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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
J Clin Exp Neuropsychol. Author manuscript; available in PMC Oct 1, 2013.
Published in final edited form as:
PMCID: PMC3434263
NIHMSID: NIHMS374266
Multidimensional effects of acculturation on English-language neuropsychological test performance among HIV+ Caribbean Latinas/os
Alyssa Arentoft,1,2 Desiree Byrd,3,4 Reuben N. Robbins,5 Jennifer Monzones,1,6 Caitlin Miranda,1 Ana Rosario,1,7 Kelly Coulehan,1 Armando Fuentes,1 Kaori Kubo Germano,1 Erica D’Aquila,1 Jake Sheynin,1 Felicia Fraser,1 Susan Morgello,3,8 and Monica Rivera Mindt1,3,4
1Department of Psychology, Fordham University
2Department of Psychology, West Los Angeles VA Healthcare Center
3Department of Neurology, Mount Sinai School of Medicine
4Department of Psychiatry, Mount Sinai School of Medicine
5HIV Center for Clinical and Behavioral Studies, Department of Psychiatry, Columbia University and the New York State Psychiatric Institute
6Department of Psychology, New Mexico VA Healthcare Center
7College of Arts and Science, New York University
8Departments of Pathology & Neuroscience, Mount Sinai School of Medicine
Acculturation has been linked to neuropsychological performance in several ethnic groups. However, research among Latina/o samples has examined primarily Mexican/Mexican Americans, and has not examined Latina/o clinical populations of Caribbean descent. This study examined associations between a multidimensional acculturation measure and neuropsychological performance among 82 HIV+ Caribbean Latina/o adults. Multivariate results showed that U.S. acculturation significantly predicted 11–14% of the variance in Global Neuropsychological functioning, Verbal Fluency, and Processing Speed, whereas Latina/o acculturation predicted 8% of the variance in Executive Function and 6% in Motor Function (trend level associations). Both linguistic and non-linguistic cultural factors had distinct effects on neuropsychological performance.
Accurately diagnosing neuropsychological impairment is essential to treating individuals with diseases that affect the brain. Research consistently shows that ethnic minorities are more likely to be misdiagnosed as neuropsychologically impaired than non-Hispanic whites due to artificially depressed neuropsychological test scores (Boone et al., 2007; Campbell et al., 2002; Heaton et al., 2009; Manly et al., 1998a). Acculturation, the process by which individuals are influenced and changed through exposure to another culture (Zea et al., 2003), may be one factor contributing to this discrepancy. In fact, greater acculturation to majority (e.g., U.S.) culture among African Americans, Asian Americans, and Latinas/os has been significantly associated with better neuropsychological performance in a number of neuropsychological domains, including executive function, attention/working memory, verbal fluency, learning, memory, and processing speed (Arnold et al., 1994; Boone et al., 2007; Coffey, Marmol, Schock, & Adams, 2005; Harris, Cullum, & Puente, 1995; Harris, Tulsky, & Schultheis, 2003, Kennepohl et al., 2004; Manly et al., 1998b). However, there are several important gaps in this current literature that merit further consideration.
The current literature on acculturation and neuropsychological functioning is limited by the circumscribed or unreported sampling of Latina/o participants, despite the fact that the Latina/o population is the largest and fastest growing racial/ethnic minority population in the U.S. (U.S. Census Bureau, 2006a, U.S. Census Bureau, 2006b, U.S. Census Bureau News, 2008). The U.S. Latina/o population is highly heterogeneous, with distinct subpopulations of different geographic origins (i.e., Mexico, the Caribbean, Central America, and South America) and racial admixtures (i.e., indigenous, African, and European). Each Latina/o subpopulation has a unique set of sociopolitical and cultural circumstances, as well as non-random geographic affinity (Llorente, 2007). The research accomplished to date with Latina/o adults has focused primarily on individuals of Mexican/Mexican American origin and has not examined other Latina/o groups (Coffey et al., 2005). Therefore, acculturation and neuropsychological functioning need to be assessed among other Latina/o subgroups, including those of Caribbean origin (Lopez-Class et al., 2011). Research has shown that factors considered to be proxies of acculturation, such as length of time living in U.S., years of education in the U.S, or language-related variables, such as language preference, English language competence, or bilingualism, are related to both English and Spanish-language neuropsychological test performance (Artiola i Fortuny, Heaton, & Hermosillo, 1998; Berry et al., 2003; Jacobs, et al., 1997a, 1997b; Harris, et al., 1995; Taussig et al., 1996). However, proxy variables provide only an indirect estimate of acculturation (Lopez-Class, González Castro, & Ramirez, 2011). Recent theory and research suggest that acculturation is a multidimensional construct and requires bidirectional measurement of acculturation to both the majority culture and the culture of origin (Abe-Kim, Okazaki, & Goto, 2001; Lopez-Class et al., 2011; Zea et al., 2003). Linguistic and non-linguistic cultural factors may also have distinct effects on neuropsychological performance; since they have not been examined separately and directly, they remain poorly understood. To our knowledge, no study to date has examined the associations between neuropsychological test performance and multidimensional measures of acculturation to both the dominant and non-dominant culture in Latina/o individuals.
Another limitation of the current literature is that few studies have examined the impact of acculturation in clinical populations. Prior studies have reported relationships between acculturation and neuropsychological functioning among neurologically healthy Latina/o adults (e.g., Arnold et al., 1994), heterogeneous samples including multiple clinical populations (i.e., neurologic, substance use, and psychiatric) of ethnic minority individuals (i.e., African American, Latina/o, Asian American; Boone et al., 2007), or specific clinical populations (e.g., HIV+, traumatic brain injury) within the African American community (Manly et al., 1998b; Kennepohl et al., 2004). However, research has not yet specifically examined these relationships within Latina/o clinical populations. This is of particular concern given that U.S. Latinas/os are disproportionately impacted by several chronic medical conditions, including HIV/AIDS (Centers for Disease Control [CDC], 2008a; CDC, 2008b), increasing their risk for neurologic complications and their need for neuropsychological services (see Rivera Mindt et al., 2010). In fact, poorer neuropsychological test performance has been reported among HIV+ Latina/o adults compared to their non-Hispanic white counterparts (Wojna et al., 2006), particularly in the area of executive function (Rivera Mindt et al., 2008). Therefore, focused research on acculturation among Latina/o cohorts is needed to help clarify these findings.
The present study sought to characterize the relationship between acculturation and neuropsychological test performance among a sample of HIV+ Latina/o adults of Caribbean origin. This study addresses the limitations of previous research by employing a multidimensional, bidirectional measure of acculturation and a well-characterized sample of Latina/o adults of exclusively Caribbean origin.
We hypothesized that U.S. acculturation in the domains of English Language Competence, U.S. Cultural Competence, and U.S. Cultural Identity would be significantly and positively associated with global and domain-specific neuropsychological (NP) test performance. Conversely, we hypothesized that Latina/o acculturation levels in the domains of Spanish Language Competence, Latina/o Cultural Competence, and Latina/o Cultural Identity would be significantly and negatively associated with global and domain-specific neuropsychological test performance. Finally, we hypothesized that summary scores of overall acculturation to U.S. and Latina/o cultures would predict a significant amount of the variance in neuropsychological test performance using multivariate regression models.
Participants
The current study sample included 82 HIV+ Caribbean Latina/o adults who participated in an NIMH-funded medication adherence study (PI: M. Rivera Mindt, PhD; K23MH079718). Participants were primarily recruited via community outreach in New York City, particularly East [Spanish] Harlem, and through self-referral. Additional recruitment occurred through clinics and related studies at the Mount Sinai School of Medicine (MSSM) in New York City.
All participants were HIV+ (confirmed by medical records), between the ages of 18–80, fluent in English and on stable antiretroviral therapy (at least 12 weeks on regimen). Only participants who self-identified as Latina/o and identified as being of Caribbean origin (e.g., Puerto Rico, Dominican Republic, Cuba) were included in the study. This study’s exclusion criteria included self-reported history of any the following conditions that could impact cognition: severe psychiatric disorder (e.g., schizophrenia, psychosis, bipolar disorder) or significant non-HIV related co-morbid neurologic or medical condition (e.g., epilepsy, brain cancer or tumor, traumatic brain injury with loss of consciousness >60 minutes, neurosurgery, Lupus, Multiple Sclerosis, Parkinson’s disease).
Procedure
Participants completed comprehensive neuropsychological and sociocultural evaluations. Blood samples were collected, from which CD4 lymphocyte counts [a measure of immunosuppression] and HIV plasma viral loads were assessed. All participants provided written informed consent. The study was approved by the Institutional Review Boards (IRB) of both Mount Sinai School of Medicine and Fordham University.
Neuropsychological Evaluation
Participants completed a comprehensive three hour neuropsychological test battery, which was administered and scored by trained psychometrists using standardized procedures. Table 1 summarizes the measures used, which assessed functioning in the following seven domains: verbal fluency, executive function, processing speed, attention/working memory, learning, memory, and motor function. Raw scores were converted to age-, education-, and/or gender- corrected T-scores using the best available published normative data (see Table 1). However, for consistency, Latina/o ethnicity corrections were not applied to the three WAIS-III subtests since similar ethnicity corrections were not available for the other NP tests. T-scores were then converted to global and domain specific deficit scores (DS), which provide a more sensitive index of neuropsychological impairment and are frequently used in HIV+ populations who often present with more subtle neuropsychological deficits (see Carey et al., 2004 for a description). Deficit scores (DS) range from 0–5, with higher scores indicating greater impairment (0 = no impairment, 5 = severe impairment). Individual tests within each domain were averaged to obtain mean domain deficit scores. All neuropsychological test deficit scores were averaged to derive the Global Deficit Score (GDS), a measure of global neuropsychological functioning. Definitions of clinical impairment were based on cut-offs established by prior research (Woods et al., 2004), and a GDS score of ≥ 0.50 was considered impaired (Carey et al., 2004). Participants also completed the substance abuse modules of the Composite International Diagnostic Interview (CIDI; World Health Organization, 1997), which yields DSM-IV diagnoses of current substance abuse disorder.
Table 1
Table 1
Normative Data Sources for Neuropsychological Tests
Sociocultural Evaluation
Participants were interviewed regarding their sociocultural and ethnic background (e.g., country of origin, ethnicity, languages spoken, etc.), and completed the Abbreviated Multidimensional Acculturation Scale (AMAS; Zea et al., 2003), a self-report acculturation questionnaire. This brief questionnaire assesses both U.S. and Latina/o (i.e., culture of origin) acculturation levels, and is comprised of six subscales, three for each U.S. and Latina/o acculturation domain. Responses to individual items on each subscale are averaged to create the subscale score: 1) Language Competence (English and Spanish, respectively; assessed by 9 test items each; possible raw scores range from 9–36; subscale scores range from 1–4); 2) Cultural Competence (U.S. and Latina/o, respectively; assessed by 6 test items each, possible raw scores range from 6–24; subscale scores range from 1–4); and 3) Cultural Identity (U.S. and Latina/o, respectively; assessed by 6 test items each; possible raw scores range from 6–24; subscale scores range from 1–4). In all of these subscales, higher scores reflect higher levels of acculturation. From these subscales, two summary measures of acculturation were computed: 1) Total U.S. Acculturation Score and 2) Total Latina/o Acculturation Score, with possible scores ranging from 1–4 for each summary score. Cronbach’s alpha coefficients ranged from .83 to .97 across AMAS subscales, and the AMAS has shown adequate validity and has been used previously with HIV+ populations (Zea et al., 2003; Zea et al., 2004).
Statistical Analyses
The Statistical Package for the Social Sciences (SPSS) Version 18.0 was used to analyze the results. All variables were normally distributed with the exception of plasma HIV viral load, which was then log transformed. Pearson correlations and linear multiple regressions were computed. A p-level of 0.05 was used to determine statistical significance. As mentioned above, average deficit scores for each neuropsychological domain and global neuropsychological functioning were used as dependent variables. Higher average deficit scores reflect worse neuropsychological functioning (i.e., negative correlations between the AMAS subscales and the NP average deficit scores suggest that higher AMAS scores are associated with better NP functioning and positive correlations suggest that higher AMAS scores are associated with worse NP functioning).
In terms of potential covariates, bivariate analyses showed that CD4 count was significantly correlated with Motor Function (r=.27, p=.03) and therefore was included as a covariate in those analyses. However, plasma HIV viral load and CD4 count were not significantly related to any other neuropsychological deficit scores (all p’s>.10). Scores on AMAS and NP test performance did not differ significantly between participants who met criteria for current substance abuse disorder (based on CIDI diagnosis) and those who did not (all p’s>.10). Also of note, the normative data for our Learning and Memory tests (see Table 1) did not provide demographic corrections for education, and Learning and Memory scores were both significantly correlated with years of formal education (Learning: r=−.27, p<.01; Memory r=−.30, p<.01). Education was also significantly associated with AMAS U.S. Cultural Competence (r=−.32, p=.01) but no other AMAS scores (all p’s>.10). Therefore, education was included as a covariate in relevant analyses.
Table 2 summarizes the demographic, clinical, and sociocultural characteristics of the sample. The sample was 65% male with a mean age of 46.79 years (SD = 7.29) and mean education of 11.84 years (SD = 2.55). CD4 count was <200 for 14% of the sample. All sample participants were of Caribbean origin: 92% were Puerto Rican, 6% Dominican, and 2% Cuban. Approximately one-third of participants were born outside the U.S. Of this subsample, participants reported living in the U.S. an average of 35.22 years (SD = 12.82). Additionally, 95% of the sample reported being bilingual or multilingual, and 5% reported being monolingual English speakers.
Table 2
Table 2
Demographic Characteristics of the Study Sample (N = 82)
As Table 3 illustrates, the overall sample endorsed high levels of acculturation to both U.S. and Latina/o culture (see AMAS Total U.S. and Total Latina/o Acculturation scores). This suggests that the sample was highly bicultural, although U.S. acculturation subscale scores tended to be slightly higher than Latina/o subscale scores (with the exception of Cultural Identity scores). Participants reported greater English language fluency than Spanish. On average, the sample met criteria for impairment (average deficit scores ≥ 0.50) in Global Neuropsychological functioning and in all neuropsychological domains, with Learning and Memory being the most impaired.
Table 3
Table 3
Acculturation Scores and Neuropsychological (NP) Deficit Scores (N = 82)
Correlations between AMAS and Neuropsychological Functioning
Table 4 summarizes the results of a series of Pearson correlations that were computed to investigate the bivariate associations between AMAS subscale scores and neuropsychological functioning (i.e., average GDS and domain deficit scores). As Table 4 illustrates, among the AMAS U.S. acculturation subscales, higher English Language Competence was significantly associated with better Global NP (r=−.32, p=.01). Higher English Language Competence, U.S. Cultural Competence, and U.S. Cultural Identity were associated with better Verbal Fluency and better Processing Speed, although some associations were at the trend level (see Table 4). Both higher U.S. Cultural Competence (r=−.27, p<.05) and higher U.S. Cultural Identity (r=−.24, p=.07) were associated with better Attention/Working Memory, the latter at the trend level. Overall, higher AMAS Total U.S. Acculturation scores were significantly associated with better Global NP (r=−.25, p=.04), Verbal Fluency (r=−.32, p=.01), and Processing Speed (r=−.33, p<.01), with a trend observed for Attention/Working Memory(r=−.25, p=.06). No other significant or trend level associations were observed among U.S. acculturation subscales and neuropsychological domains (all p’s>.10).
Table 4
Table 4
Correlations between neuropsychological (NP) average deficit scores and AMAS scores (N = 82)
Among the AMAS Latina/o acculturation subscales, higher Spanish Language Competence (r=.22, p=.09) and Latina/o Cultural Competence (r=.23, p=.07) were associated with worse Executive Function at the trend level. Spanish Language Competence was also associated with worse Learning at the trend level (r=.22, p=.09). In contrast, greater Latina/o Cultural Identity was associated with better Memory performance (r=−.27, p=.04). Overall, higher AMAS Total Latina/o Acculturation scores were only significantly associated with worse Executive Function (r=.27, p=.03). No other significant or trend level associations were observed (all p’s>.10).
Regressions Predicting Neuropsychological Functioning
Table 5 summarizes the results of a series of multiple regression analyses, which were computed to examine the combined and unique contributions of the AMAS Total U.S. and Latina/o Acculturation scores (2 independent variables) to predict global and domain specific neuropsychological average deficit scores. Results showed that the model significantly predicted 11% of the variance in Global NP functioning (F(6,61)=3.54, p=.04), 12% of the variance in Verbal Fluency (F(2,59)=4.00, p=.02), and 14% of the variance in Processing Speed (F(2,61)=4.62, p=.01). In all of these cases, only U.S. Acculturation provided a significant contribution to the model (all p’s<.05). In addition, U.S. Acculturation provided a trend level contribution (β= −.65, p=.06) to Attention/Working Memory, although the overall model was not significant (F(2,55)=1.83, p=.17).
Table 5
Table 5
Multiple regressions predicting neuropsychological (NP) deficit scores from AMAS total U.S. and Latina/o acculturation scores (N = 82)
In contrast, Latina/o Acculturation provided a significant contribution to the prediction of Executive Function (β=.49, p<.05), but the overall model only showed a statistical trend (F(2,61)=2.38, p=.10). Finally, Latina/o acculturation predicted Motor Function at the trend level (β=.56, p<.10), and the overall model also showed a statistical trend (F(2,61)=2.66, p=.06). No other significant or trend level associations were observed (all p’s>.10).
Among a sample of 82 highly bicultural HIV+ Caribbean Latina/o adults, both correlational and multivariate analyses showed that higher U.S. acculturation scores were associated with better global NP, verbal fluency, and processing speed, as well as attention/working memory (at the trend level). Correlational analyses showed that lower Latina/o acculturation was associated with better executive function and learning (at the trend level), while higher Latina/o acculturation was associated with better memory performance. Multivariate analyses also showed that lower Latina/o acculturation predicted better executive function and motor function (at the trend level).
These findings were consistent with prior work highlighting the impact of acculturation on neuropsychological test performance among Latina/o adults (Arnold et al., 1994; Coffey et al., 2005; Rosselli & Ardila, 2003). It is particularly notable that many of the measures associated with neuropsychological performance in this study are often considered to be “culture-free” because they are non-verbal (i.e., Digit Symbol, Symbol Search, etc.). However, they were significantly associated with acculturation.
One of the most important findings of the current study is that both linguistic and non-linguistic cultural factors were significantly associated with neuropsychological functioning among HIV+ Latina/o adults. This further reinforces the theory that the influence of acculturation extends beyond the effects of language. It is also notable that self-reported English language competence (based on AMAS subscale) was significantly associated with NP test performance. Consistent with the larger U.S. Latina/o population, 68% of our sample was U.S. born (~60% of U.S. Latinas/os are U.S.-born; Passel & Cohn, 2008). Our participants were English-dominant and highly bicultural (i.e., endorsed high identification to and competence in both U.S. and Latina/o culture). However, self-reported language competence still exerted an independent influence on neuropsychological test performance. These findings suggest that acculturation is a critical factor for consideration in neuropsychological test performance of Latina/o individuals, even among those who are highly acculturated to U.S culture.
While language functioning may be an important, other cultural factors were also associated with NP test performance. Additionally, U.S. and Latina/o acculturation scores were associated with distinct and separate NP scores. For example, only non-linguistic factors (i.e., U.S. Cultural Competence and U.S. Cultural Identity) were associated with Attention/Working Memory. These results suggest that the effects of acculturation are not consistent across neuropsychological domains. While this inconsistency has been demonstrated in prior research with healthy Mexican and Mexican-American individuals (Arnold et al., 1994), this is the first study to do so in a clinical, Caribbean Latina/o sample.
The associations between U.S. acculturation and performance on processing speed and attention/working memory are particularly intriguing. Some researchers contend that processing speed and attention/working memory mediate general cognitive abilities, including fluid intelligence (Jaeggi, Buschkuehl, Jonides, & Perrig, 2008; Salthouse, 1996). Therefore, it is possible that acculturation to U.S. culture could actually improve selective cognitive skills (i.e., processing speed and attention/working memory) that in turn could enhance more general neurocognitive abilities or fluid intelligence. It is possible that Westernized cultures (including U.S. culture), which place a strong cultural value on time and speed (Stewart & Bennett, 1991) may actually promote faster processing speed and better performance on attention/working memory tasks (which are often timed). The associations in this study between U.S. acculturation with processing speed and attention/working memory may serve as a potential mechanism to help us understand how cultural values and/or experience might alter neuropsychological test performance. Specifically, evidence suggests that cognition is not static and that it interacts with the surrounding environment and culture (Al-Namlah, Fernyhough, Meins, 2006; Luria, 1976; Vygotsky, 1981; Wertsch, 1994). Alternatively, it is also possible that better processing speed and attention/working memory might facilitate acculturation, perhaps through more efficient or rapid processing of environmental information. This could be examined in future research by prospectively following recent immigrants and assessing their acculturation levels and NP performance longitudinally.
Prior research has shown that higher U.S. acculturation is significantly, positively associated with executive function (Arnold et al., 1994; Boone et al., 2007; Coffey et al., 2005). However, this is the first study that we are aware of to report that lower Latina/o acculturation and cultural competence are related to better performance on measures of executive function. This finding may help to explain prior results (Rivera Mindt et al., 2008), which found that HIV+ Latina/o adults performed significantly worse only in the domain of executive function when compared to HIV+ non-Hispanic white adults on a comprehensive neuropsychological evaluation. This also highlights the important role of culture in performance on problem solving and conceptual reasoning tests (Luria, 1976; Vygotsky, 1981).
Interestingly, we found that greater Latina/o cultural identity was significantly associated with better memory performance. This finding contradicted our hypotheses, as well as the results reported in a previous study among Mexican/Mexican Americans, in which memory was not associated with acculturation (Arnold et al., 1994). To our knowledge, this is first time such a finding has been reported in the literature, and its implications are unclear. More research is needed to clarify this finding.
When acculturation was examined in a series of multiple regression analyses, total U.S. acculturation significantly predicted 11–14% of the variance in global NP, verbal fluency, and processing speed. Total Latina/o acculturation predicted 8% of the variance in executive function and 6% of the variance in motor function, reaching trend level. This may be due in part to inadequate norms, to the cultural biases inherent in tests, or perhaps to the cognitive demands of shifting cultural roles. Regardless, acculturation appears to a significant contributor to neuropsychological test performance, and may be a key factor driving previously reported discrepancies in test performance between Latina/o and non-Hispanic white individuals (e.g., Rivera Mindt et al., 2008; Wojna et al., 2006).
These findings also suggest that higher U.S. acculturation is associated with better NP performance and is more salient than acculturation to the non-dominant (Latina/o) culture. This is logical given that the neuropsychological tests used in this study (and ubiquitously in the field) were developed and normed within U.S./Western majority culture. Thus, it is also not surprising that lower Latina/o acculturation, including lower Spanish language competence, was significantly correlated with worse learning and executive functioning performance (as well as motor function in the multivariate analyses). The extant literature on language functioning reports that bilingualism can sometimes cause interference since the non-active language must be suppressed (Rivera Mindt et al., 2008). Given that our participants, on average, reported being highly fluent in both English and Spanish, their Spanish language proficiency may cause cognitive interference or competition when performing English language neuropsychological tests. For example, allocating cognitive resources to suppressing the non-active language (i.e., Spanish) may require diverting resources away from the target task. Therefore, in order to assess this more directly, future acculturation research might also examine the impact of language proficiency on neuropsychological functioning through objective language assessment.
In sum, many components of acculturation to both the dominant and non-dominant cultures—including language competence, cultural competence, and cultural identity—affect neuropsychological test performance differentially. These results support the idea that acculturation should be examined as a multidimensional construct using validated measures such as the AMAS (Zea et al., 2003). Equally important, acculturation to the dominant U.S. culture appears to be a much stronger predictor of neuropsychological performance than Latina/o acculturation, which may reflect cultural biases in tests, and therefore may be more salient for neuropsychological test interpretation (Helms, 1992). Our results further suggest that considering the impact of acculturation on neuropsychological test performance would likely improve interpretation of neuropsychological test results within this population. Even in our English-dominant, highly bicultural sample, acculturation scores accounted for a significant amount of the variance (11–14%) in global neuropsychological performance, verbal fluency, and processing speed, as well as trends in executive and motor function. These effects may have been even stronger in a less bicultural or less U.S. acculturated sample. Therefore, acculturation should be formally assessed and considered when working with Latina/o individuals, even those who are highly acculturated to U.S. culture.
Our study had several limitations. First, our acculturation measure relied on self-report. However, the acculturation measure used in this study is well-validated and previously published research has successfully utilized this measure with a similar patient population (Zea et al., 2003; Zea et al., 2004). Second, the high level of acculturation to both U.S. and Latina/o culture may have reduced the variability and restricted the range in AMAS scores, thus limiting potential associations with the neuropsychological measures. Given the relationship between acculturation and neuropsychological functioning observed in this sample, it is likely that these effects would be even stronger in less acculturated samples (as mentioned above). The relative impact of different aspects of acculturation may also vary depending on acculturation level. Third, the possible influence of substance abuse should also be considered, as this is often comorbid in HIV+ samples (Byrd et al., 2011). Although participants who met criteria for current substance abuse disorder did not differ on AMAS or neuropsychological performance in our sample, future research should examine this more thoroughly. Finally, our analyses did not control for multiple comparisons, and therefore the possibility of type I error is inflated. Future research should explore the relationships between acculturation and neuropsychological test performance in healthy control groups, as these relationships may differ in HIV+ individuals and other clinical samples.
Furthermore, research should be extended to other neurological and medical populations, as well as other racial/ethnic groups. There is a great need for this type of research as ethnic minority populations, including Latinas/os, are at greater risk for numerous diseases and disorders that impact cognition, including HIV/AIDS. Future research should also extend the current results by exploring whether or not U.S. and Latina/o acculturation levels significantly attenuate differences observed in neuropsychological test performance between Latina/o and non-Hispanic white adults. Finally, research is also needed to replicate the current findings with regard to the relationships between executive function and memory (respectively) with Latina/o acculturation. In this regard, qualitative methods may be especially useful in order to better understand these associations.
Despite its limitations, this is the first study to systematically examine the associations between distinct facets of acculturation (to both the dominant and non-dominant culture) and neuropsychological test performance using a validated, multidimensional acculturation measure within a well-characterized, clinical (i.e., HIV+) sample of Caribbean Latina/o adults. Our findings support the importance of examining acculturation to both the dominant and non-dominant cultures using a multidimensional acculturation measure, and suggest that both linguistic and non-linguistic cultural factors have separate and distinct effects on neuropsychological functioning. It is notable that acculturation significantly impacted neuropsychological test performance even among highly bicultural (including highly U.S. acculturated) individuals. Our sample is likely to reflect the large and growing segment of the U.S. Latina/o population who identify as bicultural. Currently, research suggests that 39% of U.S. Latinas/os self-identify as bicultural (Horowitz Associates, 2011). Therefore, our findings are more likely to be generalizable to these Latinas/os, and therefore clinically relevant for their neuropsychological assessment. Overall, this study highlights the multifaceted nature of acculturation and its relationship with neuropsychological functioning. In order to increase diagnostic accuracy and to improve the interpretation of neuropsychological test performance, our findings suggest that acculturation should be measured and considered when assessing culturally diverse individuals, particularly within clinical populations.
Acknowledgments
The authors wish to thank the Harlem Community Academic Partnership, the Manhattan HIV Care Network, and our participants for their contributions to our research. This research was supported by a K23 from NIMH (K23MH07971801) and an Early Career Development Award from the Northeast Consortium for Minority Faculty Development, both awarded to Monica Rivera Mindt, PhD; an R24 and U01 from NIMH (R24MH59724; U01MH083501) to Susan Morgello, MD; and an N01 from NIMH (N01MH22005) subcontracted to Susan Morgello, MD.
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