Self-rated health, gender, and acculturative stress among immigrants in the U.S.: New roles for social support

International Journal of Intercultural Relations 55 (2016) 120–132

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International Journal of Intercultural Relations journal homepage: www.elsevier.com/locate/ijintrel

Self-rated health, gender, and acculturative stress among immigrants in the U.S.: New roles for social support Sarita Panchang a,∗ , Hilary Dowdy b , Rachel Kimbro b , Bridget Gorman b a b

University of South Florida, College of Public Health, 4202 E. Fowler Ave., Tampa, FL 33620, USA Rice University, Department of Sociology, 6100 Main Street, Houston, TX 77005, USA

a r t i c l e

i n f o

Article history: Received 11 January 2016 Received in revised form 20 September 2016 Accepted 2 October 2016 Available online 25 October 2016 Keywords: Immigrant health Acculturation Self-rated health U.S.

a b s t r a c t Background: Based on different outcomes, immigrants to the U.S. may experience a decline in health with length of time or acculturation. Acculturative stress is often applied as an explanation for these changes and may be impacted by social supports and social networks, but more information is needed on the specific role of each. Thus far little research has examined acculturative stress and health by both ethnicity and gender. Methods: Drawing on the 2002–2003 National Latino and Asian American Study (NLAAS), we examine data on a nationally-representative sample of foreign-born Latino (N = 1,627) and Asian (N = 1,638) adults living in the United States. We examine relationships between acculturative stress and self-rated physical and mental health, as well as the potential role of social support factors, with a primary focus on gender. Results: As a group Latinos report more acculturative stress than Asians. However, among Latino immigrants acculturative stress has no association with health, and for Asian immigrants there is an association with physical health among women and mental health among men – but only the latter persisted after adjusting for controls. We do find that among Latino men and women, acculturative stress is health damaging when specific types of social support are low but can even be health promoting at higher support levels. Discussion: While self-rated health differs among immigrant groups, we find that acculturative stress may not be the primary driving force behind these differences, but interacts with specific elements of social support to produce unique impacts on health by gender and ethnicity. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction Immigrants are the fastest growing segment of the U.S. population, increasing from 4.7% of the total population in 1970 to about 13% in 2014 (American Community Survey). Increased immigration continues to drive scholarly and political debates centering on processes such as the “healthy immigrant effect,” whereby immigrants initially appear healthier than the native-born on a number of indicators (Hummer et al., 1999), but over time their health deteriorates to the level of the native-born (Markides & Eschbach, 2005). Acculturation and acculturative stress, theoretical concepts that highlight changes that arise following contact between individuals and groups of different cultural backgrounds (Sam & Berry, 2006)

∗ Corresponding author. E-mail addresses: [email protected] (S. Panchang), [email protected] (H. Dowdy), [email protected] (R. Kimbro), [email protected] (B. Gorman). http://dx.doi.org/10.1016/j.ijintrel.2016.10.001 0147-1767/© 2016 Elsevier Ltd. All rights reserved.

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constitute one explanatory pathway for the healthy immigrant effect. Scholarship suggests that immigrants who retain the traditions, languages, and practices of their origin country may be at lower risk for health problems than immigrants who are more highly acculturated (Hwang, Chun, Takeuchi, Myers, & Siddarth, 2005). Yet the simplicity of this pathway is being increasingly challenged (John, de Castro, Martin, & Duran, 2012) and more insight is needed on mechanisms through which acculturation shapes health outcomes. Social stress theories suggest that stressful life events are structural in nature and occur systematically along certain boundaries of disadvantage; they also suggest that social support, along with coping, can play a key role in buffering the effects of these life events on negative self-concepts which can impact well-being (Pearlin, Menaghan, Lieberman, & Mullan, 1981). A number of studies indicate the influence of social support and social networks on immigrant well-being, but findings vary based on the way these factors are operationalized. Similarly, the impact of social stress on health is a gendered process (Read & Gorman, 2010), and though some research has pointed to the way gender shapes acculturation (Parrado & Flippen, 2005), few studies have investigated the links between gender, acculturative stress, and health. 2. Background 2.1. The healthy immigrant effect Employing a variety of indicators such as mortality, self-rated health, BMI, health behaviors, and psychological disorders, research on immigrant health suggests that the health advantages experienced by immigrants decline throughout the lifecourse to levels at – or worse than – the native-born population (Menjívar, 2006), possibly because many immigrants lack access to insurance and healthcare (Ku & Matani, 2001). While international studies are not extensively discussed here due to the diversity in context, there is evidence of similar trends in Canada (Newbold, 2005) and Sweden (Wiking, Johansson, & Sundquist, 2004). Evidence suggests that the healthy immigrant effect occurs among both Asian and Latino immigrants. Among Latinos, one of the most extensively researched immigrant groups in the US, this has been most strongly documented through mortality (Hummer, Powers, Pullum, Gossman, & Frisbie, 2007). Other outcomes such as BMI or cardiovascular disorders deteriorate to levels at or worse than the native born with time spent in the U.S. especially among Latinos (Antecol & Bedard, 2006; Markides & Eschbach, 2005). For mental health, lower rates of psychiatric disorders relative to the U.S. born have been reported (Vega et al., 1998). The immigrant advantage in physical health is also generally supported through studies among Asians (Singh & Siahpush, 2001; Zhang & Ta, 2009), and mental health research assessing both self-rated health as well as psychological conditions suggests that Asian immigrants are healthier than the native born (Zhang & Ta, 2009). Firstgeneration Asians, especially women, are at lower risk for lifetime substance use disorder than later generations (Takeuchi et al., 2007), and immigrants who arrived within the last four years are less likely to report poor or fair physical health than the US-born (Zhang & Ta, 2009). This may be because those who arrive during early youth may be more educated (Leu et al., 2008). On the other hand, migrating during adolescence without clear goals may be a predictor for depressive disorders (Gong, Xu, Fujishiro, & Takeuchi, 2011), while Asian immigrants who arrive late in the life-course show a lower prevalence of mood dysfunction, possibly pointing to the relevance of life stage and the decision to migrate (Leu et al., 2008). Indeed, findings have uncovered the importance of acculturative factors besides age at migration or time spent in the US; (Kimbro, Gorman, & Schachter, 2012), for example, found that among Asian and Latino groups, bilingualism tended to be associated with better self-rated health but that other acculturative predictors varied strongly by ethnic group. Thus, the traditional concept of acculturation whereby all immigrant health declines in a time-linear fashion, is being increasingly challenged. Authors suggest several sources of variation in trends: structural reasons such as laws on immigration and healthcare access, as well as the possibility that acculturation may generally increase awareness of one’s health over time, causing an overall decline in self-assessed health (Newbold, 2005). These factors may account for findings that conflict based on the specific indicator (Frisbie, Cho, & Hummer, 2001; Salant & Lauderdale, 2003; Zhang & Ta, 2009), as well as ethnic variation in how quickly immigrant health declines (Antecol & Bedard, 2006). 2.2. Acculturative stress and social support Acculturative stress is one concept put forth by scholars that sheds more light on immigrant health trends (Berry, 1998, 2003). This stress is derived specifically from migration processes and encompasses five domains: physical difficulties inherent to migrating, biological changes such as shifts in diet and exposure to new diseases, social uncertainty, cultural isolation, and psychological struggle (Berry, Kim, Minde, & Mok, 1987; Weaver, 1993). At the same time, there is debate about the underpinnings of acculturation and acculturative stress. As mentioned previously, the generally linear nature of early conceptions of acculturation has been critiqued on theoretical and methodological grounds. Some have suggested that rather than considering groups as “more” or “less” acculturated, acculturation could be considered as occurring across specific dimensions, such as behaviors, values, and identity (Schwartz, Unger, Zamboanga, & Szapocznik, 2010). Amidst these debates, various researchers have investigated acculturative stress as a key underlying factor in immigrant well-being, finding associations with risk of depression (Weaver, 1993), anxiety (Miranda & Umhoefer, 1998), interpersonal problems (Nicholson, 1997), and lower self-reported mental health (Firestone, Harris, & Vega, 2003). Many of these findings focus on Latino

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immigrants, though a few studies suggest that results are similar between Asians and Latinos (Kim & Omizo, 2006; Shin, 1993). These negative health consequences of acculturative stress can be tempered by a variety of factors (Berry & Sam, 1997; Myers & Hwang, 2004); in fact, a vast literature points to the potential protective role of social support and social networks against negative aspects of migration – especially discrimination and acculturative stress. Finch and Vega (2003) uncovered a complex relationship between self-rated physical health and social support in a Mexican-American cohort, whereby discriminatory experiences from acculturation had an insignificant relationship with poor health, but only at high levels of social support. As social support declined, discrimination became more strongly related to poor health, indicating a protective effect of support against the health-related harm of acculturative stress. Social resources within the family seem particularly important. Family support may be somewhat influential for physical health but especially influential for mental health among Latinos (Mulvaney-Day, Alegria, & Sribney, 2007), and family cohesion is strongly related to both physical and mental health among Asians (Zhang & Ta, 2009). Other measures of social connections outside of the family may be related to socioeconomic status (SES) or demographic factors (Mulvaney-Day et al., 2007; Zhang & Ta, 2009). The relationships between acculturative stress, social support, and mental health in particular have been well described, especially with regards to discrimination. Among Asians, marital status may be a protective factor (John et al., 2012). Among South Asians in the NLAAS study, family support was found to moderate the association between perceived discrimination and past-year depression (Tummala-Narra, Alegria, & Chen, 2012), and social support has also moderated between acculturative stress and psychological adjustment among Pakistani immigrants in Canada (Jibeen, 2011). Ethnic social support is also key to reducing psychological distress among Korean immigrants in Canada (Noh & Avison, 1996), and social support more generally is protective for mental health among Korean international students in the US as well (Lee, Koeske, & Sales, 2004). By contrast, Tsai and Thompson (2013) found that discrimination and low social support were each associated with mental health problems and substance use among Filipino immigrants, but did not find a moderating role of social support specifically. Linguistic factors may affect acculturative stress differently by ethnicity: for example, in one analysis of NLAAS data on Asians, bilingualism was associated with a clear reduction in acculturative stress (Lueck & Wilson, 2010), whereas among Latinos, English proficiency predicted low acculturative stress while high native language proficiency had the opposite effect. This may point to the significance of language in the relation between immigrant and host country social networks (Lueck & Wilson, 2011; Kimbro, Gorman, & Schachter, 2012). Finally, availability and usage may matter: in a study of three immigrant groups in Finland, a relationship between perceived discrimination and psychological well-being persisted even after controlling for social support networks, but some moderation occurred with active use of support networks both in the host and home country (as opposed to only having these supports available) (Jasinkaja-Lahti, Liebkind, Jaakkola, & Reuter, 2006). It has been suggested that the effects of social support may parallel the healthy immigrant effect, whereby social support – possibly from the same culture – may be especially common among recent immigrants, and then diminish with time (Escarce, Morales, & Rumbaut, 2006). These arguments have been complicated by recent findings that uncover varying benefits from social support based on certain factors. In Finland, usage of social support from immigrant networks of the same ethnic group in the host country seemed to have a mixed impact based on country of origin (Jasinkaja-Lahti et al., 2006). There is evidence that among Asian college students in the US, foreign-born students consistently report less friend support than US´ Tirado-Strayer, & Leu, 2012). Similarly, a city-based study found that US-born Latinos consistently born Asians (Obradovic, reported more social support on multiple counts than immigrant Latinos in the same city. Ethnic enclaves brought increased support but the US-born still appeared to benefit more from them (Viruell-Fuentes, Morenoff, Williams, & House, 2013). In a foundational descriptive study, Vega et al. (1991) found that friend contacts of Mexican immigrant women tended to remain stable while family contacts became more salient over time. Finally, ethnic identity, measured as feeling close to others of the same racial or ethnic descent, appears to moderate the effect of discrimination on psychological distress among Asians; it has a protective effect for older adults but an exacerbating effect for younger adults (Yip, Gee, & Takeuchi, 2008). Based on these findings, it appears that more fine-grained analyses on co-ethnic ties with regards to immigration would be valuable. 2.3. Gender and social support in migrant health Finally, gender plays a pivotal role in health and migration. There are substantial differences in risk and mortality causes for men and women, and the social factors that shape these, too, are gendered (Bird & Rieker, 2008; Gorman & Read, 2006). Moreover, migration and acculturation are distinctly gendered processes. Although female migration is increasing, more men migrate to the U.S. than women (Hill & Wong, 2005), and for various ethnic groups male immigrants are more motivated by employment opportunity and adventure-seeking (Boyd, 1992; Curran, Shafer, Donato, & Garip, 2006), tend to migrate at younger ages (Kanaiaupuni, 2000), are more likely to want to return to their home country (Hondagneu-Sotelo, 1994), and differ from women in their health behavior trends over time (Lopez-Gonzalez, Aravena, & Hummer, 2005). Integral to this is the gendered manner in which stress manifests itself through acculturation, as stressors are processed differently based on the availability of coping resources. SES may be an important mediator for women’s health, since women have fewer socioeconomic resources to buffer from stress (Denton, Prus, & Walters, 2004), yet they also benefit from social networks or supports that protect against risks, especially depression (Umberson, Chen, House, Hopkins, & Slaten, 1996). Perhaps predictably, literature on social support and migrant health has found gender differences as well. In one study, men had less social integration but more network diversity, network size, and instrumental support (Viruell-Fuentes et al., 2013). In

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another, family support and income were the two most important predictors of depression for Mexican immigrant women (Vega, Kolody, Valle, & Weir, 1991). Qualitative and ethnographic studies, especially among Latinos, provide some insight into these trends. Accessing non kin-based ties may be more limited for first-generation immigrant women especially because of transportation constraints. However, these ties are more accessible for second-generation women and may have less of a material role than a cultural identity-reinforcing one (Viruell-Fuentes & Schulz, 2009); indeed, first-generation immigrant women, despite being part of an ethnic community, experience unique isolation (McMichael & Manderson, 2004), and the sense of reciprocity that is intrinsic to many networks means that receiving support can also entail further social obligation (Ornelas, Perreira, Beeber, & Maxwell, 2009). Among undocumented Guatemalans in Houston, Texas, women did not stand to benefit nearly as much from social ties since most of their employment was in suburban domestic work that occurred mostly in isolation from other women of the community, whereas men benefited from common employment in an ethnic grocery store chain and were better positioned to be informed about documentation and immigration laws. Consistent with this dynamic, heterosexual immigrant couples who are mixed-status may inherently deal with gender imbalances (Hagan, 1998). Clearly, there is more work to be done to investigate connections between acculturative stress and health through the lens of gender and social support. As other authors have noted (Noh & Avison, 1996), not all types of social support are equally valuable as protective factors among immigrants. This is related to a documented difficulty in assessing the characteristics of the most effective kinds of social support for different groups (Pearlin, 1989), as well as the fact that the social contexts of migration and adjustment to a host country remain somewhat undertheorized (John et al., 2012; Viruell-Fuentes & Schulz, 2009). Further, more comparative insight is needed with regards to acculturative stress experiences by gender. In this study we examine whether acculturative stress differentially shapes mental and physical health among men and women, and how the nature of this potential relationship manifests across two pan-ethnic immigrant groups. Drawing from theories of stress processes, acculturative stress, and gender, we expect that (1) women’s health will be more impacted by acculturative stress than men, and (2) the impact of acculturative stress on health will be buffered by specific kinds of social support. 3. Methods We examine data on foreign born adults from the National Latino and Asian American Study (NLAAS). Collected in 2002–2003, the NLAAS is a nationally representative community household survey designed to examine health and health care among U.S. Latinos and Asian Americans aged 18 and older. A multistage, stratified national area probability sample was drawn from the non-institutionalized U.S. population, with oversampling of areas with a moderate-to-high density of Latinos and Asian Americans. All interviewers were bilingual, and interviews were conducted in person and in English, Spanish, Vietnamese, Chinese (either Mandarin or Cantonese), or Tagalog. The overall response rate was 65.6% for Asian Americans and 75.5% for Latinos (see Heeringa et al., 2004; Pennell et al., 2004 for detailed sampling descriptions). When weighted, the NLAAS includes a nationally representative sample of 4649 adults. We limit this sample to respondents born outside the United States (n = 3265), which includes 1638 Asian and 1627 Latino immigrant adults. 3.1. Measures Our dependent measures are self-rated physical health and self-rated mental health, where respondents are asked to rate their overall physical and mental health status on a five-point scale (1 = poor and 5 = excellent). All models are stratified by gender and conducted for each pan-ethnic group (Asian and Latino). Predictor measures are grouped into four categories: (1) demographic and acculturation status, (2) stress, social networks, and support, (3) socioeconomic status, and (4) health behaviors. For demographic and acculturation status we control for age at interview and include dummy variables for ethnicity (for Asian respondents: Chinese [reference group], Vietnamese, Filipino, and Other Asian groups; for Latino respondents: Mexican [reference group], Cuban, Puerto Rican, and Other Latino groups). Acculturation includes five measures: age at migration to the U.S. (1 = before age 18, 0 = age 18 + ), citizenship status (1 = U.S. citizen, 0 = not a U.S. citizen), and frequency of English use (a continuous measure; see Alegria et al., 2004) based on the average score of three questions (e.g., “What language do you speak with most of your family?”) that query about English use among friends, family, and while thinking (1 = uses country-of-origin language all the time, and 5 = uses English all the time; ␣ = 0.86). Co-ethnic ties is based on the average response to four questions that ask respondents to rank how close they feel to people of their background (e.g., “How closely do you identify with others of the same racial/ethnic descent?”; ␣ = 0.66). In order to account for health status at migration we also measure the extent to which respondents migrated to the U.S. in order to seek medical attention (1 = not at all important, 2 = somewhat important, 3 = very important). We also assess measures of stress (see Alegria et al., 2004). Our predictor of interest is acculturative stress, a summed index (␣ = 0.71) based on responses to nine yes-no questions assessing the stress of migration-related change (e.g., “Have you felt guilty about leaving family or friends in your country of origin?”). We also control for the frequency of day-to-day discriminatory treatment on the basis of national origin/ancestry, race, or skin color (where 1 = never and 6 = almost every day), constructed from the average of nine questions about routine experiences with racial discrimination (e.g., being treated with less respect than other people; ␣ = 0.91). Negative social exchanges is an averaged index based on four questions that ask how frequently friends and family argue with and make too many demands on the respondent (where 1 = less than

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once a month and 5 = almost every day; ␣ = 0.68), while family cultural conflict is an averaged index (␣ = 0.78) based on five questions addressing issues of cultural and intergenerational conflict between respondents and families (e.g., arguments over different customs), where 1 = hardly ever or never, 2 = sometimes, and 3 = often. Also included are measures of social networks and support, including marital status and the number of persons living in the household. Additionally, positive social support is constructed from six questions (␣ = 0.73) that gauge the availability of support from friends and family, where 1 = less than once a month and 5 = almost every day. Family cohesion is constructed from 10 questions (␣ = 0.93) that gauge family closeness and communication, where 1 = hardly ever or never, 2 = sometimes, and 3 = often. Unless otherwise noted above, after finding no evidence of nonlinear associations, we treat these measures as continuous for the purposes of the analysis. We control for five measures of socioeconomic status, including years of completed schooling, employment status (1 = currently working, 0 = otherwise) and poverty status (1 = income below the 2001 federal poverty line, 0 = higher). Relative income is also included, where respondents rank from 0 to 10 how well off they are relative to all other people in the U.S. (where higher values = more well off), in addition to a measure of insurance status (1 = has medical insurance, and 0 = uninsured). Finally, we control for four health behaviors, including whether adults have a regular medical doctor who they usually visit for routine medical care (1 = yes, 0 = no), and smoking (current smoker, former smoker, and never smoked – reference). Heavy drinking is defined as 2+ drinks per day for women, and 3+ drinks per day for men (USDHHS, 2005), while respondents are classified as overweight or obese (1 = yes) based on their body mass index. 3.2. Analysis All analyses are weighted and were run using Stata 12.0, utilizing Taylor-series-approximate methods with SVY commands to adjust for the complex sample design of the NLAAS. Rates of item non-response are nonexistent or small (3% or less for all measures), and missing data on predictor measures were imputed using the multiple imputation ICE command in Stata 12.0. This study was approved by the appropriate institutional review board. We begin by presenting sample characteristics for foreign born adults, stratified by pan-ethnic identity (Asian vs. Latino) and gender. We then predict self-rated physical and mental health using a series of ordered logistic regression models (due to the categorical, non-normal, and ordered nature of the dependent measures). For Asian and Latino men and women, our models examine how acculturative stress relates to self-rated health (mental and physical), independent of demographic characteristics and other aspects of acculturation status and stress/support, socioeconomic status, and health behaviors. Following, we test whether relationships between acculturative stress and self-rated health are dependent upon the availability and receipt of social support by including interaction terms between acculturative stress and social support measures. For all interaction tests, we followed the format recommended by Hosmer and Lemeshow (2000) and tested interactions by first adding each term, one at a time, to the full multivariate model (Model 2 in Tables 2 and 3, for Asian and Latino men and women) and then evaluating significance and improvement in model fit. 4. Results 4.1. Descriptive statistics Table 1 presents weighted sample characteristics, stratified by pan-ethnic identity and gender, and shows that, on average, both Asian and Latino men self-rated their physical and mental health more positively than women. For Asian immigrants, this gender gap is significant for both mental and physical health, but for Latinos the gap is only significant for physical health. In addition to showing within pan-ethnic group gender differences, the table also displays between pan-ethnic group significant differences in our focal measures (health, acculturation, and stress, social networks, and support). On average, Asian immigrants rate their mental and physical health higher than do Latino immigrants. Men and women in both immigrant groups do not appear to differ significantly in their reported acculturative stress level, although as a group Latinos report significantly higher levels than Asians. In other measures of stress, the only significant difference observed between Asian men and women is for negative social exchanges, with men reporting slightly higher levels than women. Among Latinos, men report significantly more experiences with day-to-day discrimination, while Latinas report slightly higher levels of family cultural conflict. Across both ethnicities, other gender differences show prominently in SES, marital status, and health behaviors, largely mimicking patterns seen in other studies. 4.2. Ordered logit models: self-rated physical health In Table 2 we present coefficients from ordered logit models predicting self-rated physical health, stratified by pan-ethnic group and gender. For each group, two models are presented. Model 1 includes measures of demographic and acculturation status, in addition to measures of stress, social networks, and support. In Model 2 we add socioeconomic and health behavior measures as controls. Given our interest in whether relationships operate similarly for men and women, we confirm the significance of any observed gender differences by testing for the equality of coefficients across models for men and women within each pan-ethnic group (Clogg, Petkova, & Haritou, 1995).

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Table 1 NLAAS Foreign Born Adults: Sample Characteristics (Percentages and Means), by Pan-Ethnic Group and Gender. Immigrant Asian Adults

Immigrant Latino Adults

Female

Male

Female

Male

3.4 (1.1)* 3.7 (1.1)**

3.5 (1.0) 4.0 (1.0)

3.1 (1.1)*** 3.6 (1.1)

3.4 (1.2) 3.8 (1.1)

43.1 (13.9)

41.6 (14.7)

40.1 (16.2)*

37.9 (15.3)

16.5 21.0 31.0 31.5 – – – – 20.5 61.1 1.5 (0.8) 2.4 (1.1) 3.1 (0.6)

16.0 18.2 29.9 35.8 – – – – 26.4 57.3 1.4 (0.8) 2.5 (1.1) 3.1 (0.6)

– – – – 6.8 7.6 51.7 33.9* 36.1* 34.8 1.2 (0.7)* 1.6 (1.0)*** 3.1 (0.6)

– – – – 6.8 7.9 58.4 26.9 42.3 33.4 1.3 (0.7) 1.8 (1.0) 3.1 (0.6)

Stress, Social Networks, and Support Acculturative Stress† Number of Discriminatory Experiences Family cultural conflict† Negative social exchanges†

1.7 (1.5) 1.1 (0.9) 1.3 (0.4) 1.7 (0.6)*

1.9 (1.5) 1.3 (1.0) 1.3 (0.3) 1.8 (0.6)

2.4 (1.7) 1.1 (0.8)* 1.3 (0.4)* 1.6 (0.6)

2.3 (1.7) 1.3 (0.9) 1.2 (0.3) 1.7 (0.6)

Marital Status Married or cohabitating Divorced/separated/widowed† Never married Household size† Family Cohesion Positive social support

74.7 11.2*** 14.2** 3.0 (1.6) 3.7 (0.4) 2.5 (0.8)

73.9 4.0 22.1 2.9 (1.6) 3.7 (0.4) 2.4 (0.7)

65.5** 21.2*** 13.3 3.3 (1.6)* 3.6 (0.5) 2.6 (0.8)

74.8 7.5 17.7 3.0 (1.6) 3.7 (0.4) 2.5 (0.7)

Socioeconomic Status Currently working Years of schooling Relative Income Poor Has medical insurance

55.2*** 13.2 (3.7)*** 5.8 (2.0) 26.3* 88.4*

73.1 13.9 (3.2) 5.7 (2.0) 19.4 82.4

48.0*** 9.9 (3.9) 5.4 (2.2) 51.2*** 58.7

78.9 10.1 (3.8) 5.3 (2.0) 37.1 55.8

Health Behaviors Has a regular doctor

71.2***

62.0

63.3***

42.0

Smoking Status Current smoker Former smoker Never smoked Current heavy drinker Overweight or obese Sample Size

5.4*** 5.8*** 88.8*** 2.2*** 25.6*** 867

21.9 22.5 55.6 9.6 41.1 771

7.7*** 11.1*** 81.2*** 7.9*** 61.1*** 903

21.2 26.1 52.7 30.3 74.0 724

Self-Rated Physical Health (5 = excellent)† Self-Rated Mental Health (5 = excellent)† Demographic and Acculturation Status Age at interview Ethnicity Vietnamese Filipino Chinese Other Asian Cuban Puerto Rican Mexican Other Latino Migrated to U.S. before age 18† U.S. Citizen† Migrated to seek medical attention† Frequency of English use† Co-ethnic ties

Note: Standard deviation in (parentheses). * p ≤ 0.05 (two-tailed t-test, relative to same-group men). ** p ≤ 0.01 (two-tailed t-test, relative to same-group men). *** p ≤ 0.001 (two-tailed t-test, relative to same-group men). † p < 0.05 significant differences between Asians and Latinos in our focal measures (health, acculturation, and stress, social networks, and support).

Looking first at Asian immigrants, we see a significant and negative effect of acculturative stress on self-rated physical health in Model 1 for women only, but the coefficient is reduced to non-significance once we control for socioeconomic status and health behaviors in Model 2. Among Asian men, there is a positive association between family cohesion and self-rated physical health, while Asian women show significantly higher physical health scores if they are living in bigger households, are insured, are non-smokers, and are not overweight or obese; for both, further tests show that the size of these differences by gender is not significant. Relative income and younger age are significant predictors for both men and women; indeed, overall there are several similarities in the way measures relate to physical health scores among Asian immigrant men and women. Turning to Latino immigrants, Table 2 shows no direct relationship between acculturative stress and self-rated physical health among men or women. However, compared to Asians, the models appear to indicate more significant predictors

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Table 2 Coefficients from Ordered Logit Models, Self-Rated Physical Health by Ethnic and Gender Group. Asians (n = 1638) Females Model 1

Latinos (n = 1627) Males

Model 2

Model 1

Females Model 2

Model 1

Males Model 2

Model 1

Model 2

Demographic and Acculturation Status Age at interview −0.03 (0.01)*** −0.02 (0.01)* −0.03 (0.01)** −0.03 (0.01)** −0.04 (0.01)*** −0.03 (0.01)*** −0.01 (0.01)+ 0.00 (0.01)+ Ethnicity (reference: Chinese or Mexican) 0.40 (0.24) Vietnamese/Cuban Filipino/Puerto Rican 0.93 (0.21)*** 0.86 (0.26)** Other Asian/Other Latino Migrated to U.S. before age 18 −0.21 (0.30) 0.06 (0.20) U.S. Citizen −0.15 (0.13) Migrated to seek medical attention Frequency of English use 0.15 (0.10) Co-ethnic ties −0.02 (0.14)

0.45 (0.24) 0.18 (0.25) 0.97 (0.19)*** 0.18 (0.29)+ 0.98 (0.24)*** 0.67 (0.25)** −0.14 (0.31) −0.23 (0.20) 0.05 (0.17) 0.28 (0.18) −0.14 (0.11) −0.19 (0.12) 0.11 (0.11) 0.11 (0.14) −0.07 (0.15) 0.02 (0.19)

0.24 (0.28) 0.22 (0.31)+ 0.62 (0.26)* −0.25 (0.21) 0.19 (0.19) −0.21 (0.13) 0.06 (0.14) 0.01 (0.19)

0.76 (0.22)*** −0.12 (0.38) 0.24 (0.19) 0.17 (0.20) 0.18 (0.20) −0.23 (0.12)* 0.33 (0.10)** 0.14 (0.12)

0.43 (0.22) −0.14 (0.34) −0.05 (0.21) 0.11 (0.23) 0.07 (0.20) −0.22 (0.13) 0.21 (0.10)* 0.17 (0.14)

0.77 (0.22)*** 0.62 (0.24)* 0.10 (0.31) 0.03 (0.32) 0.70 (0.22)** 0.72 (0.23)** , + −0.13 (0.23) −0.11 (0.23) −0.41 (0.25)+ −0.41 (0.25) 0.08 (0.14)+ 0.09 (0.15) 0.40 (0.11)*** 0.31 (0.14)* 0.31 (0.18) 0.33 (0.18)

Stress, Social Networks, and Support −0.14 (0.05)** Acculturative Stress Number of discriminatory experiences−0.11 (0.08) Family cultural conflict 0.19 (0.32) 0.09 (0.18) Negative social exchanges

−0.10 (0.05) −0.10 (0.08) 0.24 (0.32) −0.04 (0.17)

−0.11 (0.05) −0.01 (0.08) −0.36 (0.31) −0.23 (0.16)

−0.09 (0.05) −0.01 (0.08) −0.32 (0.29) −0.22 (0.18)

−0.07 (0.08) 0.12 (0.11) 0.14 (0.22) −0.33 (0.13)*

−0.08 (0.07) 0.12 (0.11) 0.17 (0.21) −0.35 (0.14)*

−0.09 (0.08) −0.07 (0.08) 0.26 (0.06)*** 0.28 (0.07)*** −0.10 (0.41) −0.05 (0.42) −0.32 (0.14)* −0.33 (0.15)*

Marital Status (reference: Married or cohabitating) Divorced/separated/widowed −0.05 (0.29) Never married −0.24 (0.33) 0.11 (0.06) Household size 0.14 (0.27) Family cohesion Positive social support 0.14 (0.13)

0.14 (0.26) −0.03 (0.35) 0.16 (0.07)* 0.19 (0.29) 0.12 (0.13)

−0.21 (0.48) −0.08 (0.25) 0.04 (0.07) 0.56 (0.21)* 0.18 (0.15)

−0.14 (0.50) 0.16 (0.29) 0.05 (0.07) 0.57 (0.22)* 0.11 (0.14)

−0.00 (0.21) −0.30 (0.21) 0.03 (0.03) 0.45 (0.27) 0.21 (0.11)

0.10 (0.22) −0.15 (0.20) 0.08 (0.03)* 0.42 (0.22) 0.13 (0.13)

0.10 (0.39) 0.21 (0.28) 0.13 (0.07) 0.10 (0.21) 0.36 (0.15)*

Socioeconomic Status Currently working Years of schooling Relative Income Poor Has medical insurance

0.19 (0.18) −0.00 (0.02) 0.15 (0.06)* −0.40 (0.21) 0.54 (0.22)*

0.20 (0.28) −0.03 (0.04) 0.17 (0.05)*** 0.16 (0.32) 0.38 (0.24)

0.36 (0.17)* 0.09 (0.02)*** 0.03 (0.04) −0.27 (0.15) 0.34 (0.26)

0.58 (0.27)* 0.04 (0.03) 0.12 (0.05)* 0.10 (0.21) 0.07 (0.23)

Health Behaviors Has a regular doctor

−0.17 (0.19)

−0.01 (0.19)

−0.46 (0.23)*

−0.17 (0.17)

Smoking status (reference: never smoked) Current smoker Former smoker Current heavy drinker Overweight or obese

−0.57 (0.24)* −0.53 (0.39) 0.75 (0.54) −0.46 (0.23)*

−0.04 (0.28) −0.35 (0.23) 0.10 (0.23) −0.13 (0.20)

−0.25 (0.22) −0.46 (0.16)** −0.22 (0.20) −0.28 (0.16)

0.30 (0.21)+ 0.11 (0.23)+ 0.05 (0.26) −0.19 (0.29)

0.11 (0.41) 0.31 (0.33) 0.11 (0.07) 0.10 (0.21) 0.32 (0.15)*

p ≤ 0.05. p ≤ 0.01. *** p ≤ 0.001. + Coefficient in the corresponding same ethnic group model for women differs significantly from the coefficient for men, p < 0.05. Standard errors in (parentheses). *

**

of physical health, as well as more gender differences. For example, among Latinas, characteristics such as age, years of schooling, household size (in Model 2), and some health behaviors are more predictive; for Latino men, pertinent predictors include social network factors like discrimination and positive social support, as well as some SES factors. Further testing shows that the size of these effects does not differ between men and women. Both men and women in the Latino group show significantly poorer health with negative social exchanges and better health with more English use. While there is little evidence of a direct relationship between acculturative stress and self-rated physical health, it is possible that the two may interact indirectly. To this end, we examined whether the association between acculturative stress and physical health is dependent upon availability and receipt of social support by testing interactions between acculturative stress and the four measures of social networks and support listed in Table 2 (i.e., marital status, household size, family cohesion, and positive social support). None were significant for Asian immigrants, but among Latino immigrant men, we found a significant effect of marital status, such that never-married men have a significantly different relationship relative to married men (−0.23, p = 0.036) Cohabiting men, on the other hand, were not significantly different than married men. For ease of interpretation, we graph the predicted probability of reporting “excellent” physical health in Fig. 1. Because our outcome measure represents the full range of the self-reported health question, note that unlike many studies, we do not consolidate excellent and good health in this figure. It shows that while there is almost no relationship between acculturative stress and self-rated physical health for married (and cohabiting – not shown) Latino immigrant men, it is negative for never-

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Fig. 1. Predicted probability of excellent self-rated physical health among Latino men, by marital status & acculturative stress level. Model adjusted for all measures listed in Table 2, Model 2.

married men. Indeed, for Latino immigrant men who have never married, their predicted probability of reporting excellent health is highest at low levels of acculturative stress; but as acculturative stress increases, their probabilities converge with those for married men. 4.3. Ordered logit models: self-rated mental health In Table 3 we present ordered logit models predicting self-rated mental health in the same fashion as Table 2. For Asian immigrants we see a significant, negative relationship between acculturative stress and self-rated mental health only among men, and this association persists even after adjusting for control measures. For Asian men, self-rated mental health declines significantly with age, is lower among men migrating to the U.S. to receive some type of medical attention, and is higher when they have health insurance. Mental health of Asian women is predicted by smoking and relative income. However, additional tests for the equality of coefficients across models revealed that these effect sizes do not differ significantly between the two groups. Family cohesion is positively related to mental health for both Asian men and women. Examining the models for Latino immigrants in Table 3, again there is no direct relationship between acculturative stress and self-rated mental health for either men or women. Predictors of mental health seem sparser than they were for physical health. While women appear more significantly impacted by social factors including negative social exchanges, family cohesion, positive social support, and co-ethnic ties, these coefficients do not differ significantly from those of Latino men. Frequency of English use is a predictor for both men and women. We again explored the possibility that the association between acculturative stress and self-rated mental health is dependent upon the availability of social supports. Using the same testing sequences described for self-rated physical health, we identified two significant interactions: (1) positive social support for Latina women (0.13, p = 0.036), and (2) household size for Latino men (0.06, p = 0.049). While significant, it is important to note that the magnitude of both interactions is relatively small. First, we used the same predicted values procedure as Fig. 1 to graph the interaction between acculturative stress and positive social support among Latina immigrants (Fig. 2). Interestingly, there is a negative acculturative stress relationship with self-rated health only when received support is low; as positive social support rises, the relationship between acculturative stress and mental health flattens and then becomes positive among women who report that they receive “a lot” of support from friends and family. Fig. 3, which also predicts the probability of reporting excellent self-rated mental health, shows a similar relationship for Latino men: When Latino men live in small households – and especially when they live alone – the relationship between acculturative stress and mental health is negative; however, as household size increases this relationship becomes increasingly positive.

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Fig. 2. Predicted probability, excellent self-rated mental health among Latina women, by acculturative stress & positive social support. Model adjusted for all measures listed in Table 3, Model 2.

Fig. 3. Predicted probability, excellent self-rated mental health among Latino men, by acculturative stress & household size. Model adjusted for all measures listed in Table 3, Model 2.

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Table 3 Coefficients from Ordered Logit Models, Self-Rated Mental Health by Ethnic and Gender Group. Asians (n = 1638) Females Model 1

Latinos (n = 1627) Males

Model 2

Model 1

Females Model 2

Model 1

Males Model 2

Model 1

Model 2

Demographic and Acculturation Status Age at interview −0.02 (0.01) −0.01 (0.01) −0.02 (0.01)* −0.02 (0.01)* −0.02 (0.01)* −0.01 (0.01) −0.01 (0.01) 0.00 (0.01) Ethnicity (reference: Chinese or Mexican) 0.52 (0.24)* 0.67 (0.27)* Vietnamese/Cuban Filipino/Puerto Rican 1.15 (0.20)*** 1.13 (0.19)*** 1.19 (0.27)*** 1.21 (0.27)*** Other Asian/Other Latino Migrated to U.S. before age 18 −0.35 (0.28) −0.18 (0.25) U.S. Citizen 0.14 (0.23) 0.05 (0.23) −0.12 (0.09) −0.07 (0.08) Migrated to seek medical attention Frequency of English use 0.05 (0.12) −0.06 (0.11) Co-ethnic ties −0.03 (0.16) −0.14 (0.17)

−0.02 (0.20) 0.10 (0.19) 0.14 (0.23) −0.04 (0.35)+ 0.13 (0.37)+ −0.11 (0.24) 0.89 (0.28)** , + 0.90 (0.28)** , + 0.59 (0.19)** 0.04 (0.20) 0.06 (0.22) 0.18 (0.21) 0.06 (0.23) −0.01 (0.22) −0.08 (017) * −0.25 (0.14) −0.28 (0.14) 0.02 (0.12) 0.22 (0.13) 0.17 (0.13) 0.54 (0.09)*** −0.11 (0.21) −0.11 (0.20) 0.31 (0.15)*

Stress, Social Networks, and Support −0.06 (0.06) Acculturative Stress Number of discriminatory experiences −0.11 (0.09) Family cultural conflict 0.14 (0.25) 0.28 (0.17) Negative social exchanges

−0.03 (0.06) −0.08 (0.07) 0.22 (0.26) 0.08 (0.16)

−0.17 (0.06)* 0.16 (0.08)* , + −0.12 (0.28) 0.09 (0.16)

−0.15 (0.06)* 0.15 (0.08)+ −0.12 (0.28) 0.07 (0.14)

0.00 (0.05) −0.00 (0.05) −0.06 (0.07) −0.17 (0.10) −0.18 (0.12) 0.16 (0.08)+ −0.31 (0.20) −0.28 (0.20) −0.57 (0.37) −0.37 (0.18)* −0.39 (0.18)* −0.30 (0.21)

−0.04 (0.07) 0.16 (0.09)+ −0.56 (0.38) −0.37 (0.20)

Marital Status (reference: Married or cohabitating) Divorced/separated/widowed −0.37 (0.34) Never married 0.02 (0.33) 0.00 (0.05) Household size 0.52 (0.21)* Family cohesion Positive social support 0.20 (0.12)

−0.17 (0.38) 0.23 (0.34) 0.05 (0.06) 0.55 (0.24)* 0.17 (0.14)

−0.43 (0.34) −0.48 (0.22)* 0.02 (0.06) 0.80 (0.26)** 0.07 (0.15)

−0.33 (0.37) −0.25 (0.28) 0.02 (0.06) 0.83 (0.26)** 0.03 (0.15)

0.03 (0.22) −0.29 (0.23) −0.00 (0.06) 0.47 (0.22)* 0.33 (0.10)**

0.61 (0.45) 0.07 (0.32) 0.03 (0.06) 0.09 (0.22) 0.28 (0.15)

Socioeconomic Status Currently working Years of schooling Relative Income Poor Has medical insurance

0.26 (0.16) 0.05 (0.03) 0.24 (0.05)*** −0.17 (0.22) 0.38 (0.27)

0.19 (0.23) 0.01 (0.04) 0.07 (0.05)+ 0.23 (0.23) 0.56 (0.27)*

0.06 (0.14) 0.12 (0.02)*** −0.01 (0.04) −0.15 (0.13) 0.34 (0.20)

0.50 (0.23)* , + 0.02 (0.03)+ 0.07 (0.04) 0.10 (0.20) 0.34 (0.19)

Health Behaviors Has a regular doctor

−0.24 (0.20)

0.13 (0.18)

−0.22 (0.15)

−0.21 (0.23)

Smoking status (reference: never smoked) Current smoker Former smoker Current heavy drinker Overweight or obese

−1.05 (0.37)** −0.70 (0.26)** 0.56 (0.48) 0.08 (0.17)

−0.11 (0.21)+ −0.36 (0.27) −0.40 (0.22)+ 0.16 (0.19)

0.01 (0.24) −0.17 (0.20) −0.39 (0.26) −0.11 (0.14)

−0.01 (0.30) −0.36 (0.23) 0.02 (0.21) −0.04 (0.26)

−0.31 (0.22) −0.25 (0.27) 0.27 (0.19) 0.17 (0.24) −0.22 (0.17) 0.05 (0.12) 0.41 (0.10)*** 0.40 (0.14)**

0.12 (0.21) −0.17 (0.24) 0.05 (0.06) 0.46 (0.23)* 0.25 (0.11)*

0.52 (0.23)* 0.38 (0.27)+ 0.17 (0.35) 0.11 (0.35) 0.73 (0.25)** 0.69 (0.26)** −0.50 (0.27)+ −0.52 (0.27)+ −0.25 (0.20) −0.23 (0.20) −0.25 (0.17) −0.21 (0.18) 0.51 (0.10)*** 0.45 (0.12)*** 0.28 (0.16) 0.28 (0.17)

0.50 (0.42) −0.03 (0.26) 0.07 (0.05) 0.11 (0.21) 0.32 (0.14)*

p ≤ 0.05. p ≤ 0.01. *** p ≤ 0.001. + Coefficient in the corresponding model for same ethnic group women differs significantly from the coefficient for men, p < 0.05. Standard error in (parentheses). *

**

5. Discussion Our findings paint a complex picture in which acculturative stress may not have a direct impact on health for Asian and Latino immigrants but plays an underlying role. Descriptively, Latinos report higher levels of acculturative stress and poorer physical and mental health relative to Asians, which is consistent with previous research (Alderete, Vega, Kolody, & AguilarGaxiola, 2000; Finch, Kolody, & Vega, 2000). In our analysis, for Latino immigrants acculturative stress showed no significant association with either physical or mental health, and for Asian immigrants there was some evidence of a direct relation – specifically, with physical health among women and mental health among men – but only the latter persisted after adjusting for controls. Some prior scholarship has found a more direct relationship between acculturative stress and health (Krueger & Chang, 2008); John et al. (2012), for example, found that acculturative stress was significantly associated with past-year depression and mental disorders among Asians, but use a slightly different scale which they state more directly captures “stresses of social and economic integration upon immigration (pg. 2096).” Specific measures may thus be an important factor in whether acculturative stress emerges as a predictor. Acculturative stress does indeed matter when considered along with gender and social networks. First, consistent with prior findings, our descriptive results show that women score significantly worse on both types of health among Asians, and physical health among Latinos. Our logit models indicate the salience of social support as a buffer against deleterious health effects for both groups, in keeping with prior literature (Mulvaney-Day et al., 2007); the salience of family cohesion

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in particular for the Asian cohort has been found previously (Zhang & Ta, 2009). Specifically, interaction effects show that the relationship between acculturative stress and health is moderated by positive social support for Latinas (mental health), and by household size and marriage/cohabiting relationships for Latino men (mental and physical health, respectively). The importance of social support in Latina mental health has been emphasized in both quantitative and qualitative literature, while sociological trends indicate that living in a nuclear family may be the ideal family structure for men’s’ health (Denton & Walters, 1999). A specific health-buffering impact of household support did not emerge in our literature review, but this may be related to the relatively small number of studies that employ this variable while stratifying by gender. In fact, Vega et al. (1991) found that among Mexican immigrant women, higher family support is predicted, among other things, by more children living in the home. They also illustrate the complexity of social network composition and the relation of its components to health. We suggest that incorporating family or household size into social support concepts may be useful in future studies. Given that women in both groups appear to be socioeconomically disadvantaged to men despite having more positive health behaviors overall, we might expect to see evidence for social support as a moderator among Latina and Asian women, but this was not the case. Nor did our results demonstrate a moderating role for social support in the Asian cohort, although other studies have done so. Researchers have commented on Asian cultural expressions of distress (John et al., 2012) which may be a factor. Furthermore, the interaction effects that did emerge indicate that with household size for men and positive social support for women, the relationship between acculturative stress and mental health is even positive among Latinos. Possibly, the availability of the right kinds of support structures may turn the stress of integrating into a new society into a chance for the constructive negotiation of cultural identity, which could ultimately benefit mental health. Taken together, these findings echo previous research that indicates the highly nuanced role of specific types of social support that differ by immigrant group and gender. Overall, there is a need for increased conceptualization of the meaning of acculturative stress, and the way it is expressed by gender and culture. Researchers also have argued for a broader consideration of racial identity and host culture perspectives with regards to immigrant well-being (Tummala-Narra et al., 2012). Similarly, factors that constitute social support which buffer potential threats from stress or challenges to cultural identity can vary. Conceptually, a more detailed approach toward social support would be valuable, such as Jasinkaja-Lahti et al. (2006) who distinguish between usage and availability of supports. (Kimbro, Gorman, & Schachter, 2012) also suggest that language use could be more carefully studied as a form of connection to members of the same background or social network. Our study is not without limitations. First, while we conducted parallel analyses on each pan-ethnic group, the group differences were primarily based on gender. Scholars have noted the importance examining specific contexts behind migration (e.g. Abraído-Lanza, Armbrister, Flórez, & Aguirre, 2006; Dyck & Dossa, 2007), and expanding the current analyses to examine differences by ethnicity or national origin would be useful. Second, our study relies on cross-sectional data, yet the concept of acculturative stress is intrinsically tied to changes over time and can only be completely assessed by following individuals throughout their migratory experience. In a study examining mental health and time spent in the United States (but not nativity) among Latinos in an NLAAS sample, Cook, Alegría, and Lin (2009) posit the influence of multistage pathways toward specific acculturation-associated health effects, and there is other evidence that the nature of immigrant social supports may change over time as well (Vega et al., 1991). Finally, this analysis focused only on foreign-born adults but social support may occur in networks with a blend of legal immigrants, the US-born, and undocumented immigrants. 6. Conclusion Research has documented the importance of stresses of the acculturation process in relation to immigrant health and well-being, with poorer health outcomes being linked to higher levels of acculturative stress (Gil, Vega, & Dimas, 2006). In this study we examined how acculturative stress impacts self-rated physical and mental health among Asian and Latino immigrants, and whether this impact differs by gender within each group. Whereas some researchers posit that acculturation trends are similar between Asian and Latino immigrants (Shin, 1993; Sam & Berry, 1997), we find on a more fine-grained level that these groups experience migration-related stress differently. We also find, like some prior research, acculturative stress does not appear to be a driver of health on its own in most cases, but interacts with social support to have a gendered impact on health among Latino immigrants. A substantial body of literature, including other analysis of NLAAS data, already highlights the pivotal but complex dynamics between social support, acculturation, and health (Bird & Rieker, 2008; John et al., 2012; Gorman & Read, 2006). The present study lends evidence toward the moderating role of social support among Latino immigrants and calls for further conceptualizations of social support with regards to immigrant well-being. References Abraído-Lanza, A. F., Armbrister, A. N., Flórez, K. R., & Aguirre, A. N. (2006). Toward a theory-driven model of acculturation in public health research. American Journal of Public Health, 96(8), 1342–1346. Alderete, E., Vega, W. A., Kolody, B., & Aguilar-Gaxiola, S. (2000). Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farmworkers in California. American Journal of Public Health, 90(4), 608. Alegria, M., Vila, D., Woo, M., Canino, G., Takeuchi, D., Vera, M., et al. (2004). Cultural relevance and equivalence in the NLAAS instrument: Integrating etic and emic in the development of cross-cultural measures for a psychiatric epidemiology and services study of Latinos. International Journal of Methods in Psychiatric Research, 13(4), 270–288.

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