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The authors reviewed the acculturation literature with the goal of identifying measures used to assess acculturation in Hispanic populations in the context of studies of health knowledge, attitudes, and behavior change. Twenty-six acculturation measures were identified and summarized. As the Hispanic population continues to grow in the United States, there is a need to develop rigorous acculturation measures that include health indicators. Findings suggest that multidimensional acculturation scales are robust measurement tools when assessing nationality, cultural awareness, media and language preferences, and health status. Furthermore, aspects of Hispanic cultural lifestyle, such as beliefs about nutrition and physical activity, affect health care utilization, treatment, and prevention. Health communication researchers should consider aspects of cultural values and beliefs, and their impact on health status, for future research and health promotion interventions.
It is important to consider acculturation in a health context because it contributes to our understanding of the economic, social, and health care needs of Hispanic residents. For example, recent studies have explored positive relations between acculturation and prevalence on chronic disease, cancer screenings, utilization of health services, and health-seeking behaviors among Hispanics (Oetzel, DeVargas, Ginossary, & Sanchez, 2007; Solis & Pulley (1995). Hazuda, Stern, & Haffner (1988) postulated that place of origin and food preferences could be social determining factors for obesity and diabetes. Low literacy rates among 716 Mexican American farmworkers appeared to have a negative impact on mammography screening compliance (Palmer, Fernandez, Tortolero-Luna, Gonzalez, & Mullen, 2005). More acculturated Hispanic men and women experience better health outcomes. Similarly, a study conducted by Peréz-Escamilla and Putnik (2007) found that bicultural individuals reported better health outcomes. Acculturation can be a significant factor in health promotion efforts targeting U.S. Hispanic populations.
Taking acculturation into consideration informs the research design and ultimately development of culturally appropriate health interventions (Wallen, Feldman, & Aniker, 2002). For example, Latino cultural beliefs about causes of illness, treatment, and ways to prevent illness are significantly affected by religion, fear, and fatalism. These beliefs in turn influence health care utilization. Outside forces, supernatural forces, evil spirits, punishment from God, or hexes by brujas (witches) are perceived causes for physical disharmony (Murguía, Zea, Reisen, & Peterson, 2000). These perceptions may act as barriers to healthy lifestyle change and must be considered in any health promotion intervention.
This review aims to provide health researchers with a (a) synthesis of published acculturation measures in the context of health promotion research, (b) concept of acculturation as one of many factors influencing the health of Hispanics in the United States, (c) critical review of two acculturation measures frequently cited in the literature, and (d) recommendations for incorporating concepts of acculturation into the design, implementation, and evaluation of health interventions.
The concept of acculturation has its roots in anthropology but has been used in other disciplines such as psychology, sociology, and public health. In 1895, American anthropologist Otis Tufton Mason, who studied ethnographic differences among Native Indians, Alaskan Natives, and Africans relative to New World Europeans, coined the term acculturation (Herskovits, 1958) In 1905, German scholar Paul Ehrenreich conducted extensive anthropological research describing “areas of acculturation” in his work among South American tribes focused on language and mythology (Herskovits, 1958). Cuéllar, Arnold, and González (1995) postulated that acculturation theory involves psychological acculturation along cognitive and behavioral domains to understand cultural change among immigrant groups. In present use, acculturation refers to cultural change from the place of origin to the adoptive host society (Dana, 1996; Herskovits, 1958). Acculturation can be viewed as the vehicle to assimilation by cultural adoption of the host society’s norms, values, behaviors, and attitudes. Peréz-Escamilla and Putnik (2007) and Dawson, Crano, and Burgoon (1996) defined acculturation as the process by which cultural groups adopt the customs and behaviors of a new culture.
With a rich history spanning more than a century it is not surprising that while definitions of acculturation all refer to cultural change, there is a large degree of variability in how acculturation is defined. The word acculturation was first introduced into Webster’s Unabridged Dictionary in 1928 as “the approximation of one human race or tribe to another in culture or arts by contact” and in 1934 was revised to “the approximation of one’s social group of people to another in culture or arts by contact.”
In light of the varying definitions of acculturation, it is important to apply acculturation constructs to understanding the health of individuals moving from one society to another. Cultural lifestyle beliefs associated with dietary habits, patterns of physical inactivity, and use of folk remedies affect the development of certain diseases. Indigenous beliefs about health affect health-seeking behaviors, utilization of health services, treatment, and prevention practices, such as health education and initial and repeat health screenings.
We conducted an in-depth review of the literature employing electronic databases such as OVID, MEDLINE, and CINAHL (January 1979 to December 2006) of English-language peer-reviewed journals. Other search strategies included conducting a hand search of key journals for articles not indexed in the databases, mining reference lists of all articles in this review, and consulting noted anthropology and public health experts in the field. Keyword terms and different permutations included iterations of Hispanic, Latino, Mexican Americans, and Central and South Americans and the following terms: acculturation + [Hispanic/Latino], [Hispanic/Latino, nutrition], [Hispanic/Latino, physical activity], [Hispanic/Latino, fruits and vegetables], and [Hispanic/Latino, cancer, attitudes, fear, fatalism]. Articles were included in the review if they reported an acculturation measure and its psychometric properties (e.g., reliability, validity), explored a relationship between acculturation and health status, or applied acculturation theory (i.e., confluence of cultural norms and language preferences) to assess health behaviors and attitudes. A total of 69 acculturation instruments were found, 11 in published studies and 58 in an unpublished report focused on all minority groups, such as African Americans, Hispanics, and Asian (Taras, 2007).
The search yielded 851 acculturation/Hispanic articles, 85 acculturation/physical activity articles, and 277 acculturation/nutrition articles. Thirty-one articles were selected because they met the study criteria. Twenty-six articles included the acculturation scales in the study (as listed in Table 1). Two studies were excluded because they addressed Asian immigrants (Salant & Lauderdale, 2003) including Korean Americans (Lee, Sobal, & Frongillo, 2000). However, these studies were helpful in assessing the influence of acculturation on minority health post arrival into the host society.
There were few published acculturation measures that included scales to assess Hispanics’ knowledge, attitudes, and health risk behaviors; therefore, a few researchers opted to develop their own assessment tools (Hazuda et al., 1988; Murguía et al., 2000; Zea, Asner-Self, Birman, & Buki, 2002). The 24-item Cultural Health Attributions Questionnaire (Murguía et al., 2000) and 31-item Hazuda Acculturation and Assimilation Scale (Hazuda et al., 1988) were developed to measure Latino health beliefs influenced by religion on occurrence of illness and chronic disease. Understanding the association between acculturation and health beliefs is essential when conducting health research or developing culturally sensitive health promotion interventions.
Table 1 lists selected acculturation measures. Measures of acculturation are widely used today to assess the impact of acculturation perceptions of nationality, kinship, cultural processes, and perceived health beliefs (Oetzel et al., 2007; Peréz-Escamilla & Putnik, 2007). These scales attempt to quantify participants’ cultural and social knowledge, behaviors, and attitudes on responses to length of time in the United States, place of birth, subjective measures of acculturation, and language and media preferences. Several different models of acculturation measures have been proposed. Unidimensional models refer to a (a) linear continuum from total immersion in one’s place of origin or to the host’s culture and (b) describe assimilation by becoming part of the new culture (Lara, Gamboa, Kahramanian, Morales, & Bautisa, 2005). Bidimensional models account for ethnic diversity and refer to the extent to which individuals move comfortably between their place of origin’s culture and the adopted host society (Padilla, 1980).
Table 2 provides a detailed summary of 26 acculturation measures that focused on Hispanics. Scales ranged from 4 to 62 items (N = 21). Authors who used a 4-item scale did so to minimize respondent burden, particularly when language skills were not optimal. Wallen et al. (2002) and Norris Ford, and Bova (1996) commented that a short 4-item measure is simple, inexpensive, and involves minimal respondent burden. Assessment tools were most often administered by paper and pencil and, to a lesser degree, face-to-face interviews in the Spanish language (Wallen et al., 2002). Overall, internal consistencies ranged from .60 to .98. The psychometric properties of these scales are summarized in Table 2.
Three acculturation measures that are well researched and validated in the literature include the 20-item Acculturation Rating Scale for Mexican Americans (ARSMA), 12-item ARSMA-II (Cuéllar, Arnold, & Gonzalez, 1995), and the 12-item Bidimensional Acculturation Scale for Hispanics (BAS; Marín, Sabogal, Marín, Otero-Sabogal, & Perez-Stable, 1996). The ARSMA is one of the earliest measures, nearly two decades old. It assesses language used at home and with friends. Recent studies have employed the ARSMA as a supplemental acculturation measure. The utility of this measure was supported by Bauman’s (2005) analysis of the reliability and validity of the ARSMA-II. The ARSMA has implications for use among non-Hispanic groups because of its ability to record contextually rich facts about ethnic culture. The BAS may be favorable because of its applicability for assessment of a wide range of minority typologies within an ethnic group. For example, ethnic groups might include Puerto Ricans, Cubans, Dominicans, and Guatemalans.
Two acculturation scales developed by Marín et al. (1987) and Marín and Gamba (1996), the Bidimensional Acculturation Scale for Hispanics and the Short Acculturation Scale for Hispanics, respectively, offered the greatest degree of applicability when measuring “language use and ethnic loyalty.” Positive characteristics of these measures include (a) brevity, (b) multiple Hispanic subgroups, (c) appropriate reliability and validity, (d) ease of administration in varied settings, (e) English and Spanish versions, and (f) multidimensional domains (e.g., ethnicity, education, and generation).
The ARSMA and BAS attempt to assess the traditional aspects of Hispanic culture, such as language, cultural identify, social networks, place of origin, and media preferences, that is, the fabric of Hispanic cultural experiences. These measures have been employed to assess acculturation among minority groups in conjunction with other behavioral surveys that assess perceptions about mammography screening, healthy eating, and physical activity.
We have identified the following general recommendations based on this review of the literature:
The use of acculturation as a determining factor on the health of Hispanics living in the United States is complex. The enormous influx of Hispanics into mainland United States presents a unique opportunity to assess health care utilization needs and provide delivery systems in these groups. Such studies help in understanding the health impact of poverty, low literacy, limited education, and various religious practices. Health promotion activities should consider the influence of acculturation norms, values, and beliefs as these constructs are critical to the population health approach. Furthermore, social, cultural, and economic factors can be barriers to health-seeking behaviors and, ultimately, health care utilization, prevention, and treatment plans. Recognition of the cultural influences of acculturation challenges health researchers to incorporate acculturation measures and health promotion models for future planning, social marketing, implementation, and evaluation of health initiatives. This study was a broad overview of the literature and has several limitations. Several of the studies available in the databases were conducted with Mexican immigrants and its cultural norms. Future studies of acculturation and health among Hispanics should include a broader array of important characteristics such as the influence of religion, fatalismo, and family support in addition to place of origin and language.
The authors disclosed receipt of the following financial support for the research and/or authorship of this article:
Research in this article was funded by grants from the National Cancer Institute (NO2-CO-01002-75) and the New England Cancer Information Service (NO2-CO-51100).
Phyllis M. Wallace received her PhD in public health with a specialization in community health promotion and education in 2007 from Walden University. Currently, she is employed as a National Cancer Institute, Cancer Information Service-New England Senior Research Coordinator (SRC) at Yale University’s Comprehensive Cancer Center in New Haven, Connecticut. In her role as an SRC she is responsible for implementing the CIS-NE research agenda while collaborating with investigators to test cancer communication and education interventions to promote health behaviors. Her research focuses on employing behavior change theories and community-based participatory methods to improve health disparities among underserved and understudied populations through research, programming, and policy. She also serves as a National Society for Public Health Education Resolutions Committee Cochair with oversight for health policy development and dissemination.
Elizabeth A. Pomery received a PhD in social psychology in 2008 from Iowa State University. She is currently a postdoctoral associate at the Health, Emotion, and Behavior Laboratory at Yale University. She is currently studying the effects of message framing and tailoring, specifically in relation to messages designed to increase fruit and vegetable consumption, as well as physical activity. She is interested in research that examines health behaviors and cognitions using a social psychological theoretical framework.
Amy E. Latimer is a Queen’s National Scholar and assistant professor in the School of Kinesiology and Health Studies at Queen’s University in Kingston, Ontario, Canada. She completed her master’s and PhD at McMaster University in Canada and went on to complete a 2-year postdoctoral fellowship in the Health, Emotion, and Behavior Lab at Yale University. Her research focuses on identifying the factors that motivate people to adopt healthy behaviors and testing motivational interventions to encourage people to make healthy lifestyle choices. In addition to her research and teaching duties, she is a founding member and the project director for Kingston Revved Up, an exercise program for community dwelling adults with mobility impairment.
Josefa L. Martinez received her MHS in international public health with a concentration in social and behavioral interventions in 2006 from Johns Hopkins University. She is currently a research associate at the Health, Emotion, and Behavior Laboratory at Yale University. She is currently involved in research examining the effectiveness of persuasive messages for eliciting health behavior change. She is conducting behavioral experiments examining the utility of tailored health materials to promote fruit and vegetable consumption and physical activity among the medically underserved across the cancer continuum. Her research interests include the design and evaluation of community-based behavior change interventions for underserved populations in cancer prevention, HIV prevention, substance abuse treatment, and mental health service provision, both nationally and internationally.
Peter Salovey is the Provost of Yale University and is the Chris Argyris Professor of Psychology. He joined the Yale faculty in 1986 after receiving an AB and MA from Stanford University and a PhD from Yale University. He has authored or edited 13 books translated into 11 languages and published more than 350 journal articles and essays, focused primarily on human emotion and health behavior. With John D. Mayer he developed a broad framework called “Emotional Intelligence,” the theory that just as people have a wide range of intellectual abilities, they also have a wide range of measurable emotional skills that profoundly affect their thinking and action. He investigates, in his research on health behavior, the effectiveness of health promotion messages in persuading people to change risky behaviors relevant to cancer and HIV/AIDS.
Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this.