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1.  Acculturation and self-rated health among Arctic indigenous peoples: a population-based cross-sectional study 
BMC Public Health  2012;12:948.
Acculturation is for indigenous peoples related to the process of colonisation over centuries as well as the on-going social transition experienced in the Arctic today. Changing living conditions and lifestyle affect health in numerous ways in Arctic indigenous populations. Self-rated health (SRH) is a relevant variable in primary health care and in general public health assessments and monitoring. Exploring the relationship between acculturation and SRH in indigenous populations having experienced great societal and cultural change is thus of great importance.
The principal method in the Survey of Living Conditions in the Arctic (SLiCA) was standardised face-to-face interviews using a questionnaire. Very high overall participation rates of 83% were obtained in Greenland and Alaska, whilst a more conventional rate of 57% was achieved in Norway. Acculturation was conceptualised as certain traditional subsistence activities being of lesser importance for people’s ethnic identity, and poorer spoken indigenous language ability (SILA). Acculturation was included in six separate gender- and country-specific ordinal logistic regressions to assess qualitative effects on SRH.
Multivariable analyses showed that acculturation significantly predicted poorer SRH in Greenland. An increased subsistence score gave an OR of 2.32 (P<0.001) for reporting poorer SRH among Greenlandic men, while an increased score for Greenlandic women generated an OR of 1.71 (P=0.01). Poorer SILA generated an OR of 1.59 in men (p=0.03). In Alaska, no evidence of acculturation effects was detected among Iñupiaq men. Among Iñupiaq women, an increased subsistence score represented an increased odds of 73% (p=0.026) for reporting poorer SRH. No significant effects of acculturation on SRH were detected in Norway.
This study shows that aggregate acculturation is a strong risk factor for poorer SRH among the Kalaallit of Greenland and female Iñupiat of Alaska, but our cross-sectional study design does not allow any conclusion with regard to causality. Limitations with regard to wording, categorisations, assumed cultural differences in the conceptualisation of SRH, and confounding effects of health care use, SES and discrimination, make it difficult to appropriately assess how strong this effect is though.
PMCID: PMC3497910  PMID: 23127197
Self-rated health; Acculturation; Kalaallit; Iñupiat; Sami; Inuit; Indigenous peoples; Living conditions; SLiCA
2.  Determinants of self-rated health and the role of acculturation: Implications for health inequalities 
Ethnicity & health  2013;18(6):10.1080/13557858.2013.771147.
Self-rated health (SRH) is an important indicator of overall health, predicting morbidity and mortality. This paper investigates what individuals incorporate into their self-assessments of health and how acculturation plays a part in this assessment. The relationship of acculturation to SRH and whether it moderates the association between indicators of health and SRH is also examined.
The paper is based on data from adults in the Boston Puerto Rican Health Study, living in the greater Boston area (n=1357) mean age 57.2 (SD=7.6). We used multiple regression analysis and testing for moderation effects.
The strongest predictors of poor self-rated health were the number of existing medical conditions, functional problems, allostatic load and depressive symptoms. Poor self-rated health was also associated with being female, fewer years of education, heavy alcohol use, smoking, poverty, and low emotional support. More acculturated Puerto Rican adults rated their health more positively, which corresponded to better indicators of physical and psychological health. Additionally, acculturation moderated the association between some indicators of morbidity (functional status and depressive symptoms) and self-rated health.
Self-assessments of overall health integrate diverse indicators, including psychological symptoms, functional status and objective health indicators such as chronic conditions and allostatic load. However, adults’ assessments of overall health differed by acculturation, which moderated the association between health indicators and SRH. The data suggest that when in poor health, those less acculturated may understate the severity of their health problems when rating their overall health, thus SRH might thus conceal disparities. Using SRH can have implications for assessing health disparities in this population.
PMCID: PMC3758374  PMID: 23425383
3.  Self-Rated Health Among Adult Women of Mexican Origin 
Self-rated health (SRH), a consistent predictor of mortality among diverse populations, is sensitive to health indicators and social factors. American-born Hispanics report better SRH than their foreign-born counterparts but simultaneously report poorer health indicators and have shorter life expectancy. Using a matched prospective cross-sectional design, we analyzed data from 631 age-matched pairs of women, born in the United States or Mexico, enrolled in a cohort study based in Houston, Texas. Our first goal was to describe the relationships between SRH and health behaviors, physician-diagnosed chronic conditions, acculturation, and socioeconomic status (SES) by birthplace. Our second goal was to investigate the relative influence of SES, acculturation, health behaviors, and physician-diagnosed conditions in explaining expected differences in SRH between the two groups. Number of chronic conditions reported, particularly depression, more strongly influenced SRH than SES, acculturation, or reported health risk behaviors and the influence of birthplace is accounted for by these factors.
PMCID: PMC3940416  PMID: 24600161
Self-rated health; acculturation; SES; health indicators
4.  Linguistic Acculturation and Skin Cancer-Related Behaviors Among Hispanics in the Southern and Western United States 
JAMA dermatology (Chicago, Ill.)  2013;149(6):679-686.
To examine the association between linguistic acculturation (assessed using the Language Use and Linguistic Preference subscales from the Bidimensional Acculturation Scale for Hispanics) and skin cancer-related behaviors among U.S. Hispanic adults. We hypothesized that, compared to Hispanics denoted as Spanish acculturated, English acculturated Hispanics would report less frequent shade seeking and use of sun protective clothing and higher rates of sunscreen use, sunbathing, and indoor tanning.
Online survey study conducted in September, 2011.
Survey of Hispanic adults residing in five southern and western U.S. states.
A population-based sample of 788 Hispanic adults drawn from a nationally representative web panel.
Main Outcome Measures
Self-reported sunscreen use, shade seeking, use of sun protective clothing, sunbathing, and indoor tanning.
Multivariable regression analyses were conducted to examine predictors of the skin cancer-related behaviors. As hypothesized, English acculturated Hispanics had lower rates of shade seeking and use of sun protective clothing and reported higher rates of sunbathing and indoor tanning than Spanish acculturated Hispanics. English acculturated Hispanics and bicultural Hispanics (i.e., those with high Spanish and high English acculturation) reported comparably high rates of sunbathing and indoor tanning. Results suggested that bicultural Hispanics seek shade and wear sun protective clothing less often than Spanish acculturated Hispanics but more often than English acculturated Hispanics. Acculturation was not associated with sunscreen use.
Hispanic adults do not routinely engage in behaviors that reduce their risk of skin cancer. Bicultural and English acculturated Hispanics are particularly in need of skin cancer prevention interventions.
PMCID: PMC3689859  PMID: 23752366
acculturation; Hispanic; Latino; skin cancer; prevention
5.  Association of acculturation and country of origin with self-reported hypertension and diabetes in a heterogeneous Hispanic population 
BMC Public Health  2012;12:768.
Hispanics are the fasting growing population in the U.S. and disproportionately suffer from chronic diseases such as hypertension and diabetes. Little is known about the complex interplay between acculturation and chronic disease prevalence in the growing and increasingly diverse Hispanic population. We explored the association between diabetes and hypertension prevalence among distinct U.S. Hispanic subgroups by country of origin and by degree of acculturation.
We examined the adult participants in the 2001, 2003, 2005, and 2007 California Health Interview Survey (CHIS). Using weighted logistic regression stratified by nativity, we measured the association between country of origin and self-reported hypertension and diabetes adjusting for participants’ demographics, insurance status, socio-economic status and degree of acculturation measured by citizenship, English language proficiency and the number of years of residence in the U.S.
There were 33,633 self-identified Hispanics (foreign-born: 19,988; U.S.-born: 13,645). After multivariable adjustment, we found significant heterogeneity in self-reported hypertension and diabetes prevalence among Hispanic subgroups. Increasing years of U.S. residence was associated with increased disease prevalence. Among all foreign-born subgroups, only Mexicans reported lower odds of hypertension after adjustment for socioeconomic and acculturation factors. Both U.S.-born and foreign-born Mexicans had higher rates of diabetes as compared to non-Hispanic whites.
We found significant heterogeneity among Hispanics in self-reported rates of hypertension and diabetes by acculturation and country of origin. Our findings highlight the importance of disaggregation of Hispanics by country of origin and acculturation factors whenever possible.
PMCID: PMC3490899  PMID: 22966844
Acculturation; Ethnicity; Hypertension; Diabetes; Hispanic
6.  Change in Self-Reported Health Status among Immigrants in the United States: Associations with Measures of Acculturation 
PLoS ONE  2013;8(10):e76494.
Although acculturation may have positive effects for immigrants, including better socioeconomic profiles and increased occupational opportunities, their health profiles deteriorate with longer duration in the U.S. Prior research indicates that increasing acculturation is associated with some poorer health outcomes among immigrants in the U.S. However, most of these studies have used length of stay or English language proficiency as proxies for acculturation, and have mainly examined self-reported “current” health outcomes. This study advances knowledge on associations between acculturation and health among immigrants by explicitly examining self-reported “change” in health since immigration, in relation to acculturation-related variables. We use data from the New Immigrant Survey (NIS; 2003-2004), a cross-sectional study of legal immigrants to the U.S. In addition to testing more conventionally examined proxies of acculturation (length of stay and English proficiency), we also examine English language use and self-reported change in diet. Multivariable logistic regression analyses on 5,982 participants generally supported previous literature indicating a deleterious impact of acculturation, with increasing duration of stay and greater self-reported change in diet being associated with a poorer change in health since moving to the U.S. Although English language proficiency and use were associated with greater odds of reporting a worse change in health when examined individually, they were non-significant in multivariable models including all acculturation measures. Findings from this study suggest that when taking into account multiple measures of acculturation, language may not necessarily indicate unhealthy assimilation and dietary change may be a pathway leading to declines in immigrant health. Increasing duration in the U.S. may also reflect the adoption of unhealthy behaviors, as well as greater exposure to harmful sources of psychosocial stress including racial and anti-immigrant discrimination. Our study suggests that multiple indicators of acculturation may be useful in examining the effect of acculturation on changes in health among immigrants.
PMCID: PMC3788132  PMID: 24098515
7.  Decomposing associations between acculturation and drinking in Mexican Americans 
Acculturation to life in the United States is a known predictor of Hispanic drinking behavior. We compare the ability of 2 theoretical models of this effect – sociocultural theory and general stress theory – to account for associations between acculturation and drinking in a sample of Mexican Americans. Limitations of previous evaluations of these theoretical models are addressed by using a broader range of hypothesized cognitive mediators and a more direct measure of acculturative stress. In addition, we explore nonlinearities as possible underpinnings of attenuated acculturation effects among males.
Respondents (N = 2,595, current drinker N = 1,351) were interviewed as part of 2 recent multistage probability samples in a study of drinking behavior among Mexican Americans in the United States. The ability of norms, drinking motives, alcohol expectancies, and acculturation stress to account for relations between acculturation and drinking outcomes (volume and heavy drinking days) were assessed with a hierarchical linear regression strategy. Nonlinear trends were assessed by modeling quadratic effects of acculturation and acculturation stress on cognitive mediators and drinking outcomes.
Consistent with previous findings, acculturation effects on drinking outcomes were stronger for females than males. Among females, only drinking motives explained acculturation associations with volume or heavy drinking days. Among males, acculturation was linked to increases in norms, and norms were positive predictors of drinking outcomes. However, adjusted effects of acculturation were non-existent or trending in a negative direction, which counter-acted this indirect normative influence. Acculturation stress did not explain positive associations between acculturation and drinking.
Stress and alcohol outcome expectancies play little role in the positive linear association between acculturation and drinking outcomes, but drinking motives appears to at least partially account for this effect. Consistent with recent reports, these results challenge stress models of linear acculturation effects on drinking outcomes and provide (partial) support for sociocultural models. Inconsistent mediation patterns – rather than nonlinearities – represented a more plausible statistical description of why acculturation-drinking associations are weakened among males.
PMCID: PMC3349785  PMID: 22316139
Mexican Americans; Acculturation
8.  Lifestyle and self-rated health: a cross-sectional study of 3,601 citizens of Athens, Greece 
BMC Public Health  2011;11:619.
Self-rated health (SRH) is a popular health measure determined by multiple factors. International literature is increasingly focusing on health-related behaviors such as smoking, dietary habits, physical activity, even religiosity. However, population-based studies taking into account multiple putative determinants of SRH in Greece are scarce. The aim of this study was to clarify possible determinants of SRH with an emphasis on the relationship between SRH and lifestyle variables in a large sample of urban citizens.
In this one-year cross-sectional study, a stratified random sample of 3,601 urban citizens was selected. Data were collected using an interview-based questionnaire about various demographic, socioeconomic, disease- and lifestyle related factors such as smoking, physical activity, dietary habits, sleep quality and religiosity. Multivariate logistic regression was used separately in three age groups [15-29 (N = 1,360), 30-49 (N = 1,122) and 50+ (N = 1,119) years old] in order to identify putative lifestyle and other determinants of SRH.
Reporting of good SRH decreased with age (97.1%, 91.4% and 74.8%, respectively). Overall, possible confounders of the lifestyle-SRH relationship among age groups were sex, education, hospitalization during the last year, daily physical symptoms and disease status. Poor SRH was associated with less physical activity in the 15-29 years old (OR 2.22, 95%CI 1.14-4.33), with past or heavy smoking, along with no sleep satisfaction in the 30-49 years old (OR 3.23, 95%CI 1.35-7.74, OR 2.56, 95%CI 1.29-5.05, OR 1.79, 95%CI 1.1-2.92, respectively) and with obesity and no sleep satisfaction in the 50+ years old individuals (OR 1.83, 95%CI 1.19-2.81, OR 2.54, 95%CI 1.83-3.54). Sleep dissatisfaction of the 50+ years old was the only variable associated with poor SRH at the 0.001 p level of significance (OR 2.45, 99%CI 1.59 to 3.76). Subgroup analyses of the 15-19 years old individuals also revealed sleep dissatisfaction as the only significant variable correlated with SRH.
Slight differences in lifestyle determinants of SRH were identified among age groups. Sleep quality emerged as an important determinant of SRH in the majority of participants.
PMCID: PMC3161893  PMID: 21816035
self-rated health; health promotion; sleep; health inequalities; lifestyle; public health
9.  Self-Rated Health and C-Reactive Protein in Young Adults 
Brain, behavior, and immunity  2014;36:139-146.
Poor self-rated health (SRH) and elevated inflammation and morbidity and mortality are robustly associated in middle- and older-aged adults. Less is known about SRH-elevated inflammation associations during young adulthood and whether these linkages differ by sex.
Data came from the National Longitudinal Study of Adolescent Health. At Wave IV, young adults aged 24–34 reported their SRH, acute and chronic illnesses, and sociodemographic and psychological characteristics relevant to health. Trained fieldworkers assessed medication use, BMI, waist circumference, and also collected bloodspots from which high-sensitivity CRP (hs-CRP) was assayed. The sample size for the present analyses was N=13,236.
Descriptive and bivariate analyses revealed a graded association between SRH and hs-CRP: Lower ratings of SRH were associated with a higher proportion of participants with hs-CRP > 3 mg/L and higher mean levels of hs-CRP. Associations between SRH and hs-CRP remained significant when acute and chronic illnesses, medication use, and health behaviors were taken into account. When BMI was taken into account, the association between SRH and hs-CRP association fully attenuated in females; a small, but significant association between SRH and hs-CRP remained in males.
Poor SRH and elevated hs-CRP are associated in young adults, adjusting for other health status measures, medication use, and health behavior. In males, SRH provided information about elevated hs-CRP that was independent of BMI. In females, BMI may be a better surrogate indicator of global health and pro-inflammatory influences compared to SRH.
PMCID: PMC4313081  PMID: 24513874
self-rated health; C-reactive protein; inflammation; sex differences; young adulthood; cardiovascular risk; Add Health
10.  Gender differences in the association between self-rated health and hypertension in a Korean adult population 
BMC Public Health  2012;12:135.
Self-rated health (SRH) has been reported as a predictor of mortality in previous studies. This study aimed to examine whether SRH is independently associated with hypertension and if there is a gender difference in this association.
16,956 community dwelling adults aged 20 and over within a defined geographic area participated in this study. Data on SRH, socio-demographic factors (age, gender, marital status, education) and health behaviors (smoking status, alcohol consumption, physical activity) were collected. Body mass index and blood pressure were measured. Logistic regression models were used to determine a relationship between SRH and hypertension.
32.5% of the participants were found to have hypertension. Women were more likely than men to rate their SRH as poor (p < 0.001), and the older age groups rated their SRH more negatively in both men and women (p < 0.001). While the multivariate-adjusted odds ratio (OR, 95% CI) of participants rating their SRH as very poor for hypertension in men was OR 1.70 (1.13-2.58), that in women was OR 2.83 (1.80-4.44). Interaction between SRH and gender was significant (p < 0.001).
SRH was independently associated with hypertension in a Korean adult population. This association was modified by gender.
PMCID: PMC3306731  PMID: 22340138
11.  Self-Rated Health Trajectories and Mortality Among Older Adults 
For this article, we evaluated whether measures of prior self-rated health (SRH) trajectories had associations with subsequent mortality that were independent of current SRH assessment and other covariates.
We used multivariable logistic regression that incorporated four waves of interview data (1993, 1995, 1998, and 2000) from the Asset and Health Dynamics Among the Oldest Old Survey in order to predict mortality during 2000–2002. We defined prior SRH trajectories for each individual based on the slope estimated from a simple linear regression of their own SRH between 1993 and 1998 and the variance around that slope. In addition to SRH reported in 2000, other covariates included in the mortality models reflected health status, health-related behaviors, and individual resources.
Among the 3,129 respondents in the analytic sample, SRH in 2000 was significantly (p < .0001) associated with mortality, but the measures of prior SRH trajectories were not. Prior SRH trajectory was, however, a significant determinant of current SRH. We observed significant independent associations with mortality for age, sex, education, lung disease, and having ever smoked.
Although measures of prior SRH trajectories did not have significant direct associations with mortality, they did have important indirect effects via their influence on current SRH.
PMCID: PMC2104470  PMID: 17284562
12.  Prevalence of Major Cardiovascular Risk Factors and Cardiovascular Diseases Among Hispanic/Latino Individuals of Diverse Backgrounds in the United States 
Major cardiovascular diseases (CVDs) are leading causes of mortality among US Hispanic and Latino individuals. Comprehensive data are limited regarding the prevalence of CVD risk factors in this population and relations of these traits to socioeconomic status (SES) and acculturation.
To describe prevalence of major CVD risk factors and CVD (coronary heart disease [CHD] and stroke) among US Hispanic/Latino individuals of different backgrounds, examine relationships of SES and acculturation with CVD risk profiles and CVD, and assess cross-sectional associations of CVD risk factors with CVD.
Design, Setting, and Participants
Multicenter, prospective, population-based Hispanic Community Health Study/Study of Latinos including individuals of Cuban (n =2201), Dominican (n = 1400), Mexican (n=6232), Puerto Rican (n=2590), Central American (n=1634), and South American backgrounds (n = 1022) aged 18 to 74 years. Analyses involved 15 079 participants with complete data enrolled between March 2008 and June 2011.
Main Outcome Measures
Adverse CVD risk factors defined using national guidelines for hypercholesterolemia, hypertension, obesity, diabetes, and smoking. Prevalence of CHD and stroke were ascertained from self-reported data.
Age-standardized prevalence of CVD risk factors varied by Hispanic/Latino background; obesity and current smoking rates were highest among Puerto Rican participants (for men, 40.9% and 34.7%; for women, 51.4% and 31.7%, respectively); hypercholesterolemia prevalence was highest among Central American men (54.9%) and Puerto Rican women (41.0%). Large proportions of participants (80% of men, 71% of women) had at least 1 risk factor. Age- and sex-adjusted prevalence of 3 or more risk factors was highest in Puerto Rican participants (25.0%) and significantly higher (P<.001) among participants with less education (16.1%), those who were US-born (18.5%), those who had lived in the United States 10 years or longer (15.7%), and those who preferred English (17.9%). Overall, self-reported CHD and stroke prevalence were low (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively). In multivariate-adjusted models, hypertension and smoking were directly associated with CHD in both sexes as were hypercholesterolemia and obesity in women and diabetes in men (odds ratios [ORs], 1.5–2.2). For stroke, associations were positive with hypertension in both sexes, diabetes in men, and smoking in women (ORs, 1.7–2.6).
Among US Hispanic/Latino adults of diverse backgrounds, a sizeable proportion of men and women had adverse major risk factors; prevalence of adverse CVD risk profiles was higher among participants with Puerto Rican background, lower SES, and higher levels of acculturation.
PMCID: PMC3777250  PMID: 23117778
13.  Gender differences in the association of perceived social support and social network with self-rated health status among older adults: a population-based study in Brazil 
BMC Geriatrics  2013;13:122.
Older adults are more likely to live alone, because they may have been predeceased by their spouse and friends. Social interaction could also be reduced in this age group due by limited mobility caused by chronic conditions. Therefore, aging is frequently accompanied by reduced social support, which might affect health status. Little is known about the role of gender in the relationship between social support and health in older adults. Hence, the present study tests the hypothesis that gender differences exist in the relationship between perceived social support, social network, and self-rated health (SRH) among older adults.
A cross-sectional study using two-stage probabilistic sampling recruited 3,649 individuals aged 60 years and above. Data were collected during the national influenza vaccination campaign in Rio de Janeiro, Brazil, in 2006. Individual interviews collected information on SRH, perceived social support, social network, and other covariates. Multivariate logistic regression analyses using nested models were conducted separately for males and females. Independent variables were organised into six blocks: (1) perceived social support and social network, (2) age group, (3) socioeconomic characteristics, (4) health-related behaviours, (5) use of health care services, (6) functional status measures and somatic health problems.
Older men who did not participate in group activities were more likely to report poor SRH compared to those who did, (OR = 1.63; 95% CI = 1.16–2.30). Low perceived social support predicted the probability of poor SRH in women (OR = 1.64; 95% CI = 1.16–2.34). Poor SRH was associated with low age, low income, not working, poor functional capacity, and depression in both men and women. More somatic health problems were associated with poor SRH in women.
The association between social interactions and SRH varies between genders. Low social network involvement is associated with poor SRH in older men, whereas low perceived social support is associated with poor SRH in older women. The hypothesis that the relationship of perceived social support and social networks to SRH differs according to gender has been confirmed.
PMCID: PMC4225700  PMID: 24229389
Older adults; Perceived social support; Social networks; Social inequality
14.  Acculturation and the Center for Epidemiological Studies Depression Scale for Hispanic Women 
Nursing research  2011;60(4):270-275.
Culturally valid measures of depression for Spanish-speaking Hispanic women are important for developing and implementing effective interventions to reduce health disparities. The Center for Epidemiological Studies--Depression Scale (CES-D) is a widely used measure of depression. Differential item functioning has been studied using language preference as a proxy for acculturation, but it is unknown if the results were due to acculturation or the language of administration.
To evaluate the relationship of acculturation, defined with a dimensional measure, to Spanish CES-D item responses.
Spanish-speaking Hispanic women (n = 504) were recruited for a randomized controlled trial of Salud, Educación, Prevención y Autocuidado (Health, Education, Prevention and Self-care). Acculturation, an important dimension of variation within the diverse United States Hispanic community, was defined by high or low scores on the Americanism subscale of the Bidimensional Acculturation Scale. Differential item functioning for each of the 20 CES-D items between more acculturated and less acculturated women was tested using ordinal logistic regression.
No items on the Depressed Affect, Somatic Activity, or Positive Affect subscales showed meaningful differential item functioning, but one item (“People were unfriendly”) on the Interpersonal subscale had small results (R2 = 1.1%).
The majority of CES-D items performed similarly for Spanish-speaking Hispanic women with high and low acculturation. Less acculturated women responded more positively to “People were unfriendly,” despite having an equivalent level of depression, than more acculturated women. Possibilities for improving this item are proposed.
PMCID: PMC3137136  PMID: 21677596
acculturation; depression; Hispanic; women; CES-D
15.  Difference of the associations between self-rated health and demographic characteristics, lifestyle, and psychosocial work environment between two types of Chinese worksite 
BMC Public Health  2014;14(1):851.
Although studies of self-rated health (SRH) are conducted widely in developed countries, comprehensive assessments of the determinants of SRH in Chinese are scarce, particularly for working Chinese individuals. Determinants of SRH might differ among worksites based on differences in the nature and stress associated with different jobs, work intensity, and the lifestyles of employees.
Two thousand and forty questionnaires that addressed SRH, demographic characteristics, lifestyle, and the psychosocial work environment were administered to employees at two worksites. A total of 1644 subjects provided complete data for analysis (80.6% response rate).
Participants from government departments had significantly better SRH than did those from high-tech enterprises (61.1% vs. 67.5%, respectively). Lifestyles were significantly less healthy at government departments compared with high-tech enterprises, whereas the psychosocial work environment was better. The results of unadjusted and adjusted models revealed differences between the potential health-influencing factors of participants based on their type of worksite. In logistic regression models, gender was strongly associated with SRH in all participants, whereas length of service was correlated with SRH only in participants from high-tech enterprises. In high-tech enterprises, good SRH was less common in physically inactive subjects vs. physically active participants (OR = 0.561). In government departments, passive smoking was negatively associated with SRH significantly. Social capital (OR = 1.073) and job control (OR = 1.550) were positively correlated with SRH in high-tech enterprises. Job control was the only psychosocial factor significantly associated with SRH in government departments.
Participants from different types of worksite reported different SRH, healthy lifestyles, and psychosocial work environments. Moreover, the association between SRH and demographic characteristics, lifestyle, and the psychosocial work environment significantly differed by type of worksite.
PMCID: PMC4150959  PMID: 25128033
Self-rated health; Demographic characteristics; Lifestyle; Psychosocial work environment; Type of worksite
16.  Association of Acculturation Levels and Prevalence of Diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA)  
Diabetes Care  2008;31(8):1621-1628.
OBJECTIVE—The prevalence of type 2 diabetes among Hispanic and Asian Americans is increasing. These groups are largely comprised of immigrants who may be undergoing behavioral and lifestyle changes associated with development of diabetes. We studied the association between acculturation and diabetes in a population sample of 708 Mexican-origin Hispanics, 547 non–Mexican-origin Hispanics, and 737 Chinese participants in the Multi-Ethnic Study of Atherosclerosis (MESA).
RESEARCH DESIGN AND METHODS—Diabetes was defined as fasting glucose ≥126 mg/dl and/or use of antidiabetic medications. An acculturation score was calculated for all participants using nativity, years living in the U.S., and language spoken at home. The score ranged from 0 to 5 (0 = least acculturated and 5 = most acculturated). Relative risk regression was used to estimate the association between acculturation and diabetes.
RESULTS—For non–Mexican-origin Hispanics, the prevalence of diabetes was positively associated with acculturation score, after adjustment for sociodemographics. The prevalence of diabetes was significantly higher among the most acculturated versus the least acculturated non–Mexican-origin Hispanics (prevalence ratio 2.49 [95% CI 1.14−5.44]); the higher the acculturation score is, the higher the prevalence of diabetes (P for trend 0.059). This relationship between acculturation and diabetes was partly attenuated after adjustment for BMI or diet. Diabetes prevalence was not related to acculturation among Chinese or Mexican-origin Hispanics.
CONCLUSIONS—Among non–Mexican-origin Hispanics in MESA, greater acculturation is associated with higher diabetes prevalence. The relation is at least partly mediated by BMI and diet. Acculturation is a factor that should be considered when predictors of diabetes in racial/ethnic groups are examined.
PMCID: PMC2494621  PMID: 18458142
17.  Allostatic Load Among Non-Hispanic Whites, Non-Hispanic Blacks, and People of Mexican Origin: Effects of Ethnicity, Nativity, and Acculturation 
American journal of public health  2009;100(5):940-946.
We investigated ethnic differences in allostatic load in a population-based sample of adults living in Texas City, TX, and assessed the effects of nativity and acculturation status on allostatic load among people of Mexican origin.
We used logistic regression models to examine ethnic variations in allostatic load scores among non-Hispanic Whites, non-Hispanic Blacks, and people of Mexican origin. We also examined associations between measures of acculturation and allostatic load scores among people of Mexican origin only.
Foreign-born Mexicans were the least likely group to score in the higher allostatic load categories. Among individuals of Mexican origin, US-born Mexican Americans had higher allostatic load scores than foreign-born Mexicans, and acculturation measures did not account for the difference.
Our findings expand on recent research from the National Health and Nutrition Examination Survey with respect to ethnicity and allostatic load. Our results are consistent with the healthy immigrant hypothesis (i.e., newer immigrants are healthier) and the acculturation hypothesis, according to which the longer Mexican immigrants reside in the United States, the greater their likelihood of potentially losing culture-related health-protective effects.
PMCID: PMC2853615  PMID: 19834005
18.  Health Characteristics and Health Behaviors of African American Adults According to Self-rated Health Status 
Ethnicity & disease  2014;24(1):97-103.
Although African Americans report poorer self-rated health (SRH) than Whites, few studies have explored what factors are associated with SRH in this population. Our study described the health characteristics and health behaviors of a sample of adult church members according to SRH status.
74 African Methodist Episcopal churches in South Carolina.
1077 church members (99% African American).
Main Outcome Measures
Self-reported physical activity, fruit and vegetable consumption, fat- and fiber-behaviors, perceived stress, and presence of chronic health conditions, objectively measured body mass index (BMI), waist circumference, and blood pressure. Health-related characteristics and health behaviors across SRH categories were calculated. Analysis of covariance examined relationships between SRH and the presence of chronic diseases, the total number of chronic diseases, health-related variables, and health behaviors.
The health characteristics and health behaviors of participants worsened with declining SRH. The percentage of participants with each individual chronic health condition increased, as did the total number of chronic health conditions, as SRH declined. A higher BMI, a greater waist circumference, and higher perceived stress were associated with poorer SRH. Participants with lower physical activity and poorer fat- and fiber-behaviors also had poorer SRH. Fruit and vegetable consumption was not associated with SRH.
A better understanding of what health-related variables and health behaviors contribute to SRH may inform future interventions, as researchers and practitioners can target and effectively change the most salient factors. Fortunately, a majority of the factors are modifiable and can be prevented or reversed with changes in lifestyle.
PMCID: PMC4230694  PMID: 24620455
Self-rated Health; Health Behaviors; Chronic Health Conditions; African Americans
19.  Self ratings of health predict functional outcome and recurrence free survival after stroke 
Study objective: To measure stroke victims' self rated health (SRH) status and SRH transition, and to compare how the two are prospectively associated with disability and recurrence free survival.
Design: Prospective case registry study with face to face follow up interviews at three months, one, two, and three years. Ascertained were SRH status and SRH transition using single question assessments, Barthel Index (BI), Frenchay Activities Index (FAI), and Mini Mental State Examination (MMSE).
Setting: A multiethnic inner city population of 234 533.
Participants: Patients surviving the initial three months after a first in a lifetime stroke in 1995 to 1998.
Results: Of 690 stroke survivors 561 (81.3%) could complete the self report items. Answers to the item on SRH status did not vary significantly between the four follow up interviews. However, responses to the item on SRH transition changed significantly during follow up with three months ratings being more negative than all subsequent ratings. SRH transition, but not SRH status, showed a prospective association with long term outcome in multivariate analyses controlling for the BI, FAI, and MMSE. Compared with all other patients, patients reporting "Much worse health" at three months were more likely to be disabled ( = BI<20) at one year (OR 6.29, 95% CI 2.26 to 17.52) and their combined risk of stroke recurrence and death was increased over five years (HR 1.72, 95% CI 1.25 to 2.38).
Conclusions: Items on SRH should be used with caution in populations with high rates of disability and language problems, as many participants are unable to complete them. SRH transition may be a better predictor of disability and recurrence free survival after major medical events than SRH status.
PMCID: PMC1732360  PMID: 14652262
20.  Trajectories of Self-Rated Health in People with Diabetes: Associations with Functioning in a Prospective Community Sample 
PLoS ONE  2013;8(12):e83088.
Self-rated health (SRH) is a single-item measure that is one of the most widely used measures of general health in population health research. Relatively little is known about changes and the trajectories of SRH in people with chronic medical conditions. The aims of the present study were to identify and describe longitudinal trajectories of self-rated health (SRH) status in people with diabetes.
A prospective community study was carried out between 2008 and 2011. SRH was assessed at baseline and yearly at follow-ups (n=1288). Analysis was carried out through trajectory modeling. The trajectory groups were subsequently compared at 4 years follow-up with respect to functioning.
Four distinct trajectories of SRH were identified: 1) 72.2% of the participants were assigned to a persistently good SRH trajectory; 2) 10.1% were assigned to a persistently poor SRH trajectory; 3) mean SRH scores changed from good to poor for one group (7.3%); while 4) mean SRH scores changed from poor to medium/good for another group (10.4%). Those with a persistently poor perception of health status were at higher risk for poor functioning at 4 years follow-up than those whose SRH scores decreased from good to poor.
SRH is an important predictor for poor functioning in diabetes, but the trajectory of SRH seems to be even more important. Health professionals should pay attention to not only SRH per se, but also changes in SRH over time.
PMCID: PMC3858348  PMID: 24340083
21.  Stress and health related quality of life of Nepalese students studying in South Korea: A cross sectional study 
In recent years there has been a growing trend among students to travel for educational purposes to other countries where there is the possibility of experiencing considerable amounts of stress affecting their physical and mental functioning. The aims of the current study were to investigate the health related quality of life (HRQOL) of Nepalese students studying in South Korea to explore the relationship between HRQOL and perceived and acculturative stress, and to identify the determinants of HRQOL.
One hundred and thirty students were enrolled in this study. HRQOL was assessed using the Medical Outcomes Study Short Forms (SF-12) questionnaire. Perceived stress and acculturative stress was measured using the Perceived Stress Scale and Acculturative Stress Scale for international students, respectively. Pearson's correlation test and multiple regression analysis were performed.
Perceived stress and acculturative stress were negatively correlated with HRQOL. The highest value in the HRQOL was reported for the vitality subscale and the lowest value was reported for the role-emotional. In the regression model, perceived stress, acculturative stress, relationship with advisor, and marital status accounted for a significant (p < .001) portion of the variance (49%) in the mental component summary of the HRQOL.
The findings of this study indicate that Nepalese students studying in South Korea experience a considerable amount of perceived and acculturative stress, which is negatively related with their HRQOL. Provision of culture specific counseling and orientation programs may benefit the students. The determinants of HRQOL identified in this study were perceived stress, acculturative stress, relationship with advisor, and marital status.
PMCID: PMC3334675  PMID: 22410138
Health related quality of life; Stress; Acculturation; Students; Nepal
22.  The relationship between psychosocial status, acculturation and country of origin in mid-life Hispanic women: data from the Study of Women's Health Across the Nation (SWAN) 
To test the hypothesis that psychosocial symptomatology differs by country of origin and acculturation among Hispanic women, we examined 419 women, aged 42–52 years at baseline, enrolled in the New Jersey site of the Study of Women's Health Across the Nation (SWAN). Women were categorized into six groups: Central (CA, n = 29) or South American (SA, n = 106), Puerto Rican (PR, n = 56), Dominican (D, n = 42), Cuban (Cu, n = 44) and non-Hispanic Caucasian (NHC, n = 142). Acculturation, depressive symptoms, hostility/cynicism, mistreatment/discrimination, sleep quality, social support, and perceived stress were assessed at baseline. Physical functioning, trait anxiety and anger were assessed at the fourth annual follow-up. Comparisons between Hispanic and non-Hispanic Caucasians used χ2, t test or nonparametric alternatives; ANOVA or Kruskal–Wallis testing examined differences among the five Hispanic sub-groups. Multivariable regression models used PR women as the reference group.
Hispanic women were overall less educated, less acculturated (p < 0.001 for both) and reported more depressive symptoms, cynicism, perceived stress, and less mistreatment/discrimination than NHCs. Along with D women, PR women reported worse sleep than Cu women (p < 0.01) and more trait anxiety than SA and Cu women (p < 0.01). Yet, PR women were most acculturated (21.4% highly acculturated vs. CA (0.0%), D (4.8%), SA (4.8%) and Cu (2.3%) women; p < 0.001). In regression models, PR women reported depressive symptoms more frequently than D, Cu, or SA women, and reported trait anxiety more frequently than Cu or SA women. Greater acculturation was associated with more favorable psychosocial status, but PR ethnicity was negatively related to psychosocial status.
Psychosocial symptomatology among Hispanic women differs by country of origin and the relatively adverse profile of Puerto Rican women is not explained by acculturation.
PMCID: PMC3677597  PMID: 20210631
menopause; women; hispanic; acculturation; psychology
23.  Discrimination, Acculturation and Other Predictors of Depression among Pregnant Hispanic Women 
Ethnicity & disease  2012;22(4):497-503.
The purpose of our study was to examine the effects of socioeconomic status, acculturative stress, discrimination, and marginalization as predictors of depression in pregnant Hispanic women.
A prospective observational design was used.
Central and Gulf coast areas of Texas in obstetrical offices.
A convenience sample of 515 pregnant, low income, low medical risk, and self-identified Hispanic women who were between 22–24 weeks gestation was used to collect data.
The predictor variables were socioeconomic status, discrimination, acculturative stress, and marginalization. The outcome variable was depression.
Education, frequency of discrimination, age, and Anglo marginality were significant predictors of depressive symptoms in a linear regression model, F (6, 458) = 8.36, P<.0001. Greater frequency of discrimination was the strongest positive predictor of increased depressive symptoms.
It is important that health care providers further understand the impact that age and experiences of discrimination throughout the life course have on depressive symptoms during pregnancy.
PMCID: PMC3503150  PMID: 23140083
Depression; Discrimination; Acculturation; Hispanic Women; Pregnancy
24.  Self-Rated Health and Cardiovascular Disease Incidence: Results from a Longitudinal Population-Based Cohort in Norfolk, UK 
PLoS ONE  2013;8(6):e65290.
Self-rated health (SRH) predicts chronic disease morbidity including cardiovascular disease (CVD). In a population-based cohort, we examined the association between SRH and incident CVD and whether this association was independent of socio-demographic, clinical and behavioural participant characteristics.
Population-based prospective cohort study (European Prospective Investigation of Cancer-Norfolk). 20,941 men and women aged 39–74 years without prevalent CVD attended a baseline health examination (1993–1998) and were followed for CVD events/death until March 2007 (mean 11 years). We used a Cox proportional hazards model to quantify the association between baseline SRH (reported on a four point scale – excellent, good, fair, poor) and risk of developing CVD at follow-up after adjusting for socio-demographic, clinical and behavioural risk factors.
Baseline SRH was reported as excellent by 17.8% participants, good by 65.1%, fair by 16.0% and poor by 1.2%. During 225,508 person-years of follow-up, there were 55 (21.2%) CVD events in the poor SRH group and 259 (7.0%) in the excellent SRH group (HR 3.7, 95% CI 2.8–4.9). The HR remained significant after adjustment for behavioural risk factors (HR 2.6, 95% CI 1.9–3.5) and after adjustment for all socio-demographic, clinical and behavioural risk factors (HR 3.3, 95% CI 2.4–4.4). Associations were strong for both fatal and non-fatal events and remained strong over time.
SRH is a strong predictor of incident fatal and non-fatal CVD events in this healthy, middle-aged population. Some of the association is explained by lifestyle behaviours, but SRH remains a strong predictor after adjustment for socio-demographic, clinical and behavioural risk factors and after a decade of follow-up. This easily accessible patient-centred measure of health status may be a useful indicator of individual and population health for those working in primary care and public health.
PMCID: PMC3670935  PMID: 23755212
25.  Acculturation and Dental Visits Among Hispanic Adults 
Preventing Chronic Disease  2009;6(2):A50.
Acculturation may strongly influence use of or access to health services among Hispanics in the United States. We assessed the relationships between acculturation and use of oral health services among Hispanic adults in the United States.
Data were analyzed from Hispanic adults aged 18 years or older who participated in the 2006 Behavioral Risk Factor Surveillance System. Hispanics were defined by self-report of Spanish or Hispanic heritage. Preference to be interviewed in English or Spanish was used as a proxy for acculturation. Having had a dental visit in the previous 12 months was used as a proxy for use of oral health services.
English-speaking Hispanics were more likely to have had a dental visit in the previous 12 months compared with Spanish-speaking Hispanics (crude odds ratio [OR], 1.52; 95% confidence interval [CI], 1.36-1.71). After controlling for potential confounders, language was not significantly associated with having had a dental visit (OR, 1.05; 95% CI, 0.87-1.26; P = .61,). The most significant predictors for having had a dental visit in the previous 12 months were sex, education, income, and having health insurance.
Acculturation assessed by language spoken was not significantly associated with having had a dental visit in the previous 12 months among adult Hispanics in the United States. The common determinants of health care use, such as sex, income, level of education, and health insurance status, were the most significant predictors of use of oral health services among adult Hispanics.
PMCID: PMC2687856  PMID: 19288993

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