of acculturative stress in Korean Americans and to examine if correlations existed with level of acculturative stress and personal (e.g., age, gender) and physiological factors (e.g., BP).
2.1. Study design and sample This study was a secondary analysis of data that were collected for an exploratory, cross-sectional, descriptive study in a large Southwestern city in the United States which examined cardiometabolic risk factors in Korean Americans. We recruited a convenience sample of Korean American adults who self-identified as Korean, aged 18 and above, and able to read, write, and speak either in Korean or the English language from a locally identified Korean community (e.g., restaurants, groceries, Korean ethnic churches). We had a total of 107 participants who had completed data on acculturative stress and the personal and physiological factors. For the correlation analyses conducted in our study, we had enough power (β = 0.85) to detect correlations of 0.30 with a sample size of 96 according to G*Power 3.1.7 (Faul, Erdfelder, Buchner, & Lang, 2009). 2.2. Measures Information about acculturative stress, and the personal and physiological factors were obtained from each participant. 2.2.1. Personal factors Personal factors included the individual's age, gender, marital status, education level, annual family income level, employment status, years of U.S. education, arrival age, and years of residency in the United States. In addition, English proficiency was determined by asking the question, “In your opinion, how well do you speak English compared with most English native speakers?” Responses were rated on a scale from 1 (very much worse) to 4 (as well as most English native speakers). For the purpose of data analysis, we recoded this as a dichotomous variable (0 = very much worse–somewhat worse, 1 = only little worse–as well as most English native speakers). 2.2.2. Acculturative stress The Acculturative Stress Index (ASI) was used to measure the stress associated with adaptation to a new culture (Noh, Wu, & Avison, 1994). The ASI is available in both English and Korean languages. The scale consists of 31 items which assess acculturative stress from experiences such as homesickness, social isolation, social discrimination, sense of marginality, family problems, socioeconomic adjustment, and language difficulties. In the ASI, homesickness for example, is measured by an item that states: “I am living away from my family, relatives, and friends.” Language difficulties are examined by a question such as “I experience difficulties because of my ability to speak and understand English when I try to understand the TV/radio.” Participants rate the degree of difficulty in adapting to life in the United States on a 4-point Likert scale (from 1 = never to 4 = very often). A total ASI score was derived from the sum of the item scores with higher scores indicating greater acculturative stress. Because our focus was to measure acculturative stress in general, we used the total ASI score in this study. Reliability for the ASI was supported by Cronbach's alphas of 0.75–0.95 in research studies of Korean immigrants in Canada and United States (Ji & Duan, 2006; Moon, 2011; Noh & Avison, 1996; Rhee, 2013). Studies have demonstrated validity for the ASI: appropriate factor loadings occurring with factor scores 0.40 or above for each item; and acculturative stress scores predicting depressive symptoms (Moon, 2011; Noh & Avison, 1996). Cronbach's alpha for the ASI was 0.93 in this study. 2.2.3. Physiological measures We measured body mass index (BMI) and BP as physiological factors in this study. To assess BMI, we measured the height and weight of each participant who wore light clothing and no shoes using a portable stadiometer (Seca 217, USA) and an electronic scale (Health O meter, 71
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USA). We used the standard formula for the BMI calculation: weight (kg) / [height (m)]2 (Centers for Disease Control and Prevention, 2015). Obesity was determined by the American Heart Association (AHA) criteria related to individual BMI values: the ideal weight value is a BMI < 25 kg/m2, a person is considered overweight if BMI value is 25–29.9 kg/m2, and obese if BMI value is ≥ 30 kg/m2 (Mozaffarian et al., 2016). In addition, we determined obesity using criteria that has been specified for Asian populations including: ideal weight value is a BMI < 23 kg/m2, overweight if BMI value is 23–24.9 kg/m2, and obese if BMI value is ≥ 25 kg/m2 (Obesity in Asia Collaboration et al., 2007). For the BP measure, we used a standard procedure: having the participant rest for a minimum of 5-min in the sitting position before the BP was checked, and two readings were taken and averaged. The AHA definition of hypertension was used: a SBP of < 120 mm Hg and a diastolic blood pressure (DBP) of < 80 mm Hg were considered as ideal, and a SBP of ≥ 120 mm Hg and a DBP of ≥ 80 mm Hg were considered high (Mozaffarian et al., 2016). Equipment for each assessment was calibrated during the study at frequent intervals to maintain accuracy.
Table 1 Sample characteristics. Variable
Category
n (%)
Gender
Male Female
36 (33.6) 71 (66.4)
Agea
53.9 (10.7)
Marital status
Married Separated/divorced/widowed Education level ≤ High school (n = 106) ≥ College Income levelb ≤$49,999 (n = 104) > $50,000 Employment status Employed Unemployed Arrival age in U.S.a (n = 106)
95 12 16 90 38 66 68 39
(88.8) (10.2) (15) (84.2) (35.5) (61.7) (63.6) (36.4) 31.9 (11.1) 21.6 (12.2)
Length of residency in U.S.a (n = 104) English proficiency
2.3. Procedures After obtaining institutional review board approval from the university where the study was housed, we screened individuals for eligibility and then obtained informed consent from each participant prior to beginning the study. The data were collected at a convenient place chosen by the participant, including the university research office, participant's home, and Korean ethnic churches. All study documents (e.g., informed consent, survey questionnaires) were available in both English and Korean, and participants were given a choice to complete them in either language version. Following the BP and BMI assessments, participants received information about their BMI and BP so that they could share this information with their primary healthcare provider.
M (SD)
Very much worse–somewhat worse Only little worse–as well as most English speakers Acculturative stress (Acculturative Stress Index)
67 (62.6)
Body mass index (kg/ m2) Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg)
77 30 38 69 25 82
Ideal (< 25) Overweight/obese (≥25) Ideal (< 120) High SBP (≥ 120) Ideal (< 80) High DBP (≥ 80)
40 (37.4)
(72.0) (28.0) (35.5) (64.5) (23.4) (76.6)
50.4 (13.2) 23.6 (3.0) 121.1 (15.1) 81.3 (10.56)
Note. Sample size of subgroups is 107 except variables indicated. a Measured in years. b Family annual income.
participants were found to have arrived in the United States at age of 30 or older, 83% had been in the United States for a minimum of 10 years, 51.4% had received formal education of at least one year in the United States, and 62.6% reported they spoke English “very much worse–somewhat worse” when they compared themselves to most native speakers. The mean score for the ASI was 50.4 (range 31–124), which falls below the midpoint of the scale. More than one quarter of the participants (28%) were overweight or obese (≥25 kg/m2) based on the criteria by the AHA. When we examined BMI criteria specific for Asians (≥23 kg/m2), 45.9% of the study sample was identified as being overweight or obese. More than half of the participants had a higher than ideal value for SBP (64.5%) and DBP (76.7%).
2.4. Data analysis Prior to analysis, data were screened for entry errors, outliers, and missing values. Data were normally distributed without outliers for the variables entered into the data analysis. Due to a small number of cases of missing values (< 3% of the sample) and missing data are randomly distributed across the data set (Hair, Black, Babin, Anderson, & Tatham, 2006; Howell, 2008), we drop those values from the analyses. Descriptive statistics were used to summarize the data on acculturative stress, and personal and physiological factors. To examine correlations between level of acculturative stress and personal and physiological factors, we calculated Pearson correlation coefficients for the continuous variables of age, arrival age, U.S. education, length of residency, BMI, SBP, and DBP. Point-biserial correlations were used for the dichotomous variables of sex, marital status, education level, income, employment status, and English proficiency. Variables that were entered into the data analysis met the assumptions for the statistical analyses that were used (e.g., normal distribution, no outliers, equal variance). IBM SPSS statistics version 22.0 was used to analyze the data. An alpha level of 0.05 was used to determine significance for all statistical tests.
3.2. Variable associations The Pearson and point-biserial correlation coefficients demonstrated that many associations existed among the variables (Table 2). A positive association was found between acculturative stress and arrival age (r = 0.33), while a negative association revealed between acculturative stress and years of U.S. education (r = − 0.34), years of U.S. residency (r = − 0.43), and English proficiency (r = − 0.21). Gender was negatively associated with BMI (r = − 0.49), SBP (r = −0.34), and DBP (r = −0.37), whereas age was positively associated with SBP (r = 0.45) and DBP (r = 0.22). Employment was negatively associated with SBP (r = −0.22), while years of U.S. residency was positively correlated with SBP (r = 0.27). Acculturative stress was not correlated with BMI, SBP, and DBP.
3. Results 3.1. Sample characteristics
4. Discussion All 107 participants were first-generation Koreans, and they all chose to read and sign the consent form in Korean and complete all the study measures in Korean. Participants had a mean age of 53.9 ± 10.7 (range 30–79), a majority were women, married, and educated at a college level or above (Table 1). Slightly more than half (51.9%) of the
The level of acculturative stress in this sample (the mean ASI score = 50.4) was higher than the levels (the mean ASI score = 34–40) found in Korean Americans living in cities of Ohio, Kentucky, and Indiana (Ji & Duan, 2006; Rhee, 2013), but lower than the levels (the 72
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the less they are acculturated to the new society and also the more they experience acculturative stress (Bleakley & Chin, 2010; Ji & Duan, 2006). In another Korean American study, 14% of the participants were U.S. born, while 46.3% of the participants completed the English version of the survey (Ji & Duan, 2006). The participants who completed the English version of the survey showed a lower acculturative stress compared to participants who completed the Korean version of the survey (Ji & Duan, 2006). These findings may indicate that greater length of residency does not guarantee more acculturation to the dominant society and less acculturative stress for individuals who arrived to the United States at their older age (i.e., after puberty). The role of arrival age as a factor that may influence acculturation and acculturative stress needs further investigation. Future research exploring additional factors (e.g., ethnic identity, native language proficiency, coping strategies, support and resources in new community) that may influence acculturative stress will provide a better understanding of Korean Americans' experiences with acculturative stress, and how nursing may positively impact these factors; thereby reducing the level of stress associated with acculturation. The study findings revealed that a majority of participants had higher values of SBP and DBP than the values that had been obtained in prior results of Korean immigrants and Koreans living in their native country. The rate of obesity in our study (28% with BMI > 25 kg/m2 criteria) was higher than the rate (22.2%) reported in a study of Koreans residing in Korea (Noh, Jo, Huh, Cheon, & Kwon, 2014) although it was lower than the rates (45%–53%) reported prior in other studies of Korean Americans (Kim et al., 2015; Palaniappan, Wong, Shin, Fortmann, & Lauderdale, 2011). The rate of obesity (49.5%) with a BMI > 23 kg/m2 was higher than the rate (46%) reported in another study of Korean immigrants in California (Cho & Juon, 2006). The rates of hypertension in this sample were (64.5% in SBP; 76.7% in DBP) also greater than the rates (46%–60%) reported in Korean Americans or Koreans residing in Korea (Kim, Lee, Ahn, Bowen, & Lee, 2007; Logan et al., 2012). Our findings regarding the association of physiological factors and some of the personal factors were consistent with previous findings. A number of studies across ethnic groups (i.e., Koreans, Filipinos, and African immigrants) have reported that individuals who were older, men, employed, and stayed longer years in the Unites States showed higher values of BMI, SBP, and DBP (Afable et al., 2016; Cho & Juon, 2006; Daramola & Scisney-Matlock, 2014; Mozaffarian et al., 2016). This study also lent credence to the results of a previous study with a larger Korean population (N = 407,858) in South Korea that showed higher BMI, SBP, DBP values occurred more often in men than in women (Kim, Jee, Yun, Baek, & Lee, 2013). Consistent with prior research of African immigrants in the United States, we did not find significant associations between acculturative stress and physiological factors (Daramola & Scisney-Matlock, 2014). Researchers have suggested that the body's stress response to the longterm effect of acculturative stress can lead to cardiovascular disease risks (Lee et al., 2015; Logan et al., 2012). A meta-analysis of 125 studies (N = 223,355) reported that BP levels were related to acculturation level (SBP, d = 0.40; DBP, d = 0.43), whereas acculturation was not associated with BMI in Latinos in the United States, Turkish immigrants in Germany, and Ethiopian immigrants in Israel (Steffen, Smith, Larson, & Butler, 2006). The largest effect sizes reported of acculturation on BP occurred in immigrants at the time of initial contact with the new culture with the effect then dropping rapidly within the first 3 years of acculturation: (SBP, d = 0.66 during 0 to 3 months, d = 0.52 during 3 months to 3 years, d = 0.38 during 3 to 15 years; DBP, d = 0.65 during 0 to 3 months, d = 0.57 during 3 months to 3 years, d = 0.33 during 3 to 15 years). Given the average of > 20 years of U.S. residency in this study, the sample might have learned coping skills or utilized other resources that buffered the negative effect of acculturative stress on BMI and BP. Additional measures
Table 2 Correlations between personal and physiological factors and acculturative stress. Personal factors
Acculturative stress
BMIb
SBPc
DBPd
Gender (1 = female) Agea Marital status Education level Income Employment Arrival agea U.S. educationa Length of residencya English proficiency Acculturative stress
0.15 − 0.15 0.05 0.07 − 0.16 0.07 0.33⁎⁎ − 0.34⁎⁎ − 0.43⁎⁎ − 0.21⁎ 1
− 0.49⁎⁎ 0.08 0.14 0.06 − 0.01 − 0.04 0.04 0.08 0.03 − 0.02 − 0.11
− 0.34⁎⁎ 0.45⁎⁎ − 0.05 − 0.15 − 0.10 − 0.22⁎ 0.14 − 0.11 0.27⁎⁎ 0.04 − 0.10
− 0.37⁎⁎ 0.22⁎ 0.00 − 0.03 − 0.10 − 0.11 0.17 − 0.09 0.04 0.05 0.05
a
Measured in years. BMI = Body mass index. c SBP = Systolic blood pressure. d DBP = Diastolic blood pressure. ⁎ p < 0.05. ⁎⁎ p < 0.01. b
mean ASI score = 55–66) found in Korean immigrants residing in Canada and Korean Americans in Chicago (Lee & Holm, 2012; Noh & Avison, 1996). This variation in acculturative stress might be related to differences in the personal factors of the participants in the studies and the varying environments where acculturation was taking place. Support for these ideas comes from two older studies (Lee & Holm, 2012 [data collection in 2002]; Noh & Avison, 1996) that were conducted when fewer Koreans immigrated to Western countries. These studies indicate that Korean immigrants 10 to 20 years ago were more likely to have fewer resources for living in a new environment than they have in the present time, which could have resulted in these immigrants experiencing more stress during the process of adjusting to a new country than more recent immigrants. Future research is vitally needed to more fully examine how resources available to a Korean immigrant may impact acculturative stress, including cultural specific strategies to access resources that are congruent with the individual's values, beliefs, and traditions. Of particular interest to future research is the potential role of social support in buffering the stress of acculturation among Korean American immigrants. Our findings confirmed that a significant association existed between acculturative stress and personal factors of the immigrant. Support for these findings comes from research of Koreans, Asians, and Latinos or Latinas who had immigrated to the United States, which indicated that individuals at an older age, who had lower levels of English proficiency, none or less years of U.S. education, or less years of U.S. residency had higher levels of acculturative stress (Bekteshi & van Hook, 2015; Ji & Duan, 2006; Lueck & Wilson, 2010, 2011; Moon, 2011). As noted earlier, the length of U.S. residency and English proficiency may reflect an immigrant's degree of acculturation, and acculturative stress appears to be greater among those individuals who are less acculturated to the dominant society (Bekteshi & van Hook, 2015; Lueck & Wilson, 2010; Moon, 2011). Given that the average length of U.S. residency was about 22 years in our study participants, it was interesting that the level of acculturative stress was higher than their counterparts in other Korean immigrant studies in the United States. This could be partially explained by the mean arrival age (32 years old) to the United States, and that the Korean language remained the language of preference after so many years of U.S. residency (i.e., all participants replied to the study documents in Korean rather than English) in this study. Researchers have reported that the critical period of a new language acquisition is before puberty (Birdsong, 2006; Bleakley & Chin, 2010). The later immigrants arrive to a new society, 73
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J., Cushman, M., ... Turner, M. B. (2016). Heart disease and stroke statistics-2016 update: A report from the American Heart Association. Circulation, 133(4), e38–e360. Noh, J.-W., Jo, M., Huh, T., Cheon, J., & Kwon, Y. D. (2014). Gender differences and socioeconomic status in relation to overweight among older Korean people. PLoS ONE, 9(5), e97990. Noh, S., & Avison, W. R. (1996). Asian immigrants and the stress process: A study of Koreans in Canada. Journal of Health and Social Behavior, 37(2), 192–206. Noh, S., Wu, Z., & Avison, W. R. (1994). Social support and quality of life: Sociocultural similarity and effective social support among Korean immigrants. Advances in Medical Sociology, 5, 115–137. Obesity in Asia Collaboration, Huxley, R., Barzi, F., Lee, C. M., Lear, S., Shaw, J., ... Woodward, M. (2007). Waist circumference thresholds provide an accurate and widely applicable method for the discrimination of diabetes. Diabetes Care, 30(12), 3116–3118. Palaniappan, L. P., Wong, E. C., Shin, J. J., Fortmann, S. P., & Lauderdale, D. S. (2011). Asian Americans have greater prevalence of metabolic syndrome despite lower body mass index. International Journal of Obesity, 35(3), 393–400. Pew Research Center (2013). The rise of Asian Americans. (Retrieved from file:///F:/ Research/Articles%20for%20Research/Asian%20American%20study/AsianAmericans-new-full-report-04-2013.pdf).
that indicate cardiovascular risk disease such as family history, diet, and blood values (cholesterol and triglycerides) prior to immigration were not obtained in this study and would be included in a future study to better examine this association. Living in closer proximity to other immigrants of the same ethnicity with a longer residency may help in the procurement of necessary resources for living in a new country, which results in fewer lingual and cultural barriers (Kang, Domanski, & Moon, 2009; Schwartz et al., 2010). We may better understand whether level of acculturative stress is impacted by area where the immigrant lives (ethnic enclaves vs. nonethnic enclaves) and how this difference impacts BMI and BP by adding the variable of community setting to future study. This study has limitations. Our results may not be generalizable to all Korean immigrants residing in the United States because we collected data from one geographical region. Our sample also had a slightly higher percentage of participants who were married (88.8% vs. 56%) with higher levels of education (84.2% vs. 53% for the college education) than the general Korean population residing in the United States (Pew Research Center, 2013; U.S. Census Bureau, 2016). Acculturative stress might be not the sole stress in the life of the participants; therefore, future research needs to explore other contributing factors (e.g., family history, physical inactivity, consumption of unhealthy food) that are important in determining BMI and BP values. Nevertheless, this study has strengths. The height, weight, and BP were directly measured; therefore, they reflect the accurate physiological condition of participants rather than relying on a self-report of values by the participants. Participants were also given the choice of completing the survey questionnaire in Korean or English. This choice by the participant in replying to each survey item can be assumed to be a more reliable indicator of the participant's response with a better comprehension of each item and a decreased risk for misinterpretation to occur. 5. Conclusion Despite the lack of significant associations between acculturative stress and physiological factors (i.e., BMI, BP), the findings of this study provide researchers and healthcare professionals with greater insight related to acculturative stress in Korean Americans in the southwestern United States. A number of personal factors demonstrated significant associations with acculturative stress, BMI, and BP. These linkages support prior research into the importance of considering many factors that may predispose an immigrant to cardiovascular disease, including acculturative stress, personal factors related to immigration, and already well documented variables of BMI and BP. Conflicts of interest None. References Afable, A., Ursua, R., Wyatt, L. C., Aguilar, D., Kwon, S., Islam, N. S., & Trinh-Shevrin, C. (2016). Duration of US residence is associated with overweight risk in Filipino immigrants living in New York metro area. Family & Community Health, 39(1), 13–23. Al-Omari, H., & Pallikkathayil, L. (2008). Psychological acculturation: A concept analysis with implications for nursing practice. Journal of Transcultural Nursing, 19(2), 126–133. Bekteshi, V., & van Hook, M. (2015). Contextual approach to acculturative stress among Latina immigrants in the U.S. Journal of Immigrant and Minority Health, 17(5), 1401–1411. Berry, J. W. (2008). Globalisation and acculturation. International Journal of Intercultural Relations, 32, 328–336. Birdsong, D. (2006). Age and second language acquisition and processing: A selective overview. Language Learning, 56, 9–49. Bleakley, H., & Chin, A. (2010). Age at arrival, English proficiency, and social assimilation among U.S. immigrants. American Economic Journal: Applied Economics, 2(1), 165. Camarota, S. A., & Zeigler, K. (2015). U.S. immigrant population hit record 42.4 million in 2014. Retrieved from http://cis.org/sites/cis.org/files/imm-pop-record-sept_2.pdf. Caplan, S. (2007). Latinos, acculturation, and acculturative stress: A dimensional concept
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society as a risk factor for high blood pressure: A meta-analytic review. Psychosomatic Medicine, 68(3), 386–397. U.S. Census Bureau (April, 2014). Profile America. Facts for features. Retrieved from http://www.census.gov/content/dam/Census/newsroom/facts-for-features/2014/ cb14-ff13_asian.pdf. U.S. Census Bureau (January, 2016). American community survey. Retrieved from http:// www.census.gov/programs-surveys/acs/news/data-releases/2014/release.html.
Rhee, S. L. (2013). Acculturative stress and depressive symptoms among Korean immigrant elders residing in non-Korean ethnic enclaves. (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses. (UMI No. 3583785). Rudmin, F. W. (2003). Critical history of the acculturation psychology of assimilation, separation, integration, and marginalization. Review of General Psychology, 7, 3–37. Schwartz, S. J., Unger, J. B., Zamboanga, B. L., & Szapocznik, J. (2010). Rethinking for theory and research. American Psychologist, 65(4), 237–251. Steffen, P. R., Smith, T. B., Larson, M., & Butler, L. (2006). Acculturation to Western
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Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Original article
Acculturative stress in Korean Americans
MARK
⁎
Cha-Nam Shin, PhD, RN , Shannon Ruff Dirksen, PhD, RN, FAAN, Bin Suh, BSN College of Nursing and Health Innovation, Arizona State University, United States
A R T I C L E I N F O
A B S T R A C T
Keywords: Acculturative stress Immigrants Korean Americans Body mass index Blood pressure
Background: Acculturative stress is known to contribute to chronic diseases among many immigrants and yet this association in Korean Americans remains unclear. Aim: The study purpose was to examine the level of acculturative stress in Korean Americans and to determine if correlations existed with personal and physiological factors. Methods: An exploratory, cross-sectional, descriptive study was conducted in a sample of 107 Korean American adults. Data on acculturative stress and personal factors were collected using a survey questionnaire in addition to a direct measure of physiological factors (i.e., body mass index and blood pressure). Results: All 107 participants were first-generation Koreans. Most participants were women (66.4%), with a mean age of 53.9 ± 10.7, married (88.8%), and with a college education (84.2%). Acculturative stress was associated with a number of personal factors (i.e., arrival age, years of U.S education, years of U.S. residency, English proficiency), and the personal factors of gender, age, employment status, and years of U.S. residency were associated with the physiological factors. No statistically significant associations were found between acculturative stress and physiological factors. Conclusions: The mean acculturative stress score in this study was higher than findings from prior studies of Korean immigrants in the United States or Canada, with the rates of obesity and hypertension higher than prior reports of Korean Americans or Koreans residing in Korea. Future study is necessary with a larger sample from a variety of different geographic areas of the United States to examine further the impact of acculturative stress on physiological factors during the process of acculturation.
1. Introduction Acculturation is a process of cultural change and adaptation that occurs when foreign-born individuals interact with people from a new country (Lopez-Class, Castro, & Ramirez, 2011; Schwartz, Unger, Zamboanga, & Szapocznik, 2010). During the process of acculturation to a new environment, some immigrants may have a successful experience through which they modify their life to adjust to the host culture, while others may face ongoing challenges and difficulties that can result in continued stress (Al-Omari & Pallikkathayil, 2008; Berry, 2008; D'Alonzo, Johnson, & Fanfan, 2012). The stress associated with acculturation is referred as acculturative stress which can adversely affect an individuals' health, including the development of cardiovascular disease (D'Alonzo et al., 2012; DeVylder et al., 2013; Lee, Suchday, & Wylie-Rosett, 2015). An understanding of the factors that contribute to acculturative stress is crucial in helping to mitigate and lessen health problems that may be associated with this type of stress. As of 2014, more than 42.4 million foreign-born individuals (13.3% of U.S. population) reside in the United States (U.S. Census Bureau,
⁎
2016). Immigrants are the fastest growing segment of the U.S. population with a 350% increase in number from a total of 9.6 million in 1970 to 42.4 million in 2014 (Camarota & Zeigler, 2015). Despite a relatively short history of immigration to the United States by Koreans, their numbers have rapidly grown by 39% from 1.2 million in 2000 to 1.7 million in 2010 (Pew Research Center, 2013; U.S. Census Bureau, 2014). In 2013, it was found that 1.8 million Koreans (U.S. born and foreign born) resided in the United States (U.S. Census Bureau, 2016). Among them, foreign-born (first generation) Koreans accounted for nearly four out of five Korean Americans (Pew Research Center, 2013). This first generation Korean residing in the United States is predominantly a monolingual speaker in Korean with limited English proficiency. The degree of acculturative stress that is experienced by an immigrant would seem to vary depending on the degree of similarity or dissimilarity between the heritage culture and new culture (Rudmin, 2003; Schwartz et al., 2010). For example, White, English-speaking individuals (e.g., Canadian or Australian) may experience less stress immigrating to the United States due to similarities in language spoken
Corresponding author at: 500 N. 3rd Street, College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ 85004, United States. E-mail addresses: [email protected] (C.-N. Shin), [email protected] (S.R. Dirksen).
http://dx.doi.org/10.1016/j.apnr.2017.09.010 Received 26 January 2017; Received in revised form 12 July 2017; Accepted 23 September 2017 0897-1897/ © 2017 Elsevier Inc. All rights reserved.
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2. Methods
than Asian immigrants who are not proficient in English. White, English-speaking immigrants may also adapt somewhat easier to American mainstream with less racial discrimination if the culture is closer to their own heritage culture. In contrast, Asian immigrants to the United States may experience a higher level of acculturative stress because they may have to learn a new language (i.e., English), live in a society with different cultural values and social norms (e.g., collectivism over individualism), and sometimes deal with racial discrimination (Schwartz et al., 2010). A variety of personal factors have been found to impact the degree of acculturative stress that is experienced by immigrants. For example, Korean Americans who were men, younger, had high levels of English proficiency, who arrived to the United States at a younger age, or stayed more years in the United States experienced lower levels of acculturative stress than did their counterparts who were women, older, had low levels of English proficiency, who arrived to the United States at an older age, or stayed less years in the United States (Ji & Duan, 2006; Logan, Barksdale, Carlson, Carlson, & Rowsey, 2012; Moon, 2011). In a study of immigrants from the former Soviet Union, women and older immigrants to the United States experienced higher levels of acculturative stress than did men and younger immigrants (Miller et al., 2006). In contrast, Asian Indian immigrant men in the United States experienced higher levels of acculturative stress than did women (Conrad & Pacquiao, 2005), while older Latinos residing in the United States experienced lower levels of acculturative stress than did younger Latinos (Bekteshi & van Hook, 2015). Length of residency was not associated with acculturative stress in studies of Latinos and Nigerian immigrants to the United States (Caplan, 2007; Daramola & ScisneyMatlock, 2014). Asian Americans and Latinos with low levels of English proficiency and who stayed less years in the United States experienced high levels of acculturative stress (Bekteshi & van Hook, 2015; Lueck & Wilson, 2010, 2011). First-generation Latinos with limited English proficiency were found to experience 13% more acculturative stress than second generation Latinos (Lueck & Wilson, 2011). This is because linguistic integration for immigrants in the United States is a social requirement that enforces the acquisition of English proficiency (Lueck & Wilson, 2011). Acculturative stress has been associated with physiological changes occurring within the individual, including hypertension and diabetes in Latinos and Chinese immigrants to the United States (D'Alonzo et al., 2012; Lee et al., 2015). In contrast, acculturative stress was not associated with blood pressure (BP) levels in Korean and Nigerian immigrants to the United States (Daramola & Scisney-Matlock, 2014; Logan et al., 2012). Acculturative stress has also been linked to elevated systolic BP among Latino immigrant men, but not among Latino immigrant women in the United States (McClure et al., 2010). Due to the increased numbers of individuals who are immigrating to a new culture and the observed disparities in health reported outcomes, researchers are focusing to a greater degree on acculturation, acculturative stress, and factor which may impact this process and the ensuing stress that may result. Contributing factors to acculturative stress have been explored; however, the associations between those factors and acculturative stress are inconsistent across a limited number of studies. In particular, little information is available as to whether acculturative stress is associated with physiological factors in Korean Americans. Given that the fast growing numbers of Korean Americans, it is important to understand what factors contribute to acculturative stress and if acculturative stress is associated with physiological factors for this ethnic group. Therefore, we conducted an exploratory study to describe the level of acculturative stress in Korean Americans and to examine if correlations existed with level of acculturative stress and personal (e.g., age, gender) and physiological factors (e.g., BP).
2.1. Study design and sample This study was a secondary analysis of data that were collected for an exploratory, cross-sectional, descriptive study in a large Southwestern city in the United States which examined cardiometabolic risk factors in Korean Americans. We recruited a convenience sample of Korean American adults who self-identified as Korean, aged 18 and above, and able to read, write, and speak either in Korean or the English language from a locally identified Korean community (e.g., restaurants, groceries, Korean ethnic churches). We had a total of 107 participants who had completed data on acculturative stress and the personal and physiological factors. For the correlation analyses conducted in our study, we had enough power (β = 0.85) to detect correlations of 0.30 with a sample size of 96 according to G*Power 3.1.7 (Faul, Erdfelder, Buchner, & Lang, 2009). 2.2. Measures Information about acculturative stress, and the personal and physiological factors were obtained from each participant. 2.2.1. Personal factors Personal factors included the individual's age, gender, marital status, education level, annual family income level, employment status, years of U.S. education, arrival age, and years of residency in the United States. In addition, English proficiency was determined by asking the question, “In your opinion, how well do you speak English compared with most English native speakers?” Responses were rated on a scale from 1 (very much worse) to 4 (as well as most English native speakers). For the purpose of data analysis, we recoded this as a dichotomous variable (0 = very much worse–somewhat worse, 1 = only little worse–as well as most English native speakers). 2.2.2. Acculturative stress The Acculturative Stress Index (ASI) was used to measure the stress associated with adaptation to a new culture (Noh, Wu, & Avison, 1994). The ASI is available in both English and Korean languages. The scale consists of 31 items which assess acculturative stress from experiences such as homesickness, social isolation, social discrimination, sense of marginality, family problems, socioeconomic adjustment, and language difficulties. In the ASI, homesickness for example, is measured by an item that states: “I am living away from my family, relatives, and friends.” Language difficulties are examined by a question such as “I experience difficulties because of my ability to speak and understand English when I try to understand the TV/radio.” Participants rate the degree of difficulty in adapting to life in the United States on a 4-point Likert scale (from 1 = never to 4 = very often). A total ASI score was derived from the sum of the item scores with higher scores indicating greater acculturative stress. Because our focus was to measure acculturative stress in general, we used the total ASI score in this study. Reliability for the ASI was supported by Cronbach's alphas of 0.75–0.95 in research studies of Korean immigrants in Canada and United States (Ji & Duan, 2006; Moon, 2011; Noh & Avison, 1996; Rhee, 2013). Studies have demonstrated validity for the ASI: appropriate factor loadings occurring with factor scores 0.40 or above for each item; and acculturative stress scores predicting depressive symptoms (Moon, 2011; Noh & Avison, 1996). Cronbach's alpha for the ASI was 0.93 in this study. 2.2.3. Physiological measures We measured body mass index (BMI) and BP as physiological factors in this study. To assess BMI, we measured the height and weight of each participant who wore light clothing and no shoes using a portable stadiometer (Seca 217, USA) and an electronic scale (Health O meter, 71
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USA). We used the standard formula for the BMI calculation: weight (kg) / [height (m)]2 (Centers for Disease Control and Prevention, 2015). Obesity was determined by the American Heart Association (AHA) criteria related to individual BMI values: the ideal weight value is a BMI < 25 kg/m2, a person is considered overweight if BMI value is 25–29.9 kg/m2, and obese if BMI value is ≥ 30 kg/m2 (Mozaffarian et al., 2016). In addition, we determined obesity using criteria that has been specified for Asian populations including: ideal weight value is a BMI < 23 kg/m2, overweight if BMI value is 23–24.9 kg/m2, and obese if BMI value is ≥ 25 kg/m2 (Obesity in Asia Collaboration et al., 2007). For the BP measure, we used a standard procedure: having the participant rest for a minimum of 5-min in the sitting position before the BP was checked, and two readings were taken and averaged. The AHA definition of hypertension was used: a SBP of < 120 mm Hg and a diastolic blood pressure (DBP) of < 80 mm Hg were considered as ideal, and a SBP of ≥ 120 mm Hg and a DBP of ≥ 80 mm Hg were considered high (Mozaffarian et al., 2016). Equipment for each assessment was calibrated during the study at frequent intervals to maintain accuracy.
Table 1 Sample characteristics. Variable
Category
n (%)
Gender
Male Female
36 (33.6) 71 (66.4)
Agea
53.9 (10.7)
Marital status
Married Separated/divorced/widowed Education level ≤ High school (n = 106) ≥ College Income levelb ≤$49,999 (n = 104) > $50,000 Employment status Employed Unemployed Arrival age in U.S.a (n = 106)
95 12 16 90 38 66 68 39
(88.8) (10.2) (15) (84.2) (35.5) (61.7) (63.6) (36.4) 31.9 (11.1) 21.6 (12.2)
Length of residency in U.S.a (n = 104) English proficiency
2.3. Procedures After obtaining institutional review board approval from the university where the study was housed, we screened individuals for eligibility and then obtained informed consent from each participant prior to beginning the study. The data were collected at a convenient place chosen by the participant, including the university research office, participant's home, and Korean ethnic churches. All study documents (e.g., informed consent, survey questionnaires) were available in both English and Korean, and participants were given a choice to complete them in either language version. Following the BP and BMI assessments, participants received information about their BMI and BP so that they could share this information with their primary healthcare provider.
M (SD)
Very much worse–somewhat worse Only little worse–as well as most English speakers Acculturative stress (Acculturative Stress Index)
67 (62.6)
Body mass index (kg/ m2) Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg)
77 30 38 69 25 82
Ideal (< 25) Overweight/obese (≥25) Ideal (< 120) High SBP (≥ 120) Ideal (< 80) High DBP (≥ 80)
40 (37.4)
(72.0) (28.0) (35.5) (64.5) (23.4) (76.6)
50.4 (13.2) 23.6 (3.0) 121.1 (15.1) 81.3 (10.56)
Note. Sample size of subgroups is 107 except variables indicated. a Measured in years. b Family annual income.
participants were found to have arrived in the United States at age of 30 or older, 83% had been in the United States for a minimum of 10 years, 51.4% had received formal education of at least one year in the United States, and 62.6% reported they spoke English “very much worse–somewhat worse” when they compared themselves to most native speakers. The mean score for the ASI was 50.4 (range 31–124), which falls below the midpoint of the scale. More than one quarter of the participants (28%) were overweight or obese (≥25 kg/m2) based on the criteria by the AHA. When we examined BMI criteria specific for Asians (≥23 kg/m2), 45.9% of the study sample was identified as being overweight or obese. More than half of the participants had a higher than ideal value for SBP (64.5%) and DBP (76.7%).
2.4. Data analysis Prior to analysis, data were screened for entry errors, outliers, and missing values. Data were normally distributed without outliers for the variables entered into the data analysis. Due to a small number of cases of missing values (< 3% of the sample) and missing data are randomly distributed across the data set (Hair, Black, Babin, Anderson, & Tatham, 2006; Howell, 2008), we drop those values from the analyses. Descriptive statistics were used to summarize the data on acculturative stress, and personal and physiological factors. To examine correlations between level of acculturative stress and personal and physiological factors, we calculated Pearson correlation coefficients for the continuous variables of age, arrival age, U.S. education, length of residency, BMI, SBP, and DBP. Point-biserial correlations were used for the dichotomous variables of sex, marital status, education level, income, employment status, and English proficiency. Variables that were entered into the data analysis met the assumptions for the statistical analyses that were used (e.g., normal distribution, no outliers, equal variance). IBM SPSS statistics version 22.0 was used to analyze the data. An alpha level of 0.05 was used to determine significance for all statistical tests.
3.2. Variable associations The Pearson and point-biserial correlation coefficients demonstrated that many associations existed among the variables (Table 2). A positive association was found between acculturative stress and arrival age (r = 0.33), while a negative association revealed between acculturative stress and years of U.S. education (r = − 0.34), years of U.S. residency (r = − 0.43), and English proficiency (r = − 0.21). Gender was negatively associated with BMI (r = − 0.49), SBP (r = −0.34), and DBP (r = −0.37), whereas age was positively associated with SBP (r = 0.45) and DBP (r = 0.22). Employment was negatively associated with SBP (r = −0.22), while years of U.S. residency was positively correlated with SBP (r = 0.27). Acculturative stress was not correlated with BMI, SBP, and DBP.
3. Results 3.1. Sample characteristics
4. Discussion All 107 participants were first-generation Koreans, and they all chose to read and sign the consent form in Korean and complete all the study measures in Korean. Participants had a mean age of 53.9 ± 10.7 (range 30–79), a majority were women, married, and educated at a college level or above (Table 1). Slightly more than half (51.9%) of the
The level of acculturative stress in this sample (the mean ASI score = 50.4) was higher than the levels (the mean ASI score = 34–40) found in Korean Americans living in cities of Ohio, Kentucky, and Indiana (Ji & Duan, 2006; Rhee, 2013), but lower than the levels (the 72
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the less they are acculturated to the new society and also the more they experience acculturative stress (Bleakley & Chin, 2010; Ji & Duan, 2006). In another Korean American study, 14% of the participants were U.S. born, while 46.3% of the participants completed the English version of the survey (Ji & Duan, 2006). The participants who completed the English version of the survey showed a lower acculturative stress compared to participants who completed the Korean version of the survey (Ji & Duan, 2006). These findings may indicate that greater length of residency does not guarantee more acculturation to the dominant society and less acculturative stress for individuals who arrived to the United States at their older age (i.e., after puberty). The role of arrival age as a factor that may influence acculturation and acculturative stress needs further investigation. Future research exploring additional factors (e.g., ethnic identity, native language proficiency, coping strategies, support and resources in new community) that may influence acculturative stress will provide a better understanding of Korean Americans' experiences with acculturative stress, and how nursing may positively impact these factors; thereby reducing the level of stress associated with acculturation. The study findings revealed that a majority of participants had higher values of SBP and DBP than the values that had been obtained in prior results of Korean immigrants and Koreans living in their native country. The rate of obesity in our study (28% with BMI > 25 kg/m2 criteria) was higher than the rate (22.2%) reported in a study of Koreans residing in Korea (Noh, Jo, Huh, Cheon, & Kwon, 2014) although it was lower than the rates (45%–53%) reported prior in other studies of Korean Americans (Kim et al., 2015; Palaniappan, Wong, Shin, Fortmann, & Lauderdale, 2011). The rate of obesity (49.5%) with a BMI > 23 kg/m2 was higher than the rate (46%) reported in another study of Korean immigrants in California (Cho & Juon, 2006). The rates of hypertension in this sample were (64.5% in SBP; 76.7% in DBP) also greater than the rates (46%–60%) reported in Korean Americans or Koreans residing in Korea (Kim, Lee, Ahn, Bowen, & Lee, 2007; Logan et al., 2012). Our findings regarding the association of physiological factors and some of the personal factors were consistent with previous findings. A number of studies across ethnic groups (i.e., Koreans, Filipinos, and African immigrants) have reported that individuals who were older, men, employed, and stayed longer years in the Unites States showed higher values of BMI, SBP, and DBP (Afable et al., 2016; Cho & Juon, 2006; Daramola & Scisney-Matlock, 2014; Mozaffarian et al., 2016). This study also lent credence to the results of a previous study with a larger Korean population (N = 407,858) in South Korea that showed higher BMI, SBP, DBP values occurred more often in men than in women (Kim, Jee, Yun, Baek, & Lee, 2013). Consistent with prior research of African immigrants in the United States, we did not find significant associations between acculturative stress and physiological factors (Daramola & Scisney-Matlock, 2014). Researchers have suggested that the body's stress response to the longterm effect of acculturative stress can lead to cardiovascular disease risks (Lee et al., 2015; Logan et al., 2012). A meta-analysis of 125 studies (N = 223,355) reported that BP levels were related to acculturation level (SBP, d = 0.40; DBP, d = 0.43), whereas acculturation was not associated with BMI in Latinos in the United States, Turkish immigrants in Germany, and Ethiopian immigrants in Israel (Steffen, Smith, Larson, & Butler, 2006). The largest effect sizes reported of acculturation on BP occurred in immigrants at the time of initial contact with the new culture with the effect then dropping rapidly within the first 3 years of acculturation: (SBP, d = 0.66 during 0 to 3 months, d = 0.52 during 3 months to 3 years, d = 0.38 during 3 to 15 years; DBP, d = 0.65 during 0 to 3 months, d = 0.57 during 3 months to 3 years, d = 0.33 during 3 to 15 years). Given the average of > 20 years of U.S. residency in this study, the sample might have learned coping skills or utilized other resources that buffered the negative effect of acculturative stress on BMI and BP. Additional measures
Table 2 Correlations between personal and physiological factors and acculturative stress. Personal factors
Acculturative stress
BMIb
SBPc
DBPd
Gender (1 = female) Agea Marital status Education level Income Employment Arrival agea U.S. educationa Length of residencya English proficiency Acculturative stress
0.15 − 0.15 0.05 0.07 − 0.16 0.07 0.33⁎⁎ − 0.34⁎⁎ − 0.43⁎⁎ − 0.21⁎ 1
− 0.49⁎⁎ 0.08 0.14 0.06 − 0.01 − 0.04 0.04 0.08 0.03 − 0.02 − 0.11
− 0.34⁎⁎ 0.45⁎⁎ − 0.05 − 0.15 − 0.10 − 0.22⁎ 0.14 − 0.11 0.27⁎⁎ 0.04 − 0.10
− 0.37⁎⁎ 0.22⁎ 0.00 − 0.03 − 0.10 − 0.11 0.17 − 0.09 0.04 0.05 0.05
a
Measured in years. BMI = Body mass index. c SBP = Systolic blood pressure. d DBP = Diastolic blood pressure. ⁎ p < 0.05. ⁎⁎ p < 0.01. b
mean ASI score = 55–66) found in Korean immigrants residing in Canada and Korean Americans in Chicago (Lee & Holm, 2012; Noh & Avison, 1996). This variation in acculturative stress might be related to differences in the personal factors of the participants in the studies and the varying environments where acculturation was taking place. Support for these ideas comes from two older studies (Lee & Holm, 2012 [data collection in 2002]; Noh & Avison, 1996) that were conducted when fewer Koreans immigrated to Western countries. These studies indicate that Korean immigrants 10 to 20 years ago were more likely to have fewer resources for living in a new environment than they have in the present time, which could have resulted in these immigrants experiencing more stress during the process of adjusting to a new country than more recent immigrants. Future research is vitally needed to more fully examine how resources available to a Korean immigrant may impact acculturative stress, including cultural specific strategies to access resources that are congruent with the individual's values, beliefs, and traditions. Of particular interest to future research is the potential role of social support in buffering the stress of acculturation among Korean American immigrants. Our findings confirmed that a significant association existed between acculturative stress and personal factors of the immigrant. Support for these findings comes from research of Koreans, Asians, and Latinos or Latinas who had immigrated to the United States, which indicated that individuals at an older age, who had lower levels of English proficiency, none or less years of U.S. education, or less years of U.S. residency had higher levels of acculturative stress (Bekteshi & van Hook, 2015; Ji & Duan, 2006; Lueck & Wilson, 2010, 2011; Moon, 2011). As noted earlier, the length of U.S. residency and English proficiency may reflect an immigrant's degree of acculturation, and acculturative stress appears to be greater among those individuals who are less acculturated to the dominant society (Bekteshi & van Hook, 2015; Lueck & Wilson, 2010; Moon, 2011). Given that the average length of U.S. residency was about 22 years in our study participants, it was interesting that the level of acculturative stress was higher than their counterparts in other Korean immigrant studies in the United States. This could be partially explained by the mean arrival age (32 years old) to the United States, and that the Korean language remained the language of preference after so many years of U.S. residency (i.e., all participants replied to the study documents in Korean rather than English) in this study. Researchers have reported that the critical period of a new language acquisition is before puberty (Birdsong, 2006; Bleakley & Chin, 2010). The later immigrants arrive to a new society, 73
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that indicate cardiovascular risk disease such as family history, diet, and blood values (cholesterol and triglycerides) prior to immigration were not obtained in this study and would be included in a future study to better examine this association. Living in closer proximity to other immigrants of the same ethnicity with a longer residency may help in the procurement of necessary resources for living in a new country, which results in fewer lingual and cultural barriers (Kang, Domanski, & Moon, 2009; Schwartz et al., 2010). We may better understand whether level of acculturative stress is impacted by area where the immigrant lives (ethnic enclaves vs. nonethnic enclaves) and how this difference impacts BMI and BP by adding the variable of community setting to future study. This study has limitations. Our results may not be generalizable to all Korean immigrants residing in the United States because we collected data from one geographical region. Our sample also had a slightly higher percentage of participants who were married (88.8% vs. 56%) with higher levels of education (84.2% vs. 53% for the college education) than the general Korean population residing in the United States (Pew Research Center, 2013; U.S. Census Bureau, 2016). Acculturative stress might be not the sole stress in the life of the participants; therefore, future research needs to explore other contributing factors (e.g., family history, physical inactivity, consumption of unhealthy food) that are important in determining BMI and BP values. Nevertheless, this study has strengths. The height, weight, and BP were directly measured; therefore, they reflect the accurate physiological condition of participants rather than relying on a self-report of values by the participants. Participants were also given the choice of completing the survey questionnaire in Korean or English. This choice by the participant in replying to each survey item can be assumed to be a more reliable indicator of the participant's response with a better comprehension of each item and a decreased risk for misinterpretation to occur. 5. Conclusion Despite the lack of significant associations between acculturative stress and physiological factors (i.e., BMI, BP), the findings of this study provide researchers and healthcare professionals with greater insight related to acculturative stress in Korean Americans in the southwestern United States. A number of personal factors demonstrated significant associations with acculturative stress, BMI, and BP. These linkages support prior research into the importance of considering many factors that may predispose an immigrant to cardiovascular disease, including acculturative stress, personal factors related to immigration, and already well documented variables of BMI and BP. Conflicts of interest None. References Afable, A., Ursua, R., Wyatt, L. C., Aguilar, D., Kwon, S., Islam, N. S., & Trinh-Shevrin, C. (2016). Duration of US residence is associated with overweight risk in Filipino immigrants living in New York metro area. Family & Community Health, 39(1), 13–23. Al-Omari, H., & Pallikkathayil, L. (2008). Psychological acculturation: A concept analysis with implications for nursing practice. Journal of Transcultural Nursing, 19(2), 126–133. Bekteshi, V., & van Hook, M. (2015). Contextual approach to acculturative stress among Latina immigrants in the U.S. Journal of Immigrant and Minority Health, 17(5), 1401–1411. Berry, J. W. (2008). Globalisation and acculturation. International Journal of Intercultural Relations, 32, 328–336. Birdsong, D. (2006). Age and second language acquisition and processing: A selective overview. Language Learning, 56, 9–49. Bleakley, H., & Chin, A. (2010). Age at arrival, English proficiency, and social assimilation among U.S. immigrants. American Economic Journal: Applied Economics, 2(1), 165. Camarota, S. A., & Zeigler, K. (2015). U.S. immigrant population hit record 42.4 million in 2014. Retrieved from http://cis.org/sites/cis.org/files/imm-pop-record-sept_2.pdf. Caplan, S. (2007). Latinos, acculturation, and acculturative stress: A dimensional concept
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Rhee, S. L. (2013). Acculturative stress and depressive symptoms among Korean immigrant elders residing in non-Korean ethnic enclaves. (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses. (UMI No. 3583785). Rudmin, F. W. (2003). Critical history of the acculturation psychology of assimilation, separation, integration, and marginalization. Review of General Psychology, 7, 3–37. Schwartz, S. J., Unger, J. B., Zamboanga, B. L., & Szapocznik, J. (2010). Rethinking for theory and research. American Psychologist, 65(4), 237–251. Steffen, P. R., Smith, T. B., Larson, M., & Butler, L. (2006). Acculturation to Western
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